Cancer

In The Blog, it would seem like everyone is a troublemaker, intoxicated, or both. It would also appear that the core of my job is to act as a wall between these folks and the rest of the world, to sort them out and send them back into their little corner of the world where they linger until their next trip to the ED. And from time to time, showing “tough love” (or at least “tough medicine”) is what some patients need. But there are some patients for whom I’m a total pushover. Patients with cancer can be rude, mean, and demanding, and I’ll do anything they want.

Truth be told, I really like caring for patients with cancer. I wish I could say it’s because I can empathize with their situation. But to be frank, empathy has never been a strong suit of mine; it’s not part of my wiring. I have great difficulty putting myself in the place of others. Even when I’m sick, I feel uncomfortable with the situation rather than empathetic towards other’s ills. (This is why I think that on days I’m feeling bad, there should be a sign in the ED that says “You must be sicker than me if you want me to care.”) I wish it weren’t so, and I try to make up for it with thought and reason. So rather than being able to sense someone’s pain or discomfort, I try to think how I would cope with a similar problem. It’s an exercise that sometimes works, but often fails as an ineffective rationalization.

Maybe I like cancer patients because, despite every possible reason to be angry at the world, most of them are incredibly polite and grateful. I’m not sure why. I would think my reaction to cancer would be to grow angry that I had to spend some of my limited time in the chaotic environment of the ED instead of comfortably at home. Perhaps their attitude is different because their perspective changes. When you know your time is limited, maybe you’re willing to spend a small amount of inconvenience in the ED to buy more quality time in the long run. (I do know that for me, the only time I become conscious of time is when it’s limited.)

Maybe it’s because they’re pretty easy to care for. You already have the diagnosis in hand, and most of the time your efforts in the ED are focused narrowly on one of three things. They may have pain, which is easy to treat. (There’s no argument over pain medications here). If the pain gets under control, you write them a prescription and they go home. If not, you admit them. The patient could have a fever, in which case you check their white blood cell count. If there are enough cells there to fight infection, you write them a prescription for antibiotics and they go home. If it’s too low, you admit them. If they feel weak, you check some basic labs to make sure there’s nothing too out of whack, and them let them decide if they want to be admitted or head home to rest.

Maybe it’s because the baldness caused by the chemotherapy makes them all look younger, with the fuzzy scalps of newborn babes hidden by a jaunty baseball cap.

Maybe it’s because I feel like my job is to do something to make them better, but they’re staring down the barrel of the gun and there’s not a silly thing I can do about it. So giving them what they want may be a way to assuage my own impotent guilt. And maybe, in treating myself, I’m able to make everybody happy.

The Soda Sampler

There was one other adventure in Las Vegas I forgot to mention. Toward the south end of The Strip there’s a Coca-Cola store. As you can guess, you can buy all kinds of Coca-Cola merchandise and even have your picture taken with the Coca-Cola polar bear. (No personal cameras, please.) So late one night as we were walking back from dinner we dropped in.

The star attraction was the soda fountain on the second floor, where you could order a “Taste of the World” platter featuring 4 ounces each of sixteen different sodas on trays stacked one on top of each other. At a cheap $7.00, it was like the carbonated version of a Las Vegas buffet. It would be wrong to walk by that. (I was hoping we would get bread cubes and a spit cup to cleanse our palates between samples, but apparently bread and spit are not Coca-Cola products.)

So here’s a list of what we tasted and what I thought, in no particular order:

Inka Kola (Peru)

I’ve actually had Inka Kola before. It’s a very sweet, syrupy, bright yellow-green drink, and tastes as if someone had taken the undiluted extract of lemon-lime Gatorade and added some fizz. I actually like Gatorade, so I’m okay with the drink. I’m also intrigued with the historical aspects of its use by the ancient Inca culture. Bottles have been found in the ruins of Macchu Piccu. Archaeological studies continue. I understand the Inka Kola plant is being considered for designation as a United Nations World Heritage site.

I learned about Inka Kola on a hiking trip to South America in 1987. Even though I had read the warnings about eating food from street vendors, I was wise enough to not listen. So one night in Cuzco I bought some kind of meat-filled pastry and a bottle of Inka Cola from a very sincere-looking pushcart gourmet. The next day I was confined to my hotel room with a severe gastrointestinal illness and wound up spending quite a bit of time watching the Peruvian National Volleyball Team on television. (I also found out that Peru is pronounced Pey-ROO and not PA-roo as we gringos tend to do.) See the experiences I would have missed if I had followed sound travel advice?

That was also the trip where I learned to chew coca leaves, but that’s another tale. And I think the statute of limitations for the coca leaf tea I managed to sneak back through customs has expired. The tea itself is long gone, so don’t send the Department of Agriculture Beagle Brigade to the house. Thank you.

Sunfill Mint (India)

This drink had a very nice light green color that suggests the freshness of early spring, when there is just a touch of white still on the ground to lighten the air. It tastes like Scope mouthwash. This is probably not a bad thing if you eat a lot of Indian food, and I say this as someone who loves Indian food and who could happily eat it exclusively if confined to a single cuisine for the rest of my life. (I would undoubtedly feel some pangs for real Kansas City barbeque. But there’s got to be some way to turn a tandoori oven into a smoking pit). But I am also aware that after I eat Indian food, everyone knows it no matter how vigorously I brush my teeth. So I figure a good slug of soda with antibacterial qualities along with carbonation to dissolve any dental buildup can’t hurt. (That is what carbonation does…clean the teeth, like Dow Scrubbing Bubbles, right?)

Nestea Peach (France)

Nestea Peach didn’t look like tea and didn’t look like peach. It was clear in tone, tasting like tepid seltzer water with a twist of cardboard. Not awful, but very bland. It’s probably made that way so it doesn’t spoil the palate for real French dishes such as sautéed organ in sauce. I’m not making the organ thing up. When I was flying out of Paris on my first and only trip to the French capital, I stopped at an airport restaurant and ordered what I thought was a beef stew. I got what I asked for…just not the part of beef I anticipated. I think the taste buds…not mine, but those on the slice of tongue…is what gave it away. Judging by the size, cows must taste a lot.

Stoney Ginger Beer ( Africa)

I actually like ginger beer, and buy an Aussie version of it for myself at World Market. It’s not real beer, of course, but it tastes like spicy beer with the addition of ginger. Ginger is good for nausea, and I suspect that if we started to put ginger in our beers rather than slices of lime, we’d be a lot less prone to barf after drinking. I would like a government grant to explore this idea.

Smart Watermelon (China)

In the interest of full disclosure, I need to say that watermelon is my favorite fresh fruit of all time, followed closely by a perfectly ripe and juicy Jaffa orange. I’ll eat or drink just about anything with watermelon in it, like Midori liquor, or I’ll pair watermelon with just about any other foodstuff on the globe. (I’m probably the only guy in the history of the buffet at Paris Las Vegas who loaded up his plate with frutta della mare, macaroni and cheese, and watermelon.) So I loved this stuff. And to find that watermelon in also one of the more intellectual fruits? A bonus, to be sure. I feel bad for folks who have to drink Moronic Mango or Stupid Kumquat.

Kinley Lemon (England)

A clear soda that tasted like Spite with a bite. Not bad, but probably better as a mixer than a stand-alone. I think you could combine this with an English liquor called Pimm’s to make a drink called a Shandy, which is especially tasty when punting on the River Cam. (Just in case you were wondering where such a drink might be especially tasty. This blog strives to be a public service.)

Lift Apple ( Mexico)

It was a nice light apple soda. Pretty tasty. The Bride has some kind of allergy to processed apple products that makes her break into hives. So I can’t drink this and kiss her. (Well, I might as an experiment, but I think that would be a bad relationship moment. I’m good enough at creating those without carbonated help.)

Fanta Kolita (Costa Rica)

For years I’ve had a crush on Sophia Fanta, the grape member of the Fantanas. While she is lovely, to be certain, I’m sure that part of the appeal is that I just like the word “Fantana.” I also like the name of the group “Bananarama.” If they formed a septet they could be Fantanabananamrama.

How would you play The Name Game with Fanta?

Fanta fanta bo-anta
Banana-fana fo-anta
Fee-fi-mo-manta
Fanta!

It’s even better with Bananarama.

Bananarama Bananarama bo-ananarama
Banana-fana fo-ananarama
Fee-fi-mo mananarama
Bananarama!

The Wikipedia article on “The Name Game” indicates that if you use names such as Alice, Chuck, or Art, the result will contain “profanity or crude language.” Which it does. But it’s funny. Funny funny bo-unny. Banana-fana fo-unny. Fee-fi-mo-munny. Funny!

Bibo Kiwi Mango (South Africa)

I don’t recall exactly what it tasted like. I do know it tasted the same in English, Afrikaans, and Zulu. The Xhosa version had a little click to it.

Simba Guarana ( Paraguay)

This tasted like a heavier version of sarsaparilla. Sarsaparilla happens to be the best soda of all time. Afternoon Delight is the greatest composition in human history. If you do not agree with me, I will fight you. (Apologies to Ron Burgundy.)

Vegitabeta ( Japan)

I have no idea what this tastes like. By the time we got to this stuff, I was on my eleventh sample of sixteen, and was on some kind of sugar high. So all I could think of was Lucy doing the Vitaminavegamin commercial, and laughed so hard I almost spit the soda out my nose.

Sunfill Blackcurrant (Mauritius)

This is black cherry cola. It’s quite tasty. I wasn’t sure where Mauritius is, so I looked it up. Turns out it’s an island republic located east of Madagascar in the Indian Ocean. The Prime Minister is Dr. Navinchandra Ramgoolam GCKS FRCP MP. It was the only known habit of the dodo bird, extinct since 1681. They drive on the left. Ninety percent of the arable land is grown in sugar cane. Blackcurrant is not listed as one if it’s agricultural products. Part of me wants to say that its’ not right to have a drink you can’t raise in your own country. On the other hand, we don’t grow kola nuts in America.

It is also useful to note that I am convinced that a 4 ounce serving of soda named after a fruit is equivalent to a full serving within the fruit and vegetable food group. I also believe this to be true of Starbursts, Skittles, Gummy Bears, and Jolly Ranchers.

Bibo Pine Nut (South Africa)

If we’re supposed to eat pine nuts, why have I never gotten a can of Planter’s Mixed Nuts and found a pine nut in them?

Smart Apple (China)

Compare and contrast the Chinese concept of cognitive fruit with the Mexican idea of apples as a form of manual labor. You have fifteen minutes. Begin.

Beverly (Italy)

I’m not making this name up. It is a real soda, and a horrible one at that. It tastes like someone mixed tonic water with quinine and dropped in some mustard for good measure. I wonder if it’s used less for refreshment and more as a test of manhood, kind of like shots of cheap tequila. You think you’re a man? Drink a glass of Beverly and don’t flinch.

All I can think of is that someone must have really been dumped, and dumped hard, by someone named Beverly. It has the taste of a failed relationship, one so bad that not only did she take your money and break your heart, but probably even won over the love of the dog you’ve had for seventeen years. One also wonders if there is a whole Mediterranean cottage industry in bad sodas named after ex-girlfriends.

Mezzo Mix ( Germany)

Dull, tasteless. Kind of like German comedy. Name the last good German comedian. Can’t do it? Exactly.

(I’ve heard it said that Germans might laugh if it weren’t against the rules. But I doubt it.)

Reader Contest Winner!

(A few weeks ago, I proposed a writing contest for readers of this blog. I set up a scenario as follows:

At 7 AM on a Saturday morning a physician walks into an Emergency Department. As he turns the corner to head towards his workplace, he sees a tall, sultry, dark-haired female nurse carrying a full plastic urinal in each hand and a younger, taller, and beefier male tech with his hands full of leather restraints walking side by side.

There have been several replies, but none quite like the one I’m about to publish. It’s from a reader who will intentionally remain nameless, because if I did name him I’m certain the authorities would be at his door within minutes to pick him up. In fact, I’m not so sure I wouldn’t call them myself. It’s certainly going to make me much more careful about passing out after drinking at his house.

Here you go. Stephen King, beware!)

At 7 AM on a Saturday morning a physician walks into an Emergency Department. As he turns the corner to head towards his workplace, he sees a tall, sultry, dark-haired female nurse carrying a full plastic urinal in each hand and a younger, taller, and beefier male tech with his hands full of leather restraints walking side by side. In the distance two security officers could be seen running down a corridor in pursuit of what at first glance was a patient in an open backed gown. Seconds later the fire alarm started wailing and water poured from the ceiling spouts.

The physician ran to the front desk while patients and staff flooded past fighting their way out. He shouted to the receptionist. “What the hell is going on?” He saw the fear in her eyes as she stood paralyzed unable to speak. Slowly she pointed to the other side of the waiting room. The doctor looked around and saw a large drooling wolfhound snarling in his direction. Panic filled the air as he slowly backed away towards the door of the ED. The waiting room had emptied. He slipped on the wet floor and as he scrambled to his feet, the dog grabbed him by the right leg, sinking its teeth down to the bone. Shots rang out and the dog fell to the floor. The doctor tried to stand, but his leg buckled beneath him as he dragged himself away from the dying dog.

He looked up and saw one of the Security Officers put his gun back into his holster as he walked towards him. “I thought you were a goner, Doc,” he said. The physician didn’t recognize him, and asked if he was new. “Filling in, Doc. Let me help you.”

The Officer led him to a cubicle where, to his horror, he saw a second officer holding another physician and several nurses at gunpoint. “What the…” he began to exclaim as he was helped to a stretcher where his colleagues tried to help stop the bleeding from his leg.

“Ok, who has access to the narcotics?” said the short security guy. “Tell me, or I’ll blow his head off”. The doctor realized he was the potential victim, and said, “Give then anything they want.” Suddenly the taller officer, who had been standing next to a curtain, let out a shriek and fell over with a knife handle sticking out of his back. Pandemonium broke out as nurses screamed and the shorter security guy ran from the cubicle looking for the knifer. The doctor was helped out of the cubicle and hopped into the corridor. An old homeless man wearing a ragged combat jacket was cradling the head of the large dog, and the security guy had his gun trained at him. Shouting at the man., the guard screamed, “YOU KILLED FREDDIE!”

Out of nowhere a gurney crashed into the security guard, his gun tumbling from his hand. The ED doc looked round and saw the gowned patient from earlier – a known schizophrenic – staring wide eyed at the security officer. Seconds later the SWAT team came crashing through the main door of the ED. Not knowing who was who, they ordered everyone face down on the ground and hog tied them with plastic cables. The doctor pleaded his innocence, demanding to be released. Unable to move, he remained immobilized, and lay exhausted on the floor, slowly bleeding from his leg and losing consciousness.

At 6 AM the ED physician was awaked from a deep sleep and a disturbing dream. He looked over at his partner as reached over to wake her when he saw that his hand was covered with blood………………

Friday Night Notes

A few quick thoughts from the wee small hours of Memorial Day weekend...

We’ve come up with two new lab tests for ED use:

The serum acorn level is used to assess patients who are nuts.

The serum conjugate acorn level is used to assess those who are f…..g nuts.

And two new clinical signs:

Chester’s Sign: If you’re eating a bag of Cheetos, your nausea and vomiting can’t be that bad.

The Burgos Summer Sign (named for the pediatrician who taught it to me): If a child’s headaches, stomach pains, or other vague non-diagnosable symptoms improve during the summer, they hate going to school.

Please send royalties. Thank you.

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Last night we had a quiet moment at work. Silence in the ED is scary thing, because we’re not accustomed to it. So when it gets that way we literally band together, if only to hear the shuffling of feet. Of course, we don’t talk about it, because if we do everything will go downhill immediately.

So during our quiet moment last night, we were introduced to a medical song on You Tube by The Giggles entitled “I’ve Got the Clap.” The lyrics go something like this:

“I’ve got the clap and I’m giving it to you.
I’ve got the clap and I’m giving it to you.
I’ve got the clap and I’m giving it to you.
Who’s got the clap? I do ! I do!"

(Back in the day, we could establish this diagnosis without a word. We would walk out of a patient room, the nurse would ask what was wrong, and we would start to applaud. The nurse would then fetch the penicillin.)

It’s a very cheery tune, and before long Holly the Disco RN and I were clapping to the left and then to the right in time with the song. But sometimes we forget that there’s a clear generation gap, even in medicine. So we probably shouldn’t have been surprised when one of our younger staff members asked, “So what’s that song about? Is it that thing that helps you turn on the lights?”

Ah, for simpler times.

Things I Don't Know

About once a year I do something silly and buy a book on mathematics or physics. This act represents the height of stupid behavior on my part, because I know absolutely nothing about math, which is itself the language of physics. Math was the subject where I got I got C’s and D’s in high school, and I made it through medical school only because our program was top-heavy on biological sciences and didn’t require any college algebra or physics. The last time a math textbook passed through my hands (and generally stayed unopened) was in the 11th grade, when I was compelled to take trigonometry and analytical geometry. I’m convinced I got through that course only because 1) The teacher was also the football coach and the class was geared to the “student-athlete” 2) Pocket calculators had already been invented that did things like sines, cosines, tangents, and logrithims, eliminating the need to understand what they actually were or how to find them, and 3) There was a really big guy...an offensive lineman, as I recall…in the class. He was the only other guy in school named Howard, and his pure size and presumed power insured that nobody in class would distract my learning with appellations of affection such as “Howard the Duck.” (I have no idea whatever happened to him. I’d like to think he because some kind of professional hitman. He’s probably turned out to be a new age sensitivity counselor somewhere in California. Illusions die hard.)

But I keep thinking that a well-rounded person should know something about physics and math, so I keep buying these books. Three days ago I bought “The Physics of Star Trek” by Lawrence Krauss. I did so against my better judgment, but figured as a confirmed TOS fanatic (If you don’t know what I mean, you’re not one), I figured maybe at least I’d have a frame of reference to work with. And I understood Chapter 1, dealing the need for inertial dampers to counteract g-forces. But calculating fuel requirements for the impulse drive? That’s physics and math at the same time. I’m lost. And by the time I hit Chapter 4 dealing with microgravitational fields that warp space-time and allow interstellar travel, it was time to move on to a rerun of Jerry Springer.

For the record, here’s what I actually know about physics:

1) Newton came up with three laws. They are:

Lex I: Corpus omne perseverare in statu suo quiescendi vel movendi uniformiter in directum, nisi quatenus a viribus impressis cogitur statum illum mutare.

Lex II: Mutationem motus proportionalem esse vi motrici impressae, et fieri secundum lineam rectam qua vis illa imprimitur.

Lex III: Actioni contrariam semper et æqualem esse reactionem: sive corporum duorum actiones in se mutuo semper esse æquales et in partes contrarias dirigi.

Isn’t that helpful?

2) No, seriously, these are his three laws:

An object at rest will remain at rest unless acted on by an unbalanced force. An object in motion continues in motion with the same speed unless acted upon by an unbalanced force.

This law explains why after I sit down in my fancy comfy rolling chair at work, I have no desire to leave it for actual patient care. It also explains why, once I kick start the chair, it would roll forever if not slowed by unbalanced forces such as sticky soda residue on the floor and solid objects like walls when I hit them. It further explains everything about government and other avenues of administrative merriment.

Acceleration is produced when a force acts on a mass. The greater the mass of the object being accelerated, the greater the amount of force needed to accelerate the object.

This means that I will go faster down the hallway if Big Teddy and Matt the Brute pushes my roller chair than if Candi the Elfin Nurse does so. It also means that no matter who pushes it, the chair will go faster with me in it than it will with my personal hero, Dr. Gary Morrison, seated within it’s embrace. This is because his fund of knowledge is vast that it adds extra mass to his brain. As do brownies.

For every action there is an equal and opposite reaction.

This is why both Big Teddy and Elfin Candi will recoil just a bit on their heels when they push my chair across the floor. It’s also the rule underlying any intimate relationship. (Okay, maybe take away the “equal” part.)

3) There is something called Bernoulli’s Principal that allows airplanes to fly. It works but it makes no sense. I try not to think about it too much when I’m a heavy pressurized steel canister at 40,000 feet held up by air.

4) In high school physics class you got to shoot dart guns at tin cans and roll Hot Wheels cars down planks. That was fun.

5) I really like the “Gravity” episode of Schoolhouse Rock.

I know a bit more about math, but not much. That was brought home to me when I was first dating The Bride. In a moment of random affection, trying to be romantic and intellectual at the same time (I had already discovered that she was waaaay smarter than me), I said “I love you the square root of negative one.”

“Huh?”

“You know, the square root of negative one. A number that’s impossible to quantify. That’s how much I love you.”

She gave me that quizzical look she reserves for times when I’ve said something exceptionally stupid (as opposed to my routine ignorance)or when Duchess the Wonder Dog has decided that the greatest thing in the world is to chew up the pillows on the couch and can’t even being to fathom why you don’t share in the experience. (Which reminds me that I was the one who kept a straight face during the classic Who Can Eat a Doggie Liver Snack Contest of 2007. But I digress.)

“No you don’t,” she said.

I should have seen trouble coming, but the relationship was still new.

“Of course I do. I care for you so much I can’t begin to tell you how much.”

She shook her head. “No, you don’t.”

This was getting difficult. I’ve been in the scenario where one person says that they’re in love and the other person is not. Awkward, but workable. This one was new. I thought I loved her, but she was telling me that I didn’t. No instruction book for that one.

“No, you don’t,” she persisted. “The square root of negative one doesn’t exist. Therefore, your love doesn’t exist. You’re telling me that I mean nothing to you and I’m hurt.”

Have I mentioned that before she discovered the glories of musical theater, The Bride was going to be a math major?

“Can I love you infinity?”

“That would be acceptable.”

So the objective lesson for today is to not buy me any books about math or physics for my birthday, because I’ll never read them. And always learn about your girlfriend’s original college major before declaring your affections. It’ll save time.

Baby Tale

I recently learned of the retirement of Barbara Hunt. Barbara was a nurse I first worked with at Shands Hospital in Gainesville back in the waning years of the last millennia. Barb had been an ED nurse for over thirty years, which is amazing when you consider that, like most women, she is only 29. She was nursing even before she was gleam in her father eyes. Barb and I worked a lot of night shifts together. She was the Charge Nurse, I was the attending physician, and the chain of command reflected exactly the order indicated by the sentence. There are a lot of stories we shared, most of which have been forgotten in the wake of the daily battles, but one story stands out over fifteen years later.

It was about 2 AM when a woman in labor was brought to the door. Contrary to popular belief, delivering babies is not something we do in the ED. We do not seek out the opportunity to usher new life into this world, or to have an infant named after any of us. If you’re in labor, our goal is to get you to the delivery suite as soon as possible, because a delivery is the ED is either something that happens all by itself or is an absolute disaster, and there is nothing in between. It’s one of the few times in the ED that we actually run. (I reviewed this paragraph for accuracy with Matt Forester, one of our ED techs, who scoffed at me. He noted, “Hey when you’re a tech you run all the time. It’s just you lazy ass doctors who don’t. You just roll around in your office chairs.”) Unlike Prissy, while we do know something about birthing babes, it’s nothing we’re particularly interested in doing.

But there are exceptions, and one of them is if there is obvious crowning. Crowning occurs when the top of the scalp can be seen in the perineum (lay term: “Down there.”) Most of the time, in the name of patient decency, we don’t really check this in the waiting room. We don’t have to. We know a baby is crowning when the mother yells “IT’S COMING!” in a particularly shrill tone that is only heard during childbirth and never reproduced in any other exclamatory setting.

(There are two other noises we use as clinical clues during labor. These are known as “tachylordy” and “bradylordy,” from the Latin root words for “fast” and “slow.” Tachylordy is seen in the early stages of labor, when the woman will wail “LORDYLORDYLORDYLORDY!” in a quick, statacco, high-pitched voice. More ominous for imminent delivery is bradylordy. When you hear a deep, long, guttural. “LORRRRDY. LORRRRDY,” there’s a kid on the way.)

So when this woman made the noise, we knew we were going to have baby. Well, maybe not us directly, but we were at least going to be put in the position of standing about gawking as nature took it’s course. While I am not an obstetrician, one of the things I do remember from medical school is that primates have been having babies for millions of years, and in general they’re pretty good at doing so no matter if there’s a physician around or not. (They seem to be even better at the process of conception, but that’s another story). So after a hurried conversation between Barbara and myself as the ED techs struggled to get her on a bed, we determined that our best strategy was to stand by and provide reassurance and say soothing things like, “It’ll be okay,” and “It’ll be over soon,” and “Steve Spurrier will be back next season, you’ll see.” (It was Gainesville, after all.) While we did this, another nurse went running for an instrument pack, just in case we had to do anything. To be honest, Barbara did most of the reassurance. My job was to stand up straight, look concerned, and quietly try to figure out how to avoid doing anything more.

Working with remarkable speed (for they didn’t want to be part of this any more than I did), the techs got her on the bed, and got her clothing off. (We said a little prayer of thanks for stretch pants.) Unfortunately, the brakes on the bed were locked and we couldn’t get them to loosen up. So we shovel her onto the bed, one side of her plastered against the wall which she was now beating with her fists while calling out the name of an unidentified male in an “aggressive” fashion, all of us standing on the other side in no position to do anything useful at all. (As embarrassing as it is to say, there’s no way to do any effective work in the pelvic region from the side. No snickering, please. Thank you.)

After twenty years on the job, there are very few sphincter tone moments in the ED. (Sphincters are circular muscles that control flow through the gastrointestinal tract. There’s one between the esophagus and stomach, one between the stomach and small intestine, and one between the rectum and the outside world. It’s this latter one that concerns us here.) When they do occur, it’s usually not when people think it might be. Running a cardiac arrest or major trauma is simple, and there’s really not a lot of risk to it. The patient’s in bad shape, and in general all you can do is improve the situation. It’s not like you can make someone who’s dead a lot deader. Everyone’s list is different, but here’s part of mine:

The moment you’re waiting to see if fluid comes out of the needle you just placed in someone’s spinal canal.

The moment you defibrillate someone who had a pulse, but needed electricity, waiting to see if the pulse comes back.

The feel of the needle bumping down the collarbone as you try to start an IV in a vein you can’t see. (Tone doubles if the patient has a blood clotting problem to start.)

Being told that a patient who came into the ED walking and talking isn’t doing so anymore. (This is ALWAYS bad.)

A colleague or risk manager calling to say, “Remember that patient you saw last night?”

Needing to catch a baby.

Needing to catch a baby.

Needing to catch a baby.

So there I am, peering over he left knee, looking at the top of an infant head. She’s pushing hard. Really hard. The head’s not moving. All sphincters hit overdrive.

The equipment pack has arrived, and I’m looking through the contents. I already know what’s in there. Looking to check my equipment is a stall tactic. I know that if the baby doesn’t come, I’m going to have to do something called an episiotomy, which is where a small slit is made in the lower portion of the birth canal to give the baby’s head more room to move. I did exactly two in medical school. I managed to avoid doing deliveries during my ob/gyn rotation during residency by volunteering to see all the gynecology consults down in the ED while those folks who actually wanted to do this for a living happily took all my experience. So while I know technically what I’m supposed to do, I am absolutely terrified of having to do it.

She’s pushing to no avail. I’ve got to do something. So I fondle the instruments absent-mindedly while Barb gets out some sterile towels and places a bedpan between the patient’s knees. We’ll reposition this under her hips at the time of delivery under to catch any fluids (There will be fluids. Delivery is not pretty).

It’s been a few minutes. It’s time. I start to pick up a syringe full of local anesthetic which I’ll inject into the area to be cut.

I don’t know what it is about the ED, but sometimes just the threat of care makes things better. It can’t tell you how many times people have come in with severe problems that resolve the moment they hit the door of the ED, or the number of parents who swear their child had a fever of 136 degrees but now are doing just fine under the glow of the hospital lights. And I think what happened here is that she saw the syringe and the needle, gave one last push, thrusting her hips in the air as she exhorted her infant to join the world in (once again) “aggressive” language. And as she did, we saw an infant sail out of her pelvis, shoot two feet up in the air in a parabola that would make a mathematician proud, and land with a resounding THUNK in the bedpan. It was a three point shot from behind the arc at the buzzer, and there was nobody happier than me as I suctioned the baby, got it breathing, cut the cord, and wrapped him up in warm blankets. Crisis over, mother and child were whisked to labor and delivery for further care and clean-up. Rumor has it the child was named after the unidentified male without an aggressive prefix.

“You were going to cut her, weren’t you?” I remember Barbara asking me later that night.

Truth be told, I have no idea what I would have done. Would I have kept stalling? Would I have been brave? Fifteen years later I still don’t know. But I’m certain that given the same situation, my sphincter would react exactly the same way.

 

Internet Doctorin'

I used to think it was hard to get into medical school. I’ll never know if it really is, because I got in as an accident of fate. (More on that another day…if I’m going to be blogging every day, I can’t blow all my stories at once. Got to have a few for backup on those days when writing takes a back seat to…well, almost anything.) But I bring this up because it turns out that it’s a lot easier to get into medical school now than it ever was before. It’s not the need to turn out more primary care physicians that have led academia to swing open their gates, nor a sudden demand on the part of college students to enter a career where you can work harder and make less money than ever before while always at risk of being sued. (Who wouldn’t find that attractive?) It’s because the internet now allows everyone to go to medical school. Armed with a fresh diploma from the Wikipedia College of Doctorin’, patients are now just as qualified as physicians to tell us what’s wrong with them, what tests we need to get, and how they should be treated.

Let me say up front that I really have no problem with informed patients. They actually make life easier, especially when they understand their own disease process and recognize what we can and can’t do for them. They make better decisions regarding their care, and it’s truly more fun to work with a partner in the process. But I’ve come to believe that the internet is often a rotten source of health care information because it’s voluminous, unfiltered, and unchecked.

I’ll give you an example of what I mean from within the House of Medicine itself. Many hospitals have protocols that require nursing staff to contact the Regional Poison Control Center to notify them of any overdose patients you’ve received. There are a couple of reasons for doing so. One is medicolegal, to say that we called if something goes wrong. The second (and I suspect most valid) reason is that the more calls the Poison Control Center receives, the more they can justify their continued funding. Enhancing clinical care is not really one of the reasons to call, because what most often happens is you get a nurse or a trained technician who simply reads off or faxes you a list of every single adverse effect that has ever been reported to occur with that drug, in no particular order, and suggests a plan of care that is often impractical at best. You get too much unsorted information that may or may not actually be relevant to the case at hand.

So here’s what really happens with most overdoses. It’s surprisingly easy, and surprisingly generic. You support the patient’s vital signs by managing their respirations and blood pressure. If they have ingested any one of the handful of medications that has a specific antidote (there are less than ten you actually use) and their condition is life-threatening, you give it. You have them drink a solution of activated charcoal to bind up any spare medications floating around the gastrointestinal tract. And then you wait four to six hours, until the peak effect of the medication has likely passed by, and if they’re doing fine you send them wherever they need to go. If not, they’re admitted. Pretty easy, which is why I never really mind taking care of them. It’s a lot more straightforward than people who claim to be “weak and dizzy” (the two words we hate more than anything in the ED, even more than the phrase “accreditation site visit”). Plus, there’s usually a pretty good story that goes along with that, and if Lady Luck is on your side you can keep a bed occupied for up to eight hours by the time the psychiatric staff gets a chance to look at the patient, insuring that you won’t have to see an extra patient any time soon.

Looking for health care information on the internet is like getting it from Poison Control. There are huge volumes of information, all of it unfiltered and unweighted, and most of it without oversight. (This is why I have less of a problem with pharmaceutical ads on television than I do the internet. At least the FDA tries to regulate the content of the former, while anyone can say anything in cyberspace.) And if you look at the distribution of the information out there, it’s slanted away from science-based knowledge and much more towards hype.

Let me give you two examples of what I mean. The first is from an article entitled “UK Bans Doctor Who Linked Autism to MMR Vaccine” by Marrecca Fiore (AOL Health, May 24, 2010). It concerns Dr. Richard Wakefield, an English physician who described an association between vaccines and autism, and whose work has now been considered as invalid and unethical. (I’ve addressed this issue in a previous blog; in brief, I don’t think a firm link between the two has been established, and the risks to the population as a whole of withholding vaccination clearly outweighs any unproven ideas.) As you’d surmise from the title of the article, Dr. Wakefield has now lost his medical license in his home country. But to read the article, there are 7 paragraphs of quotes from Wakefield and his supporters, and one from an actual scientist. There is also a video clip of Dr. Wakefield defending himself, but none of anyone representing the scientific community. The comments that follow the article are bitter, vituperative, and focused on destroying vaccination programming; woe to the one or two brave souls who comment that Dr. Wakefield is in the wrong (as he clearly is…yep, I’m taking sides.) This is supposedly an impartial “news” source. So what’s the message here?

It’s even worse if you do an internet search. There is an alleged condition called Morgellon’s Disease, in which people claim to have crawling and burning sensations in the skin, persistent sores that don’t heal, and small fibers emerging from some of these lesions. I say ‘alleged” condition because nobody’s sure if it exists. Promoted by media coverage, the CDC is investigating the problem, but most dermatologists think this “disease” is really a type of delusional parasitosis (a mistaken thought that there are parasites within the skin). But if you look at the web, there is no question that this is a horrible, debilitating, epidemic disease. Of the first ten hits that came up when I did a web search, one was a Wikipedia article (which was actually reasonable) and one was a microbiology site. The other eight were all sites convinced that the syndrome exits, with quotations such as:

“Morgellons is an unexplained and debilitating condition that has emerged as a public health concern…”

“Morgellons Syndrome. A Horrifying and Fascinating Skin Disease is affecting thousands of people in the Bay Area, along the Gulf Coast, Florida…”

“Morgellons disease, or Morgellons syndrome, is a new and frightening disease that is yet to be recognised by medical science…”

“For years, doctors denied the suffering of skin parasite victims. The days of Morgellon's Syndrome denial are over. Join us and learn more.”

There’s no reason to assume the other web pages (there are 86,900 results) are any different. So what’s a patient to believe, and how does a doctor explain, let alone fight, that number?

When patients bring up information they’ve read on the internet, I can sometimes defuse the issue. I can explain that while it’s good to use the internet as a resource, you’ve got to keep in mind that it doesn’t reflect the real world or their case in particular. I’m often able to correlate their information with my clinical findings, and to direct them to more appropriate websites. But still, it’s a conversation I wish I didn’t need to have. And it’s very frustrating when the patient says, as they often do, “The website told me you would say that. You doctors are all alike. It’s because you get paid off to say stuff like that.”

Where do you go from there? You want to ask the patient if they knew they were going to get an answer that they didn’t want, why were they here in the first place?

Is it because they couldn’t find a licensed practitioner from the Wikipedia College of Doctorin’?