"Fire Phasers, Mr. Grant!"

We've all had the problem of songs getting stuck in our head.  I've noticed, however, that the problem seems to be more acute as I get older, and I think this is because as my short-term memory fades, I can no longer recall any recent tunes that involve anacondas and buns and the like, leaving large gaps in the mental day needing to be filled with retained television theme songs from the 1970's, mostly from The Love Boat, which echoes through my head constantly anytime I'm on a cruise ship, much to the total chagrin of The Teen, who, whenever he sees a cute girl on the ship and his father notices his interest, is likely to have that same father spontaneously break out in a chorus of "Love!  Exciting and New! Come Aboard!  We're Expecting You!" in off-key but most enthusiastic baritone which will hammer at his adolescent brain until he's run down the nearest staircase and the sound cannot penetrate the deck plates. Which is why, as The Teen and I ventured to the frozen North this past week to partake of the opening weekend of the Minneapolis-St Paul International Film Festival, all I've heard since I got off the airplane were the musical questions of Who Can Turn the World On With Her Smile and (you're way ahead of me) if She's Gonna Make It and, because I am a hormonally addled male nearing the end of my days of non-chemical enhanced potency, with whom, and how often.

(For the record, Minneapolis and cruise ships are not the only places this happens to me.  My brother lives in Cincinnati, and I cannot see his phone number pop up on my cell without asking myself if anyone wonders whatever became of me.  Similarly, when Ii was in Seattle a few years back, I spent half the time trying to match up the gray urban landscape and overcast sky with Bobby Sherman's descriptions.  I also spent a considerable amount of effort trying to find the iCarly building, but that's a different story.

I've not known much about Minneapolis.  There's the Mary Tyler Moore show, of course.  There's the Minnesota Vikings, the Minnesota Twins, and the late lamented Most Appropriate Hockey Team Name Ever, the Minnesota North Stars.  I know Bronko Nagurski was a Golden Gopher.  And snow.  Lots of snow.  So it was admittedly with a somewhat narrowed point of view that I arrived in the Eng Bunker of the Twin Cities and headed directly to The Mall of America.

At first glance, The Mall is breathtaking in its vastness.  (It's the only mall I've ever seen that has its own train station and attached $250/night hotel.)  I'm sure most people have heard something of it.  There is an indoor amusement park complete with roller coasters, a ferris wheel, and a log flume.  There are movie theaters, a bowling alley, a miniature golf course, and more shops and kiosks than you can count.

But once you get past that first impression of sheer size and scope, it dawns on you that it's still a mall.  Writ large, of course, and all contained within a nondescript concrete bunker to keep you warm while you do your destination shopping in the depths of December, but still pretty much just a mall with stores you can find anywhere else (although it is interesting to note that because the place is so large, there are sometimes two versions of the same store located at opposite ends or on different floors).

Remember Mary's tune that kept going through my head?  It didn't stop at The Mall. So as I'm looking through the Minnesota souvenir stores (of which, including local crafts, sports, and college memorabilia, I recall at least nine) and I'm finding myself strangely drawn to Goldy the Gopher, who seems so much more cute and cuddly and, well, mascoty, in comparison with the Chickenbird who lives thirty miles east of my house, the Kittycat who lives 45 miles to the west, and the Angry Dancing Wheat two hours to the south, but I am finding no Mary Tyler Moore show trinkets at all. I would have bought a light blue WJM blazer and done homemade podcasts with the news, I really would have.  But alas, I'm too old for consumer culture, and instead the stores are full of natural goods and healthful candies and homespun clothing and things featuring moose instead of aerodynamic tam-o-shanters or the Sue Ann Niven cookbook or t-shirts that proclaim "I HATE SPUNK!  Guess all I can do is grow with the times.  Which is why I now own a necktie shaped like a walleye.

There was one place in The Mall where the MTM theme was replaced by another, and that was at Star Trek: The Exhibition. Several years ago I had seen a Star Trek installation in Las Vegas, and was quite impressed.  I arrived at The Mall too late to go into the exhibit that night, but was able to visit the gift kiosk which, in contrast to the embarrassment of Trek riches I had seen in Vegas, was comprised of not much more than a few shelves of plastic phasers and communicators, one each of a Lt. Uhura and and a Lt. Sulu commemorative plate, and some of the requisite yellow, blue and red tee-shirts.   I did break down and buy a set of Star Trek cocktail glasses and a red leather wallet that, when you open it, has the words, "He's dead, Jim" embossed on the pocket (I'll explain it to you later.)  However, I was not willing to part with nearly seventy dollars for a cheap imitation of a medical tricorder that purported to say multiple phrases but only spouted (you guessed it) "He's dead, Jim."  It might have been fun to take to work if it said a few other things, but I've found that people who are not dead generally don't like to be scanned and told they are, and those who are dead already know it and scanning them is really redundant.

As I said, it was a pretty skimpy gift shop, and I was concerned that the exhibition itself would follow suit.  But ever the optimist, I bought my ticket anyway.  And not only was I was surprised at how much fun I had, I was even happier that The Teen, who knows William Shatner more from a bad rendition of Bohemian Rhapsody than as James T Kirk (or TJ Hooker, or Denny Crane...but trust me, he's being educated) had a blast.

At this point, I need to issue a disclaimer and note that if you're not into the World of Star Trek
or, even worse, one of those people who prefers a universe peopled with fictional furballs like Ewoks and Wookies, and whatever the hell Jar-Jar Binks is, rather than the ABSOLUTELY REAL Hortas, Talosians, and Gorns, you are going to be bored silly and wonder if your $16.95 entrance fee could have been better spent on...well, anything.

But if you are of that world, it's a 90 minute slice of heaven.  It starts out with a timeline of space travel, starting with Robert Goddard and moving through Zefram Cochrane, The Treaty of Khitomer, Voyager, and Deep Space 9.  There is an original Captain's Chair from the Enterprise-D and, more interestingly, one from the Enterprise-B, captained by Ferris Bueller's friend Cameron (don't make me explain this).  There are original costumes (was Shatner ever really that short and thin?), and an occasional set dressing where I found myself involuntarily bent over a recreation of the Engineering console on the Enterprise-D, trying desperately to bring the warp drive back online...even though I'd much rather be working alongside my childhood favorite Montgomery Scott ("Ye canna change the laws of physics!") rather than the pansy, goody two-shoes Geordi LeForge. (But at least we have Reading Rainbow.)  There are models and props that close-up you can tell are nothing but poorly painted pieces of wood and styrofoam, but at which you marvel nonetheless.  And all of this is going on while the theme songs from the five Trek series are being boomed into your head.  I'm in my element, and Mary is finally gone, replaced by the knowledge that it's been a long time getting from there to here.

For me, the piece de resistance of the entire exhibit was a recreation of the bridge of THE Enterprise.  (As Mr. Scott would say in a drunken TNG rant, "Show me the bridge of the Enterprise. NCC-1701.  No bloody A, B, C, or D.")  At heart I'm an Original Series guy, meaning that I believe that sometimes you can't talk it out and you just have to blast someone out of the sky.  So as I walked onto the bridge and stood by the rail, it like where I needed to be.  Sure, there was the Captain's chair, but it didn't feel comfortable.  You can't command while seated.  

There are some who believe that we all have past lives, and that if you look hard enough you can find out who you were from who you are.  Does it mean something that I've always read volumes about naval warfare and The Great Captains?  Does it mean anything that I'm a pretty good leader but a not-so-hot follower?  Could I be the last verse of the song "Highwayman?"  It's been a long road, indeed.

But wait, my reverie is interrupted; here's an exhibit staffer to take my picture.  And now someone else...some...well, tourist geek...wants to sit on the chair.  On MY bridge.  And as my reality comes crashing down, all I can do is take refuge in knowing that there's a candy store three flights down and to the right that makes caramel apples and an Orange Julius stand which
does, in fact ease the pain.

After the Mall we headed downtown to the film festival.  (The Teen, who is currently asleep as I write this pending his forty minute Voyage of Discovery each morning that we call Taking a Shower, has already posted his first movie review at thecriticalfrog.blogspot.com. Many more to come.)  Only been here overlooking the Mississippi for a few short hours but already like the place.  Woke up early and walked from the hotel, a brisk trot under gray skies to the one landmark I know of, which is the bronze statue of Mary Tyler Moore throwing her hat into the air at the corner of 7th street and Nicollet Mall. Took selfies.  Song is back.  She's gonna make it after all.  Me?  Somedays I'm not so sure, but I'll get a beret just in case. 

First glance means something to me, and I'm pretty sure I'm going to like Minnesota a lot. Incredibly nice people, the bird-like sing-song accent (don' 'cha know), delightfully unexpected multicultural diversity.  Even in politics, they either elect people who believe in doing genuine good and exhibiting common sense like Hubert Humphrey, Paul Wellstone, and Tim Pawlenty, and when they don't they at least recognize the process for what it is and elect buffoons (Jesse Ventura) or comedians (Al Franken).  There are moose, fish, Vikings, Timberwolves, Ole and Lena, and above all Goldy.  It strikes me as a place relatively free of pretense, where no matter how much money one has you still need to heat your garage and shovel your way out of the driveway in the dead of winter, and where politeness reigns because it takes up too much body heat to be angry.  

(Did I mention that as I sit at breakfast writing these notes at the Renaissance Hotel at the Depot in downtown Minneapolis, a place where the server remembers my choice of tea from the previous day and that knows how to DO BACON RIGHT, it's April and it's snowing?  When it's fifteen degrees higher and sunny even in my own stark Kansas?  Which probably answers the question about how this place became such a large metropolis.  You clearly have to huddle together for warmth. You get the sense that here global warming is not debated, but welcomed.)

I understand there's a lot more to explore in the Twin Cities, and I certainly intend to come back.  But not this time of year.  Perhaps the third week in July.  I understand that's when summer has been scheduled for 2016.

Family Affair

A brief note from The You Can't Make This Stuff Up Department:


In one room at the far end of the ER is a woman in her middle 30's complaining of abdominal pain.  At least that’s what she told the nurse, because her actual issue, once you get past the sunglasses with the four inch lenses that make her look like a Dollar Tree version of The Fly, is that she wants her IUD removed.  She needs it out today because her Legal Guardian, who has Power of Attorney for the patient because she is apparently "disabled" and getting Social Security, and who has (for the benefit of society as a whole) said the birth control device should most definitively stay in place, is out of town and this is the patient’s chance to "escape" and get it removed.  


With her is a considerably older man who looks "well-seasoned,” to put it politely, and who appears exceptionally eager have this offense against nature removed so he can promote his lineage within her longing womb.  The drive to spawn is overwhelming, like that of a doomed salmon fighting to get upstream, so of course an ambulance was required to get her to the ED in record time.  In Star Trek terms (and are there any other worthwhile terms?  I think not), it’s the Ponn Fa'ar.  It's Amok Time.  


When informed that I do not remove IUD’s as part of my practice, and even if I did I cannot remove her IUD against the wishes of her Legal Guardian, she says she is going to sue me, sue her Guardian, and head across the parking lot to our sister hospital in town (whose name she prefaces with a word that rhymes with “clucking”) where they will most assuredly do what she wants.  She also drives us into heartfelt introspection of our behaviors us by saying she will never come to our hospital again, in what may be thought of as a successful long-term resolution to our problem.  


Down the hall is another woman of similar age and weathering who is short of breath.  She started gasping for air as she was running down the street to the hospital to be with her sister, who has abdominal pain and came by ambulance.  She is accompanied by a teenage male who somehow is able to answer questions about her last menstrual period.  


As I’m chatting with her, the older man from the first room walks in.  My new patient identifies him as her father.  Seeing my face as I assemble the pieces in my head, she quickly backtracks to note they’re all just “really close friends."  


I’ll bet.  


Where’s the Jerry Springer Show referral line when you need it?  


(Afterthought:  This whole episode reminded me of something we need to add to our Electronic Order Entry System.  When you order an x-ray on a female patient of a certain age, you are always asked if the patient is pregnant or not.  Given our clientele, there really should be another option.  It would read something along the lines of, “Please, Lord, No!”)

Poisons and Productivity

The pharmacist in the ED sets a packet of paper in front of me, proclaiming with more than a hint of irony that this is from the Poison Control Center.  She says it like this because as far as he can tell, the Poison Control Center does very little besides telling people to go to the ER and sending faxes, and has nothing at all to do with the real work of patient care.  The Poison Control Center used to be a thing, though...tucked way deep in the bowels of most children's hospitals, they maintained a mythic quality as the repository of all toxic expertise which they would deign to share with the poor mortals when asked on bended knee.  However, as more ER residents rotated through these hospitals, we saw the Poison Control Center for what it was, a technician in a windowless basement room playing solitaire waiting for someone…anyone…to call so they could read to them off a microfiche (yep, I'm that old) whatever the latest case report was from the Lesser Mongolian Journal of Yak Toxicity.  Eventually, the docs figured that we can read a microfiche, too; and as time elapsed we could do one better and look up things on the internet.  Plus clinical overdose management has progressed remarkably, and in many ways has retreated from some of our more aggressive care of days gone by.  No more pumping stomachs, no more ipecac-barfing, no more drinking the charcoal and pooping out briquets.  (Pro tip:  They still need lighter fluid, but watch out for the pockets of methane. They explode.)  I actually miss those days; as a true believer in the occasional benefits of punitive therapy, I thought it sometimes did a word of good for those people who were using pretend overdoses to manipulate others to go through a little discomfort themselves, perhaps as a reminder that actions have consequences.

Aside from a few specific antidotes, overdose management is essentially protecting airways, stabilizing vital signs, and managing complications, exactly like it is in any other patient.  It's all pretty basic stuff.  So now all the Poison Control center has to do is tell people to go the ER and fax things telling us that Yak spit is highly toxic to...well, nobody, but that there was a case report of a Westerner who got bit by a Yak in 1974 and was so afflicted he abandoned his wife and family and lived in a yurt for three years before resuming his role as the second-best insurance agent in Chillicothe, Missouri.  So we should probably admit the patient for observation just in case this occurs.  

 

*************************

 

One of the trends in emergency medicine is to reimburse physicians based on RVU's.  An RVU is a relative value unit, and it was created to quantify the relative work load, experience, knowledge and time commitment related to a particular medical procedure or patient encounter. The idea is that the harder you work, the more patients you see and the more RVU's you generate.  It's a variation of fee for service that basically means you eat what you kill.  And it's a radical departure from traditional emergency medicine pay which is based on a hourly rate.  

While I understand the desire to drive productivity through incentivizing physicians, I'm not sure that the RVU system is right for emergency medicine.  The RVU system works best when a physician has control over his patient population and daily workload.  In that event, you can choose to work harder, faster, and drive up more RVU's. The ER doctor, however, cannot control his patient load.  People either show up at the door or they don't, and you can't control for the complexity of the patients.  There is every chance for a doctor gets penalized because it's a slow shift or because critical patients or social catastrophes (and there's a lot of those) decrease your overall productivity.  But I also think the RVU system can act as perverse incentive.  On one hand, it encourages slipshod medicine, as the goal is to generate more RVU's by running patients through the system as fast as you can. Things can get missed, patient education can be compromised, and patient satisfaction falls as they feel "rushed" through the system.  On the other, it drives up costs, as one of the ways to escalate the RVU's without taking more time with the patient is to order lots of x-rays, lab studies, and consultations, sometimes by protocol even before a provider actually sees the patient.  

Those proponents of the RVU system might point out that a strict hourly salary promotes lethargy.  Why should someone work hard, or harder, if they're getting paid the same amount no matter how much effort they expend?  The answer to that, I think, is something as simple as professional pride.  Nobody wants to be known as the slowest doc in the group, and even less as an outlier even if your pace is off.  It irritates your colleagues who, at the change of shift, walk into a full waiting room and an ER full of half-done checkouts even on good days.  And if the behavior persists, eventually the group finds its’ way without you.  

I should also confess that there is a "sore loser" component to my complaints.  Reimbursement rates for RVU's were determined the same way all reimbursement rates were calculated; through prolonged lobbying, begging, and cajoling.  When the system came out, the clear winners were the more procedure-based specialties.  Which is why, with the same four years of training, an eye doctor can charge a small fortune for spending twenty minutes removing a cataract, while I get a fraction of the dollars for spending an hour with a critical patient saving their brain, heart, lungs, and everything else that makes that eyeball possible.  Not that I dwell on it, at least not too much.  My comfort is that primary care specialists (family physicians, pediatricians) have it a lot worse.  

(This reminds me of an entire sequence of jokes about doctors and money, courtesy of Drs. Kevin Dishman and Frisco Morse:  

How do you hide a dollar from an internist?  

Hide it under a wound dressing.

How do you hide a dollar from a surgeon?  

Tape it to the EKG.

How do you hide a dollar from an orthopedic surgeon?  

Tape it to the chart.

How do you hide a hundred dollar bill from a pediatrician?

It doesn't matter.  They've never seen one.  

Okay.  maybe you had to be there.)

 

********************

 

I had just gotten back from a meeting talking about RVU's when the Poison Control paperwork landed on my desk.  The patient had ingested something called Krud Kleener, which turned out to be a weak alkali, kind of like bleach.  Nobody dies from bleach.  (I've heard rumors, though, that everyone who drinks bleach gets whiter and starts to channel Neil Diamond.  I am, I said, to that damn chair.)  

Now, if I had been an RVU guy, I would have gotten a bunch of labs.  I might have given a dose of charcoal as well.  Maybe the stuff could have eaten though the esophagus or stomach and caused a perforation. I can look for that with an x-ray, or maybe even a CT scan. I could toss an EKG into the mix as well.  The fact that none of this would have been supportable by the medical literature is besides the point. Given a small amount of medical knowledge and a smattering of latin terminology, the enterprising clinician can justify anything. 

But I don't do that.  I don't do it because of any particular drive towards cost-efficiency or the practice of evidence-based medicine. I don’t because I'm lazy, because I know that nothing I could do is going to make any clinical difference, so why bother.  I also don't do it because I know there's got to be a good story here, because the patient drank from a bottle (brought to the ER)  most clearly labeled KRUD KLEENER, and I'm the kind of guy who's willing to kill his productivity to hear the tale.  

It turns out that unbeknownst to me, locked inside my HVAC-sealed workplace cocoon, it had been a hot day outside in the real world.  The kind that makes people who are standing outside watching a yard crew cut weeds want to drink something.  Anything, in fact, that looks like water, even if it says Krud Kleener on the bottle set aside in the corner of the garden trailer, because she was pretty sure that the crew had put extra water in there because, as you know, it was a hot day.  

At this point, I've already lost some RVU's by taking the time to hear the story.  So why not go ahead and cut my productivity to the bone with a little non-reimbursable patient education?  A little Socratic method, please.  

"I think you'll be just fine.  But what have we learned?"

"Well, it's not really that guy's fault for me thinking it was water."  

A patient pedagogical moment. "No, let's try that again.  What have we learned?"  

"That I should have stopped after the first mouthful tasted bad?"  

"True, but what have we learned today that will keep us out of trouble tomorrow? What should we do if it says KRUD KLEENER on the label?" 

There's a look of puzzlement, and then enlightenment breaks out on her face like the sun after a summer afternoon storm.  

"I don't drink it!"  

Another successful patient encounter, another crisis averted.  But done way too cheaply. No RVU's for me.  Should have ordered a CT scan.

 

 

 

A Big Deal

Several years ago The Dental Amazon Empress took me to the Annual Meeting of the American Dental Association.  I must confess that despite over thirty years of medical school, residency, and clinical practice, I truly have no idea what dentists actually do. It certainly hasn't helped my knowledge base that I'm also terrified of dentists, so there was no way someone like me was ever going to become fast friends with Penelope Pick and Doris Drill and Linda the Especially Long Needle and Tabitha the Gritty Toothpaste.  (Speaking of Tabitha, I've come to understand that it's gritty because it has abrasives in it, like little piece of rocks, which is why the ancient Egyptians had rotten teeth because they wound up with sand in their bread.  Which begs the question of why we now use high-speed sanders to make sure the grit gets a chance to erode EVERY SINGLE SURFACE of your teeth while we listen to that constant RRRRRRRRRRR sound and savor the flavor of the dentifrice which tastes like you always thought a toilet cake might when the bully threatened you in the grade school restroom.  Which is why I went dry the entire fourth grade.

Being an ER doc, it's not that I'm a stranger to things like needles and knives and plastic tubes of varying sizes and shapes; and I'm certainly not adverse to their use on anyone but me.  That being said, nothing could have prepared me to browse past the displays of dental instruments for sale.  Wooden and metal tool boxes full of chisels and clamps and pliers and picks and saws and spackle guns.  And all of them sharp.  Bowel and bladder control was increasingly difficult the deeper I got into the exhibit hall.  Even the textbook vendors were parties to the terror.  When you look at the cover of a medical book, it's usually some embossed words letters upon a plain cloth cover.  (An example would be "Smith's Guide to Intra-articular Ant Farms, 3^rd Edition," with perhaps the word "New and Revised" in italics because everyone knows the literature has been rife with developments in the diagnosis and treatment of intra-articular ant farms since the last go-round.  See page 483, "Call Uncle Milton.")  However, dental books have cover photos of sharp edged pliers pulling decayed teeth from gaping bloody holes in skulls, with the titles usually printed in red so you have to hunt down the letters in the sanguine field.  And if that's not creepy enough, to demonstrate products they have these plastic disembodied mouths...not heads, just mouths...connected to freshwater pipes where you can sit and practice using your spikes and picks and drills and gouges and pliers and bone splitters in the ultimate test drive in these plastic orifi gazing skyward, just asking to be violated.  (Given that this was in New Orleans, you can take that any way you wish.)

I found myself especially interested in the chairs, but not those cushy ones that move every direction from here to Cleveland and present the illusion of comfort though a closer inspection reveals attachment points for straps and clamps.  No, I was looking at the chairs the dentists have to sit in.  To be fair, I had never even contemplated the comfort of the dentist, so wrapped up was I in my own terror, which was selfish of me.  I really should have been considering the welfare of that health care professional who was about to put power tools in my head. I did not realizethat dentists often suffer from chronic neck and back problems from having to position themselves all day at odd heights and angles, and to hold still for what must seem like epochs while doing delicate procedures.  And I also realized that it was now, as it never had been before,  in my best interest to think of these things, because if the The Empress came home one night aching and tired on a day I was off, I should probably not respond to her distress with acompetitive, "Oh, yeah?  Well, I only got in a three hour nap, not four like I planned, AND my afternoon cocktail by the pool was ruined because we were out of the good vodka and I had to use that cheap stuff instead.

So the thought of dental backaches is percolating through my mind as The Empress and I stroll up Canal Street later that evening.  A rather large individual waddles past us on the sidewalk in the other direction, knocking us off our route by the expanse of their…ummm…personality.  I hear her sigh.  “Lean over that for an hour and hurt for a week.”  Which is how I learned that the pannus has become a scourge of the dental world.

A pannus, you say?  What's a pannus?  The word pannus was not part of my training twenty-five years ago. Due to the expanding American waistline, it's now everyday vocabulary.  A pannus, briefly put, is that belly fat that overhangs the lower abdomen and all parts nether and below in the morbidly obese.  The Pillsbury Dough Boy, while pleasingly plump, does not have a pannus. Santa Claus...and bless his heart, he can't help it, he only gets out once a year and offsets that one day of exercise with Lord knows how many cookies...does. Some people are so big they have more than one.  There is no official medical word I know of for multiple pannuses, so let's call them pannini.  I've also independently determined that the possessor of a pannus is a pannerian; a pannerian from the United States, Canada, or Mexico in known as a PanAmerican.  (Thanks.  I'll be here all week.)

So I'm trying to work out how a dentist deals with a pannus, and I'm not going to ask the Amazon Empress because if she tells me, I'll know that at some point in her professional life some part of her has encountered one, and as much as I care for her there are some things about her I just don't want to know, like if any part of her ever touched a pannus, whether by accident or intent.  I figure you have to lay the chair down almost flat, move as far up to the head as you can but you still have to navigate around those huge arms and neck rolls. No wonder dentists wind up with bad backs.  But it you bring the patient too far back and lower the head so you can work on them sitting near the crown of the scalp to avoid the neck and arms, you run the risk of the pannus flipping over and whatever's been hiding under that fold tumbles onto your freshly laid carpet.  (And you don't want whatever's been hiding under there.  I can personally attest to finding a ham sandwich.  No, you don't want to know.)

Because of the increasing number of Larger Americans, it's not uncommon for me to see folks with pannini in the ER.  I had a three-folder in the other day.  She quite literally weighed close to a quarter ton and had two major complaints.  One was that she had gained 10 pounds in the last three days and wanted to know why.  The other was that she said she couldn't eat.

There are three ways to handle a scenario like this:

1) You can be forthright and honest.  "You weigh a quarter of a ton.  You can eat. You've proven it.  And as for gaining ten pounds...how the hell would you even know?"

2)  You can look thoughtful and empathize.  "I understand how weight can be deceiving. When you're a larger person such as yourself, common household scales often have trouble with accurate readings.  We'll do some lab tests to make sure your weight gain isn't related to fluid retention or some other medical condition.  We'll also check to insure that your lack of appetite hasn't made you dehydrated or malnourished.  If everything looks good, we can probably let you follow up with your doctor.  I'm sure your own doctor who knows you best will do a great job of sorting out your problems, much better than we can do here in the ER."

3)  You stifle a laugh behind a grimace, roll your eyes while standing behind the patient listening to the lungs so they can't see, move to the pat their ankle...at least I think it's an ankle, it might be a hock...leave the room as quickly as possible, walk twenty feet away onto a tiled floor, and drop a tray of instruments so no one can hear you say "WTF?"

Because I am an exemplary physician (or at least act like one, my Academy Award for Best Supporting Doctor in a Caring Role standing proudly on my mantelpiece).  I prefer a mixed approach.  I will begin by providing thoughtful counsel and a promise that we will, to the best of our ability, alleviate her concerns that she may have an emergency medical condition.  Then when I realize I have not reassuringly patted the ankle, but the tip of a similarly descended breast (the feel is no different, but the widening smile and dreamy sighs cannot be mistaken), I go immediately to option three, but rather than simply using the acronym I painstakingly articulate every syllable contained within the phrase as I immerse my hands in a tsunami of bactericidal foam.

We are still left with an acute clinical problem.  What's the best way to determine if the patient is able to eat or not?

I am a great believer in the power of donuts.  I am certain that the root cause of most pain in the morbidly obese is donopenia, which is a lack of active donut molecules in the body.  I think that if you told these folks that I could make your poundage-provoked pain go away forever with diet and exercise, or I could make you feel better right now with a doughnut, the vast majority (pun intended) would opt for the little fried ring.  I also believe that if offered morphine or doughnuts, most patients would find more relief from the latter.  It's only because you can't do a double-blind experiment...for there is no placebo for a doughnut...that my theory remains unexplored.

(I also have great faith in the power of bears.  I have a Bear Theory of Pain Control.  There is a lot of focus now on pain as a "vital sign," and any number of scales have been devised to assess pain.  All of them are subjective, and all of then are total crap.  But I do like the ones where 10/10 means the pain is so bad you're unconscious.  So if you come to the ER and tell me your pain is10/10 or greater...something you need to be conscious to do...I will ask you if your pain is worse than being mauled by a bear.  If you say yes, I will bring a bear into the room, liberally apply a slave of salmon paste and honey, and see what happens.  If your original pain is still 10/10 after being mauled by the bear, I will then, and only then, actually believe you and give you a narcotic.)

This patient offered another opportunity to explore the clinical use of the doughnut.  When you have a patient who says they can't eat or drink, it's incumbent upon the physician to address this before discharging the patient home.  Feeding and watering the patient is called a "PO challenge." (PO is for the latin "per oris," or "pie 'ole.")  This is actually one of the very few rules in emergency medicine.  If someone can normally eat, drink, walk, and talk before they get to the ER, you'd better have a good reason if they go home unable to do so.  Making certain that someone can keep down some fluids, and possibly the ubiquitous ER turkey sandwich as well, is actually a critical point in clinical disposition.

So we thought that what we could do is give the patient a doughnut.  If they can eat the donut, then they will be able to keep themselves fed and watered at home.  And what better place to put the doughnut than on top of the pannus.  It's a large, flat surface that is easily accessible to the patient, even when recumbent and at rest.  We were so delighted by our Eureka moment that we broke out into song:

There's a doughnut on your pannus.  Eat it now.
There's a doughnut on your pannus.  Eat it now
There's a doughnut on your pannus.
It can be your PO challenge.
There's a doughnut on your pannus. Eat it now.

(Sung to the tune of "She'll Be Coming Round The Mountain")

 This song caught fire in the ED, and now it's close to the top of Our Hit Parade (#1 this week:  "We Are Never Never Ever Giving You Drugs in the ER" by  Michael Barton.)  But like most clinical advancements, more questions arise.  Which doughnut works best?  (Answer:  Hostess Donettes.  Small, convenient, each package contains six tests, and your patronage supports the economically crucial plastic snack cake industry).  And if the doughnut is indeed gone, how do you know the patient ate it and it did not roll on the floor?  (Answer:  Powdered sugar leaves a trail).

Science marches on.

Shaken, Not Stirred

A long time ago, in an ER far, far away. I wrote a post about pseudoseizures, or seizures that are faked. Of course, because nobody does anything intentionally anymore, and everything is the fault of someone or something else (see "fibromyalgia"), we now call then Psychogenic Non-Epileptogenic Seizures (PNES seizures...and that's exactly how it's pronounced, much to the glee of our prehospital crews who get to report this finding over the airwaves).  I often make fun of patients with pseudoseizures, and often rightfully so.  Some of them are so badly done that you can't help but laugh, especially when the sound of your merriment makes them open their eyes and then turn away when they see you staring and pointing from a disrespectful distance.  (Pro tip:  No flopping.)  But if I'm being honest, there's also a part of me that has a sneaking admiration for one done right.  I can't even figure out how to shake it, bake it and make it bounce, let alone coordinate a rhythmic tremor of all extremities coupled with some raspy breathing and suppressing any response to pain.  So for those brave souls willing to undergo getting stuck by multiple needles simply for a whiff of rectal valium...well, in my own way I salute you.  If you're a worthy opponent, I don't mind being beaten at the game.  

(I'm not beaten often, but I do commend a guy several years ago who came in with flank pain.  He gave me the perfect, Wikipedia-referenced story for a kidney stone.  But not only was he complaining of the right pain at the right time in the right place, but writhing in the most convincing fashion and even managing to get some blood in his urine (I know how they do that) and to break out in a cold, pale sweat (that one's still beyond me).  He got two doses of Dialudid, a strong narcotic that's about as good as we got.  He felt better, his pain went way...and his workup was totally negative. No kidney infection, no kidney stone, no tear in a major artery causing his blood to pool in his abdomen.  Only a request for a note before he went home saying we had given him narcotics in the ER to give to his probation officer the next day before his scheduled drug test.  Well played.)  

This particular time, however, I'm not so convinced about this woman in her early twenties.  Neither are the paramedics, who have correctly diagnosed a PNES seizure over the radio, prompting multiple guffaws from everyone except the nursing student who couldn't figure out how a female could have such a thing.

When she arrives, her eyes are closed and she's shaking all of her arms and legs.  A bit off in tempo, one arm slightly more rapid than the other, but a fair effort. (At least there's no flopping.)  The closed eyes means I can't do Seizure Detective Trick #1,which is something I call the Stooges Maneuver.  You spread you index and middle finger apart like a fork and jab them towards someone's eyes.  If they blink, the seizure is fake.  (This is also how you tell if someone who claims to be blind can actually see).  The maneuver is enhanced if you say "Nyuk Nyuk Nyuk" during the process.

Now we go to Seizure Detective Trick #2:  The Hand in the Face. In essence, if I hold your hand about your face and let it drop, the awake person will reflexively move their hand to avoid it falling onto the face.  The truly unconscious person will let it fall.  

I lift her right hand and place it a foot and a half above her nose.  Holding her lightly by the wrist, I let go.  

The hand stays above the face, for a moment, then gradually arcs downward to lay on her shoulder.  

It's not real, but she made a valiant try, so there's no reason to be rude about it.  I bend down and whisper to her, as if we're sharing a confidence.  "You know, you're not really having a seizure.  It's okay to stop."  

She opens her eyes, staring straight ahead.  

"I c-c-c-c-c-c-can't."

I give her shoulder a pat.  "No, I think you c-c-c-c-c-c-can." 

With one last intense shudder, it does.  Norman Vincent Peale, meet the PNES.