Zen and the Art of Laceration Repair

"When we lose our conscious thoughts, our stress and worries will go with them. Stillness and quietude will take their place."

I got an E-mail from Shinga who asked me to expand on my comment about preparing children for painful or scary procedures.

I don't claim to be an expert in anything, but I have found certain techniques to be useful in the course of my practice. I really don't like categories or labels either, but if these maneuvers are related to zen meditation, breathing control, hypnosis, or any other technique that helps people relax, sit still and endure uncomfortable procedures then you can call it whatever you want. These steps are so basic that I would expect most docs and nurses probably use them anyway, but I have received many appreciative comments from family members and staff regarding my "calming effect" on patients, so I thought I'd try to figure out what I do that helps accomplish this.

I'm sure most who read medical blogs are familiar with the standard ways we are taught to put children at ease, so I won't go into detail about those. I don't wear a white coat, I keep a relaxed demeanor at all times, I sit at the patient's level, I smile and talk directly to them in a soft gentle reassuring voice, I avoid making loud noises such as slamming the door or banging the mayo stand, I don't let them see the needles. I take my time with them. I try to calm down the parents, because parents who are freaking out will always make the child more nervous too. I let the parent hold the child the majority of the time, if that is the position of comfort for both.

Most lacerations in kids I prefer to close with Dermabond if it is reasonable to do so, but if there is a significant likelihood of improved cosmetic or functional outcome with sutures or other methods then I will offer various options to the parents. The wound still has to be cleaned though, so they are going to have to sit still and relax a bit, and their fear needs to be addressed in an individually appropriate fashion. Not all kids can be easily comforted verbally.

For certain complicated lacerations and of course all reductions of fractures, I prefer to chemically sedate the child with ketamine, unless contraindicated. If an injury has the potential for complication if not adequately revised, or if the location of a wound requires extensive cleaning or debridement, then I prefer to have the child completely still, pain free, and unaware. My zen mastery, though formidable, occasionally requires some chemical augmentation.

Ketamine turns a scary, painful, psychologically traumatic, and possibly rushed or inadequately performed procedure into a calm easy situation for everyone involved: patient, family, and staff. I despise the "brutaine" technique of just wrapping the screaming kid in a sheet and torturing her, although rarely such an approach is necessary just to get the local anesthesia injection over with in a child who cannot be comforted.

Simple lacerations and "just in case" splints typically only require reassurance. Optimally, I would prefer to have the child lying on the stretcher with the parent at the head of the bed or beside them, holding their hand. I typically prefer to have a trusted nurse who is also gentle, relaxed, and good with kids to stabilize the area requiring attention. If a local anesthetic is required, I tell the child that it will sting just a little bit, but only for a second. Then they won't feel anything else. It'll be OK.

Once all the equipment is arranged, and everyone is situated and ready, I place a hand on the patient and talk to them directly and slowly in a calm voice, telling them to take in a deep breath and let it out slowly. This should be repeated a couple of times so they can allow themselves to relax. Focus their attention on breathing out. "Take a deep breath and let it out slowly.........again." I breathe with them, face to face. "Goooood." Occasionally, some kids are still going to cry when you start to approach their injury, and almost all will cry when you inject the lidocaine. "Deeeeeep breathhhh" I repeat calmly. I still will give them the opportunity to let me inject slowly, because if they can handle the first half cc or so and still stay still, then the rest is much less painful. I've personally never found EMLA to be worthwhile, and kids hate the freeze spray.

If they are too agitated with that approach, then I usually just get the local over with as quickly as possible then back off for a minute. Typically, once the local is in they are able to be calmed with the breathing approach again, and they sometimes will even fall asleep during the procedure itself.

Someone mentioned on another blog about working with a physician they called "Dr. Ativan" because of his relaxing effect on patients. That's my style as well. My personal belief is that if patients' anxiety level can be reduced through relaxation techniques, of which breathing control is probably the most important component, then their procedure will be less traumatic and better appreciated by everyone.

Breathing exercises like the one mentioned above can also help to induce a more relaxed state in oneself, during a stressful shift or when trying to fall asleep for example. I personally underwent a sleep study in which I achieved stage 2 sleep in only 3 minutes. It works....try it.

ADDENDUM: It would be interesting to hear any more "tricks of the trade" others have found to be helpful in calming young patients, including pharmacological agents of choice.

Fading Scars and Memories

This is why I usually look at the old chart before seeing a complicated patient.

He was really old, and he was sent from the nursing home because his hematocrit was 18% (he had lost more than half of his blood cells somehow). I was surprised at how cheerful and coherent he appeared. Pale, yes, but in no distress and complaining of nothing. He denied any black or bloody stools, and his abdomen was soft and nontender. His stool was a little bit dark, however, and it tested positive for occult blood. His heart rhythm was normal, and his vital signs were perfect.

"Do you know why you are on Coumadin?" I asked him.

"I have a St. Jude valve," he replied. "Dr. Famous put it in me in 1977."

I was impressed how sharp his mental status was at that age, and how well he was tolerating his profound anemia. "This must have been a really gradual loss of blood," I told him confidently, "or else you wouldn't be looking so good right about now. Do you have a doctor here? Have you been admitted to this hospital in the past couple of years?" I asked.

He looked puzzled. "No....."

"Well, I'll find a doctor to tank you back up and make sure you're OK."

I reviewed his medical record and learned that he had been admitted here just a month before for anemia and GI bleeding. "I guess he fooled me," I told my nurse. "He isn't as sharp as I thought." As I was about to discover, neither was I.

"Page Dr. Stonewall! Let's get this guy admitted!"

As I was presenting the case to our hospitalist, I was shocked and embarrassed to note on further review of the patient's discharge summary that he had undergone a partial hemicolectomy to remove an intestinal tumor. Just last month. I didn't remember seeing a scar on his belly though. Had I examined him without pulling up his shirt? I didn't think so, but I sure didn't remember any scars on him. Damn, was I having a 5 am stupidity attack? I hate those.

"Why don't you check and make sure he doesn't have a colostomy or something," my colleague said icily, twisting the sword before I had even fallen all the way onto it.

I went back in to re-examine him, pulling up his gown. Still no scars; whew...now I was relieved but still confused. I pulled down his diaper a bit more, and hidden in a poorly-turgored skin crease of the right lower quadrant was a superbly well-healed scar, faded to the point of near invisibility from his anemia. He'd had an inguinal hernia there that happened to coincide with the site of the tumor, so the incision paralleled the inguinal ligament, exactly corresponding to the Langer's skin tension lines. Beautifully done, I might add.

How Much to Do

One of the things that intrigues me about Emergency Medicine, and life in general I guess, is that part of what defines you as different from others is how much time and effort you put into each situation. If you shake a person's hand or look them in the eyes a fraction too long or not long enough, it changes the meaning of the act. If you call your friend every 5 minutes it's too much, but every 5 years may not be often enough. If you tell your wife you love her once a month it's not enough, but every minute is too often. So there is a balance that we all must find.

During a shift, of course the balance of time is important as well. I really am not fond of social introductions and formalities, so I prefer to get those out of the way as quickly as possible, which is probably slightly disconcerting for some folks. A quick knock, a rush into the room, forced hurried handshakes all around (I'd rather not, really, but it's an annoying historically important social requirement like saying "bless you" after a sneeze, and so I do it anyway), I look each person in the eye and introduce myself, then it's to the chair or the bedside and let's get to the reason we both came. Whew. Honestly, I'd prefer it if only one family member were there. It saves time, and I get a better story that way, but some families are more touchy-feely than others. I understand.

I prefer to spend the majority of my time with each patient listening to them tell me their complaint, preferably in their own words, while I sit down and watch them intently, observing every expression and studying every nuance of their presentation. As Osler said, "if you listen to the patient, they will usually tell you what is wrong with them." My exam for some complaints is often just a formality, a sort of ritual dance that I must then perform to satisfy the billing system and make the patient feel like I am "doing something." I'll spend as much time as I need on the key areas, but the whole multi-body system exam in a patient who can give a good history is often less valuable in terms of acquired data/sec/joule of expended energy. To me, anyway. For the same reason that the review of systems is important, however, occasionally I will find a something crucial and unexpected on a quick general examination, but more often than not it just creates additional issues to "work up" with laboratory testing. I'm much more likely to dawdle over a key component of the history than to listen intently for a fourth heart sound though.

The clearer the ability to communicate, the less necessary the examination and laboratory studies become. With an unconscious patient or an unaccompanied patient with dementia, all of the time spent at the bedside can be used on the examination, which is sometimes a refreshing change of pace. As the ability to communicate decreases, it becomes necessary to order more tests and it becomes more likely that the patient will be admitted. That includes language barriers, of course. While an interpreter is always appreciated, they are really most helpful in narrowing down a chief complaint or two. I can rarely extract the nuanced features of a history that enable me to make quality diagnoses via an interpreter, but if there is time to spend, I'll give it a shot. Dizziness or "chest pain" are hard enough to figure out in patients who speak English, so sometimes it's better to just order the gamut of tests, admit if possible, and move on. If I'm going to discharge such a patient, even with a good interpreter it is sometimes difficult to be sure the instructions are as detailed and appropriate as necessary.

How much time do you spend on a little girl with a broken arm or a cut on her face, making her feel comfortable before you fix her? How long do you spend telling her parents about the procedure you plan to do, or proposing alternate courses of action? Do you make that courtesy call to the patient's doctor or not? Do you see the chest pain guy first or the backboarded MVA guy? The migraineur or the back painer? Do you just intubate the old lady who can't breathe well and get it out of the way, or try to stabilize her while you talk to the family about "end of life" issues? How much do you tell them about the whole "breathing machine" thingy and what that entails?

Every situation is different, of course, but we all have our own typical style that makes us who we are. Ultimately, the fractures will be splinted, the chest painers will be admitted, the lacerations will be sutured and will probably heal in a similar fashion, the various nonspecific symptoms may or may not be accurately diagnosed and will certainly be treated in myriad ways, but the pathway we take to reach those ultimate destinations might be quite different between physicians.

On a good night, everyone gets what they need.

Peer Review

Dear Dr. Chairman:

I am sorry to hear that Ms. Doe ultimately succumbed to her terminal illness. However, I am uncertain how to respond to your inquiry. I note that the committee did not mention any specific concerns regarding my medical treatment of the patient, so I assume you would like me to respond to the complaints by the patient’s family member.

I believe that my treatment of this patient was completely appropriate. I disagree with the committee that there was a clear indication for admission of this patient, but obviously that issue is irrelevant since I arranged for her admission regardless of the absence of any absolute indication to do so. I will use our apparent disagreement about that particular issue to help you try to understand what really happened that night, and how it relates to what happens every night.

A sodium level of 129 is not an indication to admit a patient, as you well know. A fall in an elderly patient is not an indication to admit either, nor is vague generalized weakness. Obviously a urinary tract infection is not an indication for admission, particularly in the absence of vomiting. If anyone on that committee truly believes that any of those findings are a "clear indication to admit" a patient, I wish that you would notify the entire medical staff of your specific recommendations so that we can expedite such admissions in the future.

Personally, my philosophy is that any elderly patient who “just doesn’t feel good” and requests admission should be admitted to the hospital regardless of laboratory findings, but as you are doubtlessly well aware, many physicians disagree with such a conservative approach. Certainly the presence of several minor abnormalities of laboratory studies or a general impression that a patient might benefit from a little tune-up in the hospital can outweigh the absence of an obvious admission criterion, and that consideration was essentially the reason that I arranged for the admission of this particular patient. After receiving intravenous fluids and antibiotics, if she had decided that she wanted to go home or if she were denied admission by her physician, she could have been seen in the office the following morning without any adverse outcome, so this was essentially what many would consider to be a “soft” admission.

When I told Ms. Doe that her own doctor was not on call, I did not intend to imply any sort of refusal or inability to treat her, but instead my purpose was simply to inform her that the covering physician might not be familiar with her specific situation. When I stated that her tests did not show any abnormalities which required admission, it was to prepare her for the possibility that the on-call physician might not agree to admit her. This is an approach that I have occasionally found to be helpful because many physicians at this facility are often hesitant to admit patients unless they meet specific criteria, despite the patient’s or family’s preference for inpatient management. As I mentioned, I would personally favor admitting every elderly patient who falls, feels weak, has mild electrolyte abnormalities, or just doesn’t want to go home. The challenge that I and my fellow emergency physicians routinely face is to convince another busy doctor to admit such a patient, particularly when we must awaken them after midnight.

The post hoc “clear indication for admission” as determined from the midday setting of a Peer Review Committee conference room is often not so clear from the perspective of the typically exhausted on-call physician who is awakened from the comfort of his warm bed by a BEEPBEEPBEEP after a full day’s work, multiple other admissions, and a long list of complicated patients still to be seen in the morning. So I occasionally warn certain patients that they “might be able to go home” in order to ease their potential disappointment when, as often occurs, I am forced to send them home against their will, dragging their prepacked suitcase behind them.

I therefore am certain that I never said “I’ll admit her” to the family because I don’t have the authority to admit any patient. As a lowly emergency physician contracted to manage the night shift in the ER, I am always required to find another physician on staff who is willing to accept my patient to their service; consequently the patient, their concerned family, and I are always dependent upon the judgment, whim or mercy of the attending physician on call. In reality, every physician is less likely to be agreeable when asked to accept relatively “soft” admissions, if they are on “no doc” call, if they have already admitted many patients that day, or if they are covering their partners’ patients overnight (among other factors). Some other physicians just prefer to admit as few patients as possible no matter what the specific circumstances happen to be. These are incontrovertible truths.

Keep in mind that I have zero incentive to discharge any of the patients I see in the ER...in fact, it would be much easier and less risky for me to just admit everyone that comes in. I’ve never received any pats on the back, financial incentives, or glowing letters of commendation for admitting fewer patients than the average; nor have I ever been chastised for admitting too many patients. Yet every patient that I discharge has the potential to get sicker, have a bad outcome, or get angry at me because their symptoms were not adequately controlled in the outpatient setting, so the allegation that I grudgingly agreed to admit this patient only after multiple protests and threats by the family is totally absurd and completely untrue. I don’t recall her family ever threatening to take Ms. Doe to Big City Hospital, but such a statement would not have caused (or enabled) me to change my management in any way. I am the patient’s advocate, not their adversary. Their true adversary is usually at home sleeping while I stay awake all night doing his dirty work for him. Some of our physicians on staff at Our Little Hospital can, and do, refuse this type of admission, believe it or not.

I would confidently wager that every practicing physician on your committee has refused an admission from me at least once during my ten years in practice at Our Little Hospital. It is also probably fair to say that many of those patients that I was forced to send home wanted to be admitted every bit as much as Ms. Doe did that night, and that their families were probably just as upset that their expectations were unmet. In reality, those rebuffed patients were probably even angrier since they actually were discharged, as opposed to Ms. Doe, whose relative was apparently upset with the very discussion of the possibility that she might have been discharged, despite the fact that she was ultimately admitted and given the best treatment that our facility could offer her. The difference, of course, is that the sine qua non of this particular complaint was the family’s grief and frustration at the loss of their loved one, and I therefore do not begrudge them the opportunity to vent their emotional release towards me, even though I feel it is undeserved. I understand their frustration, I sympathize with their loss, and I forgive them for their misdirected hostility.

I hope and pray that every member of your committee thinks about Ms. Doe and the anguish of her family before refusing an admission from me or from any of my emergency medicine colleagues in the future. I wouldn’t even bother to call and ask another physician to admit a patient unless there was a good reason to do so. There are only a handful of physicians at Our Little Hospital who have never refused an admission from me. If any of them happen to be on your committee, I would like to tell them this: that you have my eternal respect and gratitude, and it is truly my pleasure to work with you to provide the best possible care for our patients. You make my difficult job significantly easier, and you provide a welcome sanctuary for those of us in need. Thank you and God bless you. To everyone else, I pray that you can understand how you might be somewhat complicit in fostering complaints of this nature, and that you might deign to be a little more receptive when your mercy is sought henceforth.

I will be happy to answer any further questions or concerns you have about my involvement in this case or to discuss any other ways we can improve the care we provide to our patients. Thank you very much for your understanding.

Steamed Shellfish

A true delicacy at a reasonable price, and easy to prepare.

One pound littleneck clams
One pound mussels
One pound shrimp
Half of a red onion, sliced thin
Celery, sliced thin
Mushrooms, sliced thin
White wine, one bottle
Butter, one stick
Garlic
Noodles of choice

First, prepare the shellfish by removing the shells from the shrimp, pulling the beards off the mussels, and scrubbing the shells of the clams and mussels with a firm kitchen brush. Set aside.

Bring a half bottle of white wine and a stick of butter to a boil in a large pot. Add a tablespoon of minced garlic, stirring well. Pour the rest of the wine into glasses for you and your companion, and drink while you cook. You'll need another bottle for dinner.

Add the seafood and veggies to the pot and steam over medium-high heat for at least 5 minutes or until all the clam and mussel shells have opened, stirring occasionally. Prepare the noodles per package instructions.

Pour the sauce from the seafood pot over the noodles, and stir well. Distrubute the noodles and seafood into bowls, and serve immediately. Amazingly good.

Doctor Becomes Patient, Part 2

Things seemed to be going pretty well after my dental procedures last week. The worst of the pain only lasted a couple of days, so I was able to resume working without missing a shift. Right before my last of three night shifts in a row, I noticed one of my tires was a little flat, and I remembered I had some Fix-A-Flat in my trunk. After a cursory inspection, it looked OK to me, so I proceeded to do a quick inflate/fix.

As soon as I screwed the tubing on the valve stem and pressed the button, BOOOOM!!!! It blew up in my face. With both eyes burning like hell, I ran blindly through my cluttered garage to the water faucet in my back yard. As I furiously scooped water into my face, I looked down and saw my arm had a couple of big chunks gouged out of it. I must have caught it on something as I ran. I didn't even feel it.

After a few minutes of irrigation, my eyes felt better but now my scrubs and shoes were soaked with water. And I was late for work. I can't stand being late for work. With my wife pleading, "Honey, you need to go to the ER!" (umm, that's where I'm going, sweetie) and my daughter crying "Is Daddy going to be blind now?" I changed clothes as fast as I could, and I borrowed my wife's car to go to work.

But that wasn't when I became a patient. Nope, I treated myself for all of that.

The next day, my tooth began hurting again. Not just my tooth, but the entire half of my face. And not just hurting, but HURTING! I called my dentist in the afternoon, and he was nice enough to come in after hours and give me another nerve block, which totally relieved my pain....for two hours. Then it came back worse than ever. My dentist had given me some of the anesthetic to inject myself as a nerve block, but it just wasn't working. I was writhing in agony, crying out with intolerable pain.

So I went to the ER where I work, tears rolling down my face the whole way, running red lights and speeding recklessly to the hospital at 3 am. My dentist had called one of his colleagues who had agreed to see me in the morning, but I just could not wait. One of my partners took pity on me and gave me a shot of Demerol which allowed me to catch a couple of hours sleep. I'd never had it before. It did help my pain, but I didn't get a "buzz" and it really didn't seem to be the sort of thing that people would malinger for. Maybe it's more enjoyable if you aren't really in pain.

Then I had the root canal, and here I sit back home praying that that horrible awful pain doesn't come back. I have an entirely new respect for dental pain, my fellow patients, and I will not make you wait ever again before medicating you.

UPDATE: Amazingly, 18 hours later, I have zero pain except with pressure on the involved tooth. I really had serious concerns that there might be another coexisting condition (trigeminal neuralgia, brain tumor, aneurysm?) that we were missing, but it seems that it all came from that rotten tooth and exposed nerve.

Psychosis

"Stop playing around! You need to keep still!" I heard my nurse yelling from the patient's room. He stormed out, visibly angry. "What a drama. She's playing games with us, and I'm not going to get stuck with a needle." Our patient had "fainted" in the waiting room, and per protocol required IV access. We didn't even know her name yet.

She was 25 years old but still lived with her parents, both of whom accompanied her. "What's going on?" I asked (my open-ended question of choice). She looked at me fearfully, but didn't answer. I smiled...."Why did you come here to see us tonight?"

"Tell him about your stomach" her mother prompted.
"Yeah, my stomach hurts" she mumbled, glancing around furtively.

"Well, when did it start hurting?" I smiled again.
"When I was six." she replied.
I looked at her mother for a hint of guidance. "Is that right?"
"No, but she hasn't eaten or slept for the past two days." the mother replied.

The family first noticed something was wrong during church services on Sunday, where she had been singing with unusual passion and volume. She even ran up on stage and grabbed the microphone from the preacher and began giving her own sermon to the congregation. She made quite an impression, apparently.

"I feel better, I want to go home! Let's go, Momma!" my patient said abruptly, as she started to get up. She went from lethargic to agitated in the blink of an eye.

"Ma'am," I said, "You came here to get some help. You fainted in our waiting room. Now I need you to relax and tell me what's the matter." I placed my hand on her arm to re-assure her.

"DON'T TOUCH ME!!!!!!!!" she yelled. She bared her teeth at me like a wild animal, so I took a step back. "I need to go to work!" It was midnight.

"What kind of work do you do?" I asked. She looked away and started to sing to herself.

"She's a teacher at the high school." her mother said.

She didn't look like a druggie, and she didn't look sick. That left psychotic. She didn't know what year it was and couldn't name the president of the US. She thought I was one of the principals at her school.

I looked the patient in the eyes. "Listen to me. You are an educated person. I would expect you to be able to tell me very clearly and concisely what is the matter, and sit still for an evaluation. For some reason, you are not thinking clearly or acting normally. I'd like to try to find out why. We are going to need to draw some blood and I need you to give us a urine sample.

"I'm going to faint" she said, and dramatically flopped her head back on the pillow. Then she sat up immediately and started babbling in a language known only to her.

Everything was normal: CT brain, metabolic and thyroid panel, urinalysis and drug/tox screens. She finally let me examine her abdomen, and it was benign.

"I'm concerned about this change in your personality" I told her. "I'm afraid your judgement is impaired, and you need to be evaluated in the hospital by a psychiatrist." Since this was her first episode ever, it was unclear how bizarre she might get. She agreed to be admitted, and she was accepted by the psychiatric hospital. I was surprised she never required sedation, just a calm approach and the support of her family.

Often these patients turn suddenly aggressive and become more agitated requiring chemical sedation and physical restraints. I have seen similar patients run in a panic out of the ER and across a busy street without regard for their own safety. It is imperative to have someone with them at all times and to frequently re-evaluate them for change in status.

If physical restraints are to be used, it is essential to use chemical sedation as well, and to administer it as soon as possible. The use of multiple personnel to physically hold down an agitated patient, or the use of leather straps without sedating such a patient can lead to irreversible cardiac arrest from asystole. This is especially true if the patient is under the influence of stimulants such as cocaine or amphetamines. Agitated delirium is a truly life-threatening condition, and must be treated appropriately.

Fried Chicken Breast Strips

One of my first jobs was as a fry cook at Grandy's, so I know how to fry chicken.

As with most things in life, preparation is the key to success. Fresh ingredients, clean oil, and precise temperature + cooking time are necessary to create the best fried chicken.

For the chicken, I use boneless skinless fillets and remove the fat, cutting each fillet into the desired sized pieces (or leave whole if you prefer). I like to rub on a little Grub Rub and marinate the strips in the refrigerator, but this is optional.

For the batter, make a solution of 3 whole eggs (or egg whites if your diet insists) and equal amount of milk, stirring well in a bowl. Dump all the breast pieces in this and allow to soak.

The breading is made with a mixture of breadcrumbs and cornmeal, mixed in a bowl. You can vary the proportions of each, but I usually use about a 2:1 ratio (primarily breadcrumbs). The cornmeal makes the breading a little crunchier. Use one hand to take the chicken strips out of the egg bath, and the other hand to coat the chicken in the breading. This keeps your hands from getting gunky. Place the breaded pieces onto a plate, and you can fry them immediately or refrigerate until you are ready. If you want a thicker crust, dip the pieces back in the egg and crumbs again.

I prefer to use a deep fryer; although excellent results can be obtained with a cast iron skillet, it just takes more caution. With a deep fryer, it's easier to get better consistency with a large batch, and the built-in temperature gauge and timer makes it simple. Any oil will do, but I use Mazola corn oil. Preheat the oil to 350-355 degrees, use small batches in a single layer, and set the timer for 5 minutes per batch. Remove the finished pieces to dry on paper towels, and sprinkle with a little cajun spice if desired. Allow the oil to reheat to 350 before starting the next batch. The light will go off on the deep fryer when the oil is at the proper temperature.

My preferred side dishes are macaroni and cheese and corn on the cob.

Cook plenty, because they make really good snacks the next few days as well. These strips are perfect to take along on a picnic or fishing trip. The same technique also makes really great fried shrimp too, but reduce the cooking time to 3 minutes.

Russell Miller, MD: The Go-To Guy

One of my heroes died this week. When I got the e-mail with only his name as the subject, I paused for a second before I opened it. Nobody ever seems to e-mail you with good news about somebody. Goddammit.

If you saw him at the bait shop or the Wal-Mart with a dirty shirt and his belly sticking out, you would probably never guess that he was such an accomplished physician. Getting into his beat-up old Jeep, you might doubt he was employed at all (except for the EMS stickers on the back window). His Texas accent and his plain manner of speaking completed his facade. But he always looked you in the eyes, and if you were fortunate enough to spend some time with him, you could tell that he feared nothing.

I generally avoid funerals, but I forced myself to see this one, for the spectacle as much as anything. Of course, it was packed. Many dozens of paramedics and firefighters in uniform, saluting him. Women crying, men trying not to. Doctors and nurses, department chairmen, community leaders everywhere. The church overflowed; not only was there no place to sit, there was hardly any place to stand. The most ironic thing about his funeral was the fact that he was the one who was usually recruited to give the eulogy, to put things in perspective for us. To summarize the life of the deceased. And now, despite the huge crowd in that church, not a single person there could possibly explain why this great man decided to take his own life.

He was the go-to guy. If there was a major disaster, he was the one you would want to coordinate the response. He could move patients and direct resources like nobody I have ever seen. Chaos and tragedy never seemed to faze him. Russ was the stereotypical ER cowboy, because he pioneered the role. For me to say I admired him would be an understatement. I envied him. I wanted to be as capable and confident as he was under pressure. He was the reason I chose to do what I do. His leadership skills were extraordinary. If he was around, it didn't matter how crazy things got, he would be in control of the situation. And yet, despite his direction of various emergency medical institutions in Southeast Texas, it always seemed to me that he never sought recognition. People instead sought his leadership.

He was an even greater human being than he was a physician. His generosity was legendary. If a friend needed a place to stay, he opened up his home to them, for as long as they needed. Anything he had he would share with his friends...it went without saying. I've never met anyone as selfless before or since. He was a tinkerer, always working with his hands, always fixing stuff. And he was without a doubt the messiest human being I have ever known. Clutter was just another form of chaos, and that was his comfort zone. He was a pilot, an astronomer, a calligrapher, an outdoorsman, and an enigma.

For whatever reason, he left this life on his own terms. I'll miss him, and I'll never forget him.

Scalpel's Seafood Soup

There is nothing better than homemade soup. The key is making your own stock. Do not settle for packaged broth....do it right. This recipe makes 10-12 hearty servings.

2 pounds raw shrimp, with shells
6 snow crab halves (or 8 oz pasteurized crabmeat if you're lazy)
small carton of mushrooms, sliced
one can of corn
one bunch celery
one green bell pepper
one onion, if desired
one-two spoonful garlic, chopped
salt and pepper to taste
olive oil
glass of white wine
6 ounces of egg noodles
saffron, if you want to get ritzy

First, make the stock by removing the shells from the shrimp and placing them into a large pot. Cut the leafy tops off the celery and add them into the pot too. Add a handful of rosemary if you have some. If you have the crab legs, remove the meat (setting aside) and add the shells to the stock pot. Cover with plenty of water and bring to a rolling boil. Boil for 10 minutes, then simmer for another hour or two, occasionally mashing and stirring the shells/legs/celery to extract all the goodness. Remove the solids with a slotted spoon, and then strain the liquid through a cheesecloth or coffee filter. After straining, the stock should be free of solid material or cloudiness. Simmer over low heat, or refrigerate until ready to cook. The stock can even be frozen for later use.

While you are simmering the stock, you can cut the vegetables. Slice the mushrooms thin and chop the celery, onion and pepper. If the shrimp are large, you may want to halve or quarter them as well. Sautee the shrimp quickly over medium high heat using a tablespoon of olive oil and a spoonful of garlic, and remove the shrimp from the pan to set aside. Add another dollop of oil to the pan, then sautee the vegetables for a couple of minutes and add them to the finished (strained) stock. Then pour a half cup of white wine into the sautee pan and scrape up all the goodies stuck to the pan. Bring the wine to a boil while whisking the pan, then pour everything into the stockpot, stirring well. Add 6 ounces of egg noodles and bring the pot to a boil for 10 minutes. Then add all of the seafood. You can also add oysters, scallops, mussels, clams, grilled chicken, or whatever you have available. It's a great way to get rid of leftovers. For creamier soup, add a little heavy cream or half and half before boiling. Or to just make it thicker, add a few teaspoons cornstarch (dissolve in water first). You can serve immediately or simmer it all day. It's actually better after being refrigerated and served the next day. Add a pinch of saffron right before serving.

Once you start making your own soup, you'll never be satisfied with canned soup again.

Pain management

I view it as a duty and privilege to adequately control pain in my patients. It is imperative that the patients take an active role in their health as well, however. Just writing a prescription is not sufficient therapy for many chronically painful conditions. If back or leg pain is present in the setting of obesity, then weight loss is just as important as pharmaceuticals. Physical therapy and exercise, in most cases, are essential. Maintaining functionality, including continuing employment when at all possible, is important not only for psychosocial and financial reasons but to promote structure and a positive self-image. The natural release of endorphins one achieves with a satisfactory family/job/exercise situation is more effective long-term than just narcing someone up and letting them get fatter, lazier, and more withdrawn from society. Depression is frequently present and must be treated as well.

Opioids are important, but they need to be used wisely...with the goal of maximizing potential. Pain relief should be an intermediate goal, not the ultimate goal. The ultimate goal is return to function. Anyone can be made comfortable with medication, but if they are just a comfortable blob nodding off on the couch, why bother?

Pain management needs to be directed by one physician, but in certain cases a multispecialty approach can be helpful (Ortho/Neuro/Psych, for example). A carefully worded pain management contract, where the patient agrees to be honest about his compliance with therapy and the medications he obtains, is mandatory. Visits to the ER for breakthrough pain should be rare, not routine. It must be made clear that lost or stolen prescriptions will not be replaced, and that changes in the amounts of medications taken must be approved by the managing physician. The patient therefore is involved with the plan, and shares some responsibility for getting better.

The goal should be to get better, not just to feel better.

When doctor becomes patient

One of the best things about being a doctor is that you usually don't have to go to the doctor yourself. Physician, heal thyself, right? I rarely get sick, and I have fortunately not had any significant physical injuries either. I have never missed a scheduled shift since getting my medical license 15 years ago.

Unfortunately, my lack of preventive maintenance finally caught up to me today.

I hadn't been to the dentist in over 20 years. In fact, my mother made my last dental appointment for me. In college I had better things to do, in medical school I was too busy and poor, in residency I never found the time, and by then I had gotten out of the habit of seeing a dentist, so why bother? Since then, I have lost a couple of fillings and cracked a couple of teeth, but nothing a little ibuprofen wouldn't take care of.

But lately the pain required round-the-clock ibuprofen, and I could no longer chew on one side without excruciating pain, so I figured it was time to pay the piper. So today, after four night shifts in a row, 3 hours sleep, and two hours of dental procedures, I'm now in even worse pain than before. The procedures itself were relatively painless. Nitrous has a wonderful effect on one's outlook. I'm a bit foggy about the discharge instructions, but I recall the dentist telling me there was a chance he would have to refer me to an endodontist if I had horrible pain afterwards. Something about an exposed nerve pulp. He wrote me some vicoprofen just in case. Soon, I would be very, very glad he did.

I started to feel the pain during my 45 minute drive home. The skin over my cheek was still totally numb, but my tooth and jaw were aching. I noticed that I was becoming unusually irritated with the idiot drivers who impeded my progress to the pharmacy. I gave my prescription to the pharmacy tech (while feeling a little self-conscious about filling a narcotic). The pain was getting so bad, it began to make me nauseated, so I asked for a prescription pad so I could write myself some Zofran too. "Are you going to wait for the prescription?" she asked. I wanted to yell at her and say "Can't you see me wincing and squeezing my temples? That means yes!" But it might have made my face hurt more, so I just nodded meekly and walked away to pace the aisles.

Zofran is amazing. I have zero nausea now. I've administered it to many patients, but I'd never needed to try it myself. I give it my highest recommendation.

Vicoprofen, not so amazing. There is still no way I can sleep with this much pain, even though I have only had a total of six hours sleep the past two days. But it's tolerable. Barely. If I didn't have that prescription, I would probably have to go to the ER myself, another "drug-seeker with a toothache."

I've already spent $2000 today, I think I'll try to hold out a bit longer.

Oooo oooooh, that smell

He was blind from long-standing poorly-controlled diabetes, but he continued to keep his hemodialysis appointments faithfully. Minus one leg, he was able to ambulate with his prosthesis, although frequently his traumatized stump swelled up, so he used crutches as often as not. Not that it hurt. He had long ago lost the sensation in his legs. He just couldn't get the stump to fit in the old cuff. He was "waiting on a new one." But that wasn't his complaint today.

"Something stinks, doc. That isn't me is it?"

His "good leg" was now gangrenous and festering, and nobody had noticed. He only knew that something stunk, and the smell followed him everywhere.



She was a proud but quiet woman from South of the border, and she spoke not a word of English. Her family brought her to the ER because she was "getting weaker" and had a foul odor about her. Probably a UTI, I thought. We'll need her to change into a gown so I can examine her, I told her daughter. My Spanish was not so good in those days, and I was relieved to have a family member who could translate for me.

I stepped outside to give her privacy while she changed, and I had barely closed the door when I heard a yell from inside the room. "Doctor!" My first thought was that she had fallen. I rushed inside the room to see the woman with her head bowed and her daughter with a frightened expression. "Mira!"

The woman raised her blouse to reveal a necrotic, foul-smelling tumor the size of a grapefruit which replaced her left breast. She had never told anyone about it because she was embarrassed.

The need for speed

My patient had an intracranial hemorrhage, so I called her personal physician immediately, followed by the Neurosurgeon on call. The Neurosurgeon arrived in just a few minutes, well before the primary doc. She asked me, "how did he beat me here?"

I answered, jokingly, "Porsche."

I honestly had no idea what type of car the guy drove, I was just trying to be funny. But he looked at me quizzically, and asked "How did you know?"

I replied, "If I was a Neurosurgeon, I would drive a Porsche 911 Turbo."

Sure enough, that's what he had. Brand new, too.

Favorite Quotes

Part II
She's 21 years old, with three children and 4 previous abortions. I didn't ask her the sequence. She's pregnant again, and wants to be checked out. She complains of pain, but she's not really tender on exam. It's too early to hear fetal heart tones. I suspect she just wants an ultrasound. She knows the routine. When the examination is completed, we find that she has a viable intrauterine pregnancy. I ask her what her plans are.

"I think I'll keep this one," she said.

She must be rich, I thought to myself. I can barely afford my two kids, and I certainly couldn't have supported four at her age.

Breaking bad news

There is no feeling quite like the first moment I enter the room, when I know and he doesn't. It's sort of like opening the door to the "family room" after an unsuccessful CPR, when everyone is looking at you sort of hopefully, searching your expression for a clue to your next words. Only in this case, he really has no idea at all that you are about to tell him probably the worst news he has ever had. Or ever will have. It's surreal.

I don't know why, but I always say "I'm sorry" first. I guess it sets the mood. But it's also the absolute truth. I really am sorry.

I then say that we found a mass. It's probably cancer.

You have to say the C word so it sinks in how serious it is. Probably everything I say after that goes unremembered, but I have an unfortunately well-rehearsed speech in which I tell him that we won't know for sure until further tests are done, and what sorts of things he can expect to face. I never tell anyone "how long they have" because they may get in a fatal car accident on the way home, or they may be one of the lucky ones.

But I will tell them that most people won't live for 5 years if it is brain cancer - but only if they keep insisting on a time frame. As big as this one is, less than a year is more likely. But what a dificult year that will be. I really don't like to give prognoses, but I have seen over and over that many doctors won't, so generally people have unrealistic expectations. If nothing else, I am a realist and I don't pull any punches. I tell it like it is, because I would want to know everything if our roles were reversed.

The last thing I tell him is to not give up, because the ones who fight are the ones who have the best chance at beating it. And to make the most of whatever time he has left on this earth. Good advice for all of us, really.

Wash Your Hands

More than a century and a half has passed since the discovery by the great Hungarian physician Ignaz Semmelweis that handwashing prevents disease transmission. And yet, even today, his name is unknown to many medical professionals and his simple but effective mandate is inconsistently followed. Unheeded in life, forgotten after death.

A quote from the excellent review I linked above:

Ignatz Semmelweis, whose story this is, was a pioneer in medical prophylaxis, the innovator of hand-washing and antiseptic solutions for surgeons and obstetricians. Unbelievable as it seems, professors and their students in medical universities went from the dissecting room, where they demonstrated and practiced delivering babies from cadavers, to the Lying In rooms where they examined women about to give birth — all without washing or disinfecting their hands. A gratuitous rubbing of their bloody hands on their lab coats was considered ample readiness, and in fact the presence of bloody matter on their coats was deemed almost a badge of honor. Semmelweis turned that all around in a revolution that was to save millions of new mothers' lives all over the world. Did the majority of the doctors take kindly to removing their "badges of honor" for the sake of saving lives? One would think so, and one would be very wrong.

There are many lessons we can learn from this man's remarkable story. But it seems we still haven't learned the most important one of all: wash your hands.

Favorite Quotes

Part I
Schoolteachers' night out ends badly when one of them overindulges and unfortunately does a drunken faceplant on the sidewalk. She has moderate abrasions to her nose, forehead, and upper lip, and a 1 cm linear superficial cut to her eyebrow. They ask for a plastic surgeon. It's after midnight.

I explain that with a simple cut like that, the outcome will be the same no matter who sutures the wound, and I am an expert at such things anyway. The patient's schoolteacher friend shrieks at me....."It's her FACE, doctor!!!!!"

Umm, yeah. I know. But it's after midnight. Do you have a personal plastic surgeon? Well, no.

So I call in a plastic surgery resident, who sutures the wound.

Time

Whether you consider time the fourth dimension or not, it clearly is important to all of us. We all have a finite amount of it in our lives (on this earth anyway). Time spent in a waiting room, whether one is in pain or simply having other appointments that must be kept, seems like wasted time. Time spent waiting always seems to pass much slower than time spent "doing something."

Once you finally make it back into the "treatment area" of the ER, you might think that time will go much faster. Think again. If there weren't already a lot of patients ahead of you, or at least one very sick patient that needed a lot of attention, you wouldn't have had to wait that long in the first place. Most ERs have several rooms, and you just entered the last one.

While I am able to decide in about half a second that your sore throat and stuffy nose is less critical than the other patient who is vomiting blood across the hall, I might not have time to explain that to you. Sorry. I can also determine that you are going to survive with or without treatment in about 10 seconds, and that you probably don't need antibiotics for your viral illness in less than a minute. It might take a bit longer to explain these things to you, so in order to save time, we both might just prefer to give you an antibiotic anyway. After all, you've waited a few hours to be seen, you don't want to leave empty-handed, do you? I didn't think so.

Oh, and after I've stabilized the person who is vomiting blood, sutured the little girl with the cut on her face (who required quite a bit of my time to comfort and prepare for her traumatic ordeal), medicated the guy screaming with his kidney stone who thought he was going to die but was afraid that he wouldn't, and quickly evaluated the three other people with chest pain to get their workups started (they have to wait a bit longer time for their tests to come back, so I can pop in and see you now) . . .

it really doesn't do either of us any good when the first thing I hear from you is a complaint about how long you had to wait. It might have been better use of our time if you had spent your time preparing a concise statement of the medical issues that caused you to seek attention at 2 am. And when I ask you "what seems to be the trouble?" answering "didn't you read the nurse's note?" or "you tell me" isn't helpful or funny. Just get to the point.

Every minute you spend complaining about something neither of us can do anything about is another minute I must either shortchange you of some of our time together, or another minute the person after you has to wait to be seen. You don't want me to rush you, do you? So don't expect me to rush the patients in front of you so I can see you a couple of minutes sooner. You'd still be upset anyway, so I'm not going to stress out, run around, cut corners, or compromise anyone's care so you can go feed the dog.

My time philosophy is this: I really don't care how long you have to wait to be seen. My first goal is to make sure that nobody dies on my watch. My second goal is to make sure that everybody that needs care urgently to prevent serious complications gets that care as soon as possible. My third goal is to relieve pain in those who truly need it. Acute pain is more important than chronic pain. If you don't fall into one of those categories, it really doesn't matter to me how long you have to wait, because even if it is several hours it is still much sooner than you could be seen anywhere else. Deal with it.

When I finally DO get around to see you, I'm not going to rush you. I've already made sure that the people who needed to be evaluated before you have been taken care of. At this point, you are the most urgent patient in my ER, and I will give you all the attention that you require. That's my job.

Oops.....excuse me, I have to answer a page.

"Thank you, doctor!"

An elderly lady was brought into the ER by her daughter. She was so out of breath she couldn't even talk, breathing over 40 times a minute in gasps, her frail body heaving with each breath. She was having a heart attack, and her lungs were filled with fluid.

After an hour and a half of aggressive medical management she was pain free, breathing comfortably and able to speak. She was so mad at her daughter for bringing her in against her will, and angry at me for not letting her die. She was most upset with the bruises on her hands from the nurses' IV attempts. I knew that once she started complaining, that was a good sign she was feeling better.

I told her that if she wanted to die, she should have stayed home. I wasn't going to let her drown in front of me and I wasn't going to put her to sleep. Despite her heart attack, she did not have a terminal condition. It was reversible.

She asked, "How much longer does an old woman need?" She was depressed because her husband had died the year before, and she wanted to follow him. I told her that when it was her time, she would join him, but not tonight.

As she was being wheeled up to her room, I was touched because she finally seemed to show some gratitude. "Thank you doctor.....Thank you doctor," she said, holding up her hands....."for these bruises you gave me!"

I love my job. :)

Wild Animals

Part I

A 13 year old boy was coming to Houston with his parents to escape the hurricane. His fishing rod was in the back of the SUV, as was his dog. The dog tried to eat the fishing lure on the end of the rod, and a hook got stuck in his mouth. In the panic that ensued, the boy tried to help the dog and a treble hook on the same lure got stuck in his thumb. Now the kid and the fishing rod were attached to the frightened thrashing dog. Bummer.

The parents cut the hook somehow, took the dog to the vet and the kid to the ER. What an expensive day for them, on top of the stress from the hurricane and the long drive.


Part II

A 76 year old man who lives on a ranch out of town was awakened by a noise in his kitchen. He went to investigate and found a raccoon on top of his microwave. I asked him, "So what did you do?"

He said in a beautiful Texas drawl, "Well, I went over and tried to choke it to death." His hands and arms looked like they had been shoved in and out of a thorny rosebush 20 times, and he had a deep cut over his eyelid. He fell down during the battle and cut his eyelid. He asked me what I would have done in his situation. I answered, "Well I can tell you what I would NOT have done. Why didn't you get a bat or something?" He didn't have one, he said. "I guess he got the better of me." That thing must have been like a screeching, chattering buzzsaw, shredding that poor old man up. He was still able to throw it out the door.

Part of me admires him for being a tough old Texan, but yowch!

There are only three animals whose bites always require rabies shots in the US: bats, skunks, and raccoons. The shots have to be given into the wound, when possible, and repeated every few days. I saw him a few months later for something else, and he was doing great.

Still more stomach pumping fun....

A middle age man also got his stomach pumped and the charcoal mixture instilled. He then began to have copious diarrhea, as expected. The goal is to try to empty the stomach and intestines to get the offending medication out of the body before it can be absorbed. Things were going exactly as planned.

Anyway, this guy, who was also drunk and obnoxious, kept wanting the nurses to wipe his ass for him. His nurse was a golfing buddy of mine, a guy I have worked with for 10 years. He is a big ole country boy, well over 300 pounds, he is one of the best ER nurses anywhere, and he is unflappable.

So the patient comes out of the room and stumbles toward the bathroom in his hospital gown saying, "My ass is raw, come wipe my ass when I'm done." My buddy says, "You can clean yourself up, I'm not doing it for you."

The patient said, "Well you'll clean this up then." He lifted up his gown, bent over, and sprayed the black charcoal/diarrhea mixture five feet onto the wall and all over the floor.

My friend never missed a beat. He picked up the intercom, smiled at the patient, and said calmly.... "Housekeeping to Team A."

When the housekeeper arrived, the look on her face was unforgettable. Talk about a shitty job.

Perspective is important

A teenage girl who was pregnant tried to kill herself by ingesting a bunch of pills. In the vast majority of cases of overdose, the patient takes a medication that wouldn't kill them no matter how many they took, or takes an inadequate amount. It's an attention-seeking move....a call for help.

Nevertheless, in my younger days, I used to pump their stomach anyway as a form of negative reinforcement. Getting one's stomach pumped is very unpleasant. The tube we shove down the esophagus is as thick as your thumb, then we pump in and suck out a gallon of saline or tap water, then we pump in a pint of charcoal mixed with sorbitol, which acts as a laxative. We have big beefy guys to hold the patient down, if necessary.

Now, in my kinder gentler middle age, I give them the opportunity to just drink the charcoal if they prefer. That is memorable enough, usually just as effective, and there is less risk of injury.

Anyway, this pregnant girl got her stomach pumped, and some of the charcoal/vomit mixture got on her T-shirt after we pulled the tube out. When she realized this, after she had tried to kill herself and her baby mind you, and after we (perhaps) saved her life... she complained that we had ruined her T-shirt.

Veggie Tales

A well dressed 40 year old woman came into the ER complaining of a cucumber stuck inside her vagina. I typically ask the patient to tell me what their complaint is in their own words, but I made an exception this time because of the embarrassment factor. She already had to tell the triage nurse once.

With my favorite nurse assisting, we tried to remove the object. The patient was placed in the stirrups, and I inserted the speculum. Sure enough, there it was. Half a cucumber. It must have broken from the abuse.

The problem was, it was stuck pretty deep. And this was no ordinary cucumber. It was the biggest freaking cucumber I had ever seen, in diameter anyway. If you make a circle by putting your thumbs and index fingers together, you get the idea. I asked for some long ring forceps and tried to pull it out, but seeds and little chunks would just break off.

Finally, I just stuck both hands in and told her to PUSH! The thing came out just like a baby. I gave her a referral to follow up with a gyn doc, but I doubt she went.

The next day, one of the nurses put a dill pickle on my desk as a joke.

Scalpel or sword?

Words can cut delicately, like a scalpel, or slash viciously like a sword. I prefer to use the scalpel.