Life's Rich Pageant

One of the interesting things about being an ER doc is the opportunity to meet people from all walks of life; from all parts of the world, from every socioeconomic class. Accidents and emergencies affect all of us eventually. If I have time, I try to get to know them a little bit, to learn something about their life, or at least try to get a feel for what sort of person they are.

I have met professional athletes and multimillionaire CEOs who travel by helicopter, and some local and national political figures and TV newscasters. I have been face to face with plenty of death row and life inmates, battered spouses (men and women), people contemplating suicide and those who tried and failed. I've met every sort of drug addict and psycopath, hundreds of homeless scavengers, gypsies, and various people from probably most of the free countries in the world. And of course, plenty of plain folks like me. Everybody's got a story, and sometimes we both happen to have time to just talk a bit.

I am especially delighted to see someone really really old with all of their mental faculties intact, like the 95 year old woman I met tonight. Married 70 years, she was a former schoolteacher. She looked like she could still teach, if she wanted to.

I recently took care of a young man who was just released from prison at age 30. He has been incarcerated since he was 10 years old. Unfortunately, he was too intoxicated to tell me much, but I would have liked to hear some of his stories.

I recall one inmate I treated several years ago who was 40 years old, with terminal metastatic breast cancer. She kept saying that she wanted to get paroled so that she could see her children one last time before she died. I even wrote a letter to the governor, asking that she might be given leniency. A couple of months later I saw a story about her on a local TV newscast and learned that she was serving a life sentence for arson and attempted murder. She had set her house on fire with her husband and children sleeping inside.

ADDENDUM: During my arrangement of the post, I cut out (and forgot to paste) my mention of the camaraderie with the policemen, firefighters, and paramedics. They always have some of the best stories to tell, and most people rarely have the opportunity to interact with them outside of a professional capacity. Spending time with them when we have a few minutes to trade stories is one of my favorite pleasures. God bless all of them for what they do to keep us safe.

This must never happen

Two patients named Sanchez (name changed) were in our ED at the same time. One was an elderly lady, the other a young man. Neither spoke a word of English, nor did their families. The unfortunate Mr. Sanchez had fallen after a few too many cervezas and had an obviously broken or dislocated finger. Mrs. Sanchez was suffering from altered mental status, presumedly from hepatic encephalopathy. The patients were not related, as far as we know.

I looked at the hand X ray of Mr. Sanchez, and I was surprised to see that it was entirely normal. Could the radiology technician have X-rayed his other hand? I found an interpreter and asked Mr. Sanchez which hand was imaged. He didn't remember getting any X-rays at all. He was so drunk that I still wasn't sure, but his parents confirmed his story.

His finger was grotesquely angulated, and there was no way this was his film, so I asked for a repeat X-ray which clearly showed the displaced fracture.

So whose X-ray was it? As it turns out, they had X-rayed the hand of Mrs. Sanchez's husband, who wasn't even a patient. I wonder what he was thinking when the tech came to take him to the radiology suite?

Mr. Sanchez?

Si (yes, I am Mr. Sanchez)

Follow me, I'm going to take you to X-ray

Que? (I don't speak English, lady)

Tech gestures with hand to follow her...

Things I Have Noticed

1) If you present to the ER with chief complaints of headache AND chest pain, then you are most likely suffering from an anxiety disorder. You get bonus points if you are a youngish female. Caveat: this assumes that there is no fever, that the blood pressure is reasonably normal, and that no nitroglycerine has been given. Certainly patients with chest pain who are given nitroglycerine often complain of headache afterwards. And patients with the flu usually hurt all over and it's obvious they are sick. These are not the patients I am considering. Typically, patients with heart attacks don't complain of headaches, and patients with intracerebral catastrophes don't complain of chest pain.

Don't worry, I'm still going to do the CT scans, ECG, cardiac monitoring, and blood tests anyway. I'll probably even admit you. Maybe you've got Lyme Disease. Probably not. Expect a humongous bill when you are discharged with nothing. It costs a lot to make sure your anxiety disorder isn't something worse, and either of your complaints MIGHT be something serious. However, in my experience, the presence of chest pain and headache together is almost diagnostic of anxiety disorder without any tests at all. Unfortunately the lawyers have trained us to order a gazillion tests and overadmit to cover our butts.

Interestingly, studies show that performing MRI scans on patients with chronic headaches is cost effective (due to decreased utilization of subsequent resources), but it is cheaper to empirically treat patients (with proton pump inhibitors) who are diagnosed with noncardiac chest pain rather than working them up further for gastrointestinal causes.

2) You cannot feel when your blood pressure goes up, and it is not causing your headache. In fact, patients with high blood pressure are less likely to get headaches. And if you are worried about a blood pressure of 160/90, then it is likely your anxiety that is driving up your blood pressure. You've probably been taking your BP every 5-10 minutes, and you will bring me several handwritten pages of the strikingly similar BP readings. Which brings me to #3....

3) A patient who has multiple somatic complaints and brings a meticulously detailed litany of their often nonphysiologic symptoms is batshit crazy. There is nothing physically wrong with that person. But she too will undergo the expensive megaworkup. And she will be shocked...SHOCKED!... that all her tests came back normal. "Then why do I feel this way?" she will ask. When I suggest that her symptoms are likely psychosomatic or anxiety-related, she will storm out of the ED in anger, not even willing to consider the possibility that she might have a psychiatric condition. But she does. As soon as she pulls out THE LIST, I know immediately.

In Honor of Joints

Congratulations on your new blog.





Satisfy My Soul

Roots Rock Reggae

Stir It Up

Pain in the butt

I strained something in my sacroiliac area this weekend. Thursday I had played golf for the first time in a year or so, and I awakened Friday with generalized soreness, as I expected. In my experience, the best way to work out the soreness is to stay active, so I powerwashed the patio and worked on the pool a bit. As I bent over to dump some chemicals in the pool, a sharp pain in my left lower back/buttock area screamed HELLO!

"You have ignored me for a long time, but this.....SHARP.....PAIN! will ensure that you give me my proper respect from now on," my butt muscle taunted. Even so, it seemed nothing more than a little tweak; a nuisance that would soon be over and done with. I've had worse, I thought.

Not so, my middle-aged body was about to tell me the next morning. When I awakened, I found that I couldn't turn over without the sensation of a hot poker impaling my butt cheek. Nor could I sit up. And yet, my bladder begged relief of its discomfort too. I must get up. As I forced myself to stand up, I let out a scream that would have made Howard Dean jealous. My vision started to go black as I nearly passed out, so I lay back down on the bed.

My son came running to see what was the matter, never having heard such a shreak before, certainly not from me. I must have a low pain tolerance, I thought to myself. It took me twenty minutes and several more Deans to get out of bed and limp to the bathroom.

It's weird how one little muscle can stop you in your tracks. The ability to walk is a complicated symphony of movements, and if any one component is injured then walking becomes difficult. The main impairment with this injury is the ability to bend over or to get out of a chair. Unfortunately, these are two motions that are required numerous times during the course of an ED shift, and so until I am healed I am unable to work.

I can barely put my pants on, and driving is out of the question. But I'm getting better, slowly.

New treatment for DVT

This blows me away. A deep venous thrombosis is crossed with a wire via a percutaneous approach, balloons are inflated on either side of the clot, a thrombolytic is administered through ports between the balloons (remaining in the target area), a spinning twisted wire acts like a blender which chops up the clot, and then everything is sucked back up into the catheter. Instant cure. Video animation here.

From the website of the catheter manufacturer (Bacchus Vascular):

The Trellis® - 8 Peripheral Infusion System is an advanced Isolated Thrombolysis catheter with two occluding balloons, drug infusion holes between the balloons, and mechanical drug dispersion capabilities. This pharmaco-mechanical combination enables focused treatment of thrombus within a targeted vessel.


Looks promising to me. I have no financial (or any other) connection with this company, by the way, but I wish I did.

Painful Toenail

Psycho Therapy

Damn, I miss the Ramones. And I love YouTube.
The future of media is on-demand downloads.

I Don't Wanna Walk Around With You


Blitzkrieg Bop (amazing video!)



Rockaway Beach

Teenage Lobotomy

Pinhead

Shock Treatment/Kill That Girl

R.A.M.O.N.E.S.

MTV Movie Award Medley - a must see!

Themes

The themes were well-defined that week. One night it was the head injury theme. Three come to mind, if only because they all were equally doubtful in their mechanisms. But who am I to cast aspersions on a carefully constructed history?

Can a softball really break so many bones in the face? I suppose it can, but yuck. That one took calls to three different surgeons before I found one who sounded confident about fixing it. While I was dealing with that conundrum, my nurse said "OMG, the one in the waiting room is even worse than him!" Worse how, I asked. "Well, her eye is sticking out and stuff." Her eye? "Well her eyelid, I guess. But it's gross." That's what happens when you wait until the next day to seek attention. The eyelids can swell grotesquely. She reportedly broke up a barfight and got hit in the face with a chair. You always have to wonder about left facial injuries, because most people punch with the right hand only. Then there was the frying pan that mysteriously fell off a high shelf at work, striking the dude without obvious sign of injury. Yes, you can have a work note.

The next night it was the viral upper respiratory theme. I had that bug myself, so I know that it can't be treated. But I treated most of them anyway, because I'm not an antibiotic Nazi. If I tell you that it's viral and that antibiotics won't help, but you still want antibiotics anyway, then go for it little mama. I hope you have enough money left to pay my bill. Honestly, I'd rather overtreat a thousand snotty nose kids than get one complaint letter that says "that doctor told me it was a virus, but the next day my pediatrician said it was pneumonia." Did he do an X-ray? Probably not, he just wanted to be the "good cop." Thanks a bunch, oh master of small adults.

Finally, the theme I hate most of all: the young woman with left arm numbness. Early 30s, employed, worried, insured. At least you'd better hope you are insured, honey, because you won't believe how expensive the workup is for that complaint. Is it a stroke? A "mini-stroke?" A heart attack? A "warning of a heart attack?" Pinched nerve in the neck? Stress? "Gas?" For some cultural reason I don't understand, many nonwhites often presume that the cause of every symptom from the rectum to the fingertips is "gas." Which is fine with me, because that answer is probably as reasonable as anything I am going to be able to figure out, even after 10K worth of tests. Your mama is usually right about gas, I must admit.

The elderly lady who "just isn't eating" "just isn't herself" or is "weak and dizzy" is much easier, because she'll probably have something abnormal on one of her tests, even if it's just a UTI or chronic microvascular disease on her CT. But the 30 year old chick with no sign of anything on her exam, CT, ECG, or megalab workup? She's a harder sell, but if she wants to be admitted, I'll try to spin it. Then she can be discharged by someone smarter than me, with a diagnosis of GERD.

Otherwise known as gas.

Chief complaint of the night

"Oh my GOD....Finally!" the old woman said as I entered the room. She'd only checked into triage 45 minutes ago, I recalled, and her chart said that she'd cut herself a few days ago. Yup, it was starting to get a little red. I wondered what her hurry was. Not another facelift, I hoped. It looked like she'd already maxed out on those. Was she late for her etiquette lesson, perhaps?

"My dog is in the car. I had no idea it would take this long."

Cat of the day

Taser Deaths and Agitated Delirium

Eager to blame the deaths of violent suspects on the police officers who subdue them, ACLU types often call for a moratorium on the use of Tasers.


If you have never seen this hilarious video of a disrespectful young woman who thinks she can ignore the orders of a police officer ("Get out of the car now, or I'm going to taze you!"), then you are in for a treat. Bzzzzzzzzt!

How about a moratorium on "playing the race card," honey?

This extensive review of 167 deaths which were associated with the use of tasers by police officers revealed that the vast majority of suspects died as a result of agitated delirium related to cocaine and/or methamphetamine abuse. I didn't see a single instance in my quick review of those cases where the use of the taser was identified as the cause of death. And I don't recall any cases where drug abuse or psychotic agitation wasn't a feature.

It is unfortunate that police officers, medical personnel, and security officers are inappropriately blamed for the deaths of crazed drug abusers when in reality these deaths are a well-known endpoint to the condition known as agitated delirium.

Patients with agitated delirium in the setting of a simulant-induced psychosis commonly die while they are being subdued and restrained, whether they have been tazed or not. Yet every time I read about such an occurrence in the media, it is presented as an unusual event. Maybe it was the taser....maybe it was the chokehold.....

Maybe it was the drugs. Ya think?

Automated External Defibrillator

Three Houston-area teenagers died last month during football practices, and another local teenage athlete died this week while running track.

Next week, the University Interscholastic League will consider requiring each high school in Texas to have an AED on site.

An automated external defibrillator (AED) is a portable electronic device that diagnoses and treats cardiac arrest by re-establishing an effective heart rhythm. An AED is called external because the operator applies the electrode pads to the bare chest of the victim, unlike internal defibrillators, which have electrodes surgically implanted inside the body of a patient (like the one sported by Vice President Dick Cheney).

Once the pads are attached to the patient by a trained bystander, the AED diagnoses the heart rhythm and determines if a shock is needed to treat fibrillation. If the device determines that a shock is necessary, it will charge in preparation to deliver the shock. When charged, the device instructs the user to ensure no one is touching the victim and then to press a button to deliver the shock. After the shock is delivered, the device again monitors the heart rhythm of the victim to determine if another shock is necessary.

While we can't say that such a device would have saved the lives of the young athletes who recently died, these devices clearly have been shown to increase the chance of survival after witnessed cardiac arrests.

The American Red Cross claims that more than 200,000 Americans die of sudden cardiac arrest every year, and that up to 50,000 of these deaths could be prevented by initiating the Cardiac Chain of Survival and having an automated external defibrillator (AED) available for immediate use at the time of the emergency.

Full Moon Weekend

Good luck everyone. I'm off.

HAHAHAHAHA! (evil laugh)

Frog of the day

I found this little critter as I was cleaning out the pool. At first I thought he (she?) was just another leaf, but when I tried to scoop it up it swam away amazingly fast. Eventually, superior technology won out, and I brought it back to land.

An Army Nurse at Gitmo Speaks Out

Great stuff, from Patterico. This is an interview with a male psychiatric nurse who spoke at length with most of the detainees at Guantanamo Bay during his assignment there.

I know Zarqawi, the terrorist said to the American. I am going to have Zarqawi cut off your family’s head while you watch. Then he will cut off your head.

The terrorist said it all in a matter-of-fact way, looking the American straight in the eye.

The American was not frightened. There was little danger that the terrorist was going to carry out his threat . . . at least any time soon.

The terrorist was a detainee at Guantánamo Bay, Cuba, and the American was an Army nurse who worked with Guantánamo detainees with psychological and/or behavioral problems. For six months, he spoke with detainees on a daily basis, and built a rapport of sorts with some of the most troublesome terrorists at Guantánamo.

He discusses the true nature of the detainees who are being held at that facility in this part of the interview.

Stashiu is not able to share specific details of conversations he had with specific individuals, for reasons having to do principally with patient confidentiality, and in part with operational security. But he can give you, the reader, a good overview of what types of human beings are being detained at Guantánamo Bay.

I asked him that very question: what are the detainees like? Stashiu said:

For many of them, think Ted Bundy. Educated, charming, and without conscience for those they consider infidels. Some are truly ill and were taken advantage of because of it. For example, one routinely asked us for an explosive suicide vest so he could assassinate Osama Bin Laden or George Bush for us, whoever he could find first (he was completely serious).

If you are the least bit interested in the war on terror (and who isn't), you might want to read the whole series.

More Nonsense

When I first started working at this emergency department several years ago, one page did it all. The triage nurse would write the patient's chief complaint, a basic past medical history, the initial vital signs, the current medications, and the allergies. All on one fourth of a page.

Below that there were several lines for physicians to order medications, and at the bottom there was an area to order laboratory tests and radiology studies.

Over time, various changes to this effective document have been proposed by meddling management types, certainly with the best of intentions but unfortunately lacking the benefit of reason. For a few months we had a little red stamper the triage nurse had to stamp on this sheet and check off yes/no boxes relating to TB warning signs. Fever? Night sweats? Weight loss? I'm not sure who authorized the discontinuation of that initiative, but probably someone finally realized that we just don't have enough TB cases where I work to justify such an aggressive screening program during triage.

Now we have a little box in the corner for the triage nurses to check documenting that they have asked the patient "if anyone has threatened them." Yes/No. I'm not sure what we do with that answer, but the box remains. Sometimes checked, sometimes not.

A witty nurse manager decided one day that our nurses were no longer going to take vital signs in triage. I swear to God this is true. Well, you might be thinking, the techs can take vitals too, that might be a way to save some time. But nobody was going to take them, according to this plan. The vital signs would be taken after the patient was brought back to a room. The very second I heard this I told the triage nurses working with me that I didn't really care if they did anything else BUT take vital signs, but they sure as hell weren't going to omit them while I was working. Of course they all agreed with me, and I never heard anything else about it again.

The latest revelation is that the physicians medication orders are no longer allowed to be written in the space provided for that purpose. There is a gray box covering the area which says "do not write orders in this space." We have another separate page to write our medication orders now.

The medication allergy section has been grayed out too. The triage nurses have been told not to write the patient's allergies on the triage note. Do they write that important information on the page where we order medications? Of course not. There is a totally separate page for allergies to medications. And another page to write down the patient's current medications. And about 10 more pages of other administrative crap that serves to camouflage those pages so that we can't find them when we need them.

Shock the monkey!

Quote of the day

LAKELAND, Florida (AP) -- Officers fired 110 rounds of ammunition at the man suspected of killing a sheriff's deputy, according to an autopsy and records released by the sheriff's office Saturday.

Angilo Freeland -- who was suspected of fatally shooting the deputy after being pulled over for speeding Thursday -- was hit 68 times by the SWAT team members' shots, the examination showed. He also was suspected of wounding a deputy and killing a police dog.

Polk County Sheriff Grady Judd said he was not concerned by the number of shots fired.

"You have to understand, he had already shot and killed a deputy, he had already shot and killed a K-9 and he shot and injured another deputy," Judd said by phone Saturday. "Quite frankly, we weren't taking any chances."

Ten SWAT officers surrounded Freeland on Friday as he hid beneath brush and a fallen tree in a rural area. Authorities say he raised the gun belonging to the deputy he had killed, prompting nine officers to fire.


"I suspect the only reason 110 rounds was all that was fired was that's all the ammunition they had," Judd said.

Sheriff Grady Judd....you are the man.