"How Can You Tell?"

He was a middle-aged smoker, half a foot taller than the average male, and quite slender. Like many Texans, he had a penchant for spicy food and the reflux esophagitis to go with it. He'd been admitted a few months previously for an extensive chest pain workup which failed to detect any problems with his heart, but which did provide him with the diagnosis of a small hiatal hernia. And yet his father had died of a heart attack at a similar age, so he worried, as would most of us.

He was taking his proton pump inhibitor as prescribed, and he watched his diet as reasonably as any of us living in Tex-Mex heaven could be expected to do. But from time to time, he would still get chest pains, and each time he agonized whether to return to the ER for another $10,000+ workup. When he does finally decide to come to the ER, here is our dilemma:

• A normal ECG does not rule out a heart attack
• The first set of normal cardiac enzymes does not rule out a heart attack
• A GI cocktail, even if successful in relieving his pain, does not rule out a heart attack
• Epigastric pain described as "indigestion" does not rule out a heart attack, and in fact is a relatively common presentation for MI
  
• Epigastric tenderness does not rule out a heart attack
• The absence of shortness of breath or diaphoresis does not rule out a heart attack
  
• Tall slender individuals might have Marfan's Syndrome or spontaneous pneumothoraces, and yet a normal chest X-ray does not rule out dissecting aneurysm or pneumothorax. So he gets a CT scan too.
  

He just wanted to know what he could do to settle the issue so he didn't have to bankrupt himself with frequent ER visits, because he understood that every time he came in he was going to get a thorough and expensive workup. But he had seen what happened when his father didn't take his own chest pain seriously.

Should he get a heart cath? If his arteries were totally normal perhaps that would save him some money over time, but if he had any subtle coronary disease at all, he would still probably be need to be admitted each time he presented to the ER. Maybe CT angiography would be a reasonable alternative, although patients with his risk profile would still give ME heartburn if I sent any of them home.

It's a tough question with no easy answers. Of course quitting smoking, avoiding spicy food, and maybe a fundoplication procedure might help. Then again, they might not.

Quote of the Night

This one courtesy of a really old and really sweet yet slightly demented lady who had fallen and couldn't get up. After we worked her up and fixed her injuries, she'd been in the ER for quite a while. When I went in to check on her, she asked meekly:

"Am I going to get some soup?"

Why, yes. Yes you are.

Quote of the Night - Memorial Weekend Edition

An agitated psychotic man had sought care at the VA hospital before coming to our facility, but they wouldn't see him because he didn't have a DD 214 form.

"Are you a veteran?" I asked.

"I'm a veteran of the intergalactic war, man."

"Oh. Thanks for your service."

When Patients Attack

Nice post by EM Physician, and an older article I came across by Dr. Edwin Leap.

Uniformed and armed security is a wonderful thing in an ED.

MedBlogs and HIPAA

The section of HIPAA that appears to apply to medical bloggers is as follows:

WRONGFUL DISCLOSURE OF INDIVIDUALLY IDENTIFIABLE HEALTH INFORMATION

SEC. 1177.

(a) OFFENSE.--A person who knowingly and in violation of this part--

(1) uses or causes to be used a unique health identifier;

(2) obtains individually identifiable health information relating to an individual; or

(3) discloses individually identifiable health information to another person,

shall be punished as provided in subsection (b).

(b) PENALTIES.--A person described in subsection (a) shall--

(1) be fined not more than $50,000, imprisoned not more than 1 year, or both;

(2) if the offense is committed under false pretenses, be fined not more than $100,000, imprisoned not more than 5 years, or both; and

(3) if the offense is committed with intent to sell, transfer, or use individually identifiable health information for commercial advantage, personal gain, or malicious harm, be fined not more than $250,000, imprisoned not more than 10 years, or both.


The most important question seems to be "how is Individually Identifiable Health Information (IIHI) defined or interpreted?"

As best I can determine, IIHI is information that can actually link a patient to health information, or which can actually identify an individual or provide a reasonable basis for identifying the individual.

So what are the minimum requirements for bloggers to de-identify patient information and remain in compliance with this statute? The long version is here, but I'll give an overview of the criteria that seem to apply to bloggers.

The following information must be removed:

• Names
• All geographic subdivisions smaller than a State including street address, city, county, precinct, zip code, and their equivalent geocodes
• All elements of dates (except year) for dates directly related to an individual, including birth date, admission date, discharge date, date of death; and all ages over 89 and all elements of dates (including year) indicative of such age, except that such ages and elements may be aggregated into a single category of age 90 or older
• Full face photographic images and any comparable images
• Any other unique identifying number, characteristic, or code

Based on my interpretation of this, I'm not certain that non-anonymous bloggers should present medical cases at all unless the cases are radically altered or very generalized. If it is known that a physician, nurse, or other healthcare worker practices at a certain facility, for example, then the second requirement seems to be violated. Similarly, posts stating that a certain patient event occurred "last night" or "last week" seem to be in violation. I think "recently" would probably seem to be vague enough.

I'm certainly not an attorney and I'm probably misinterpreting the rule, but it seems like something we should discuss.

The Waiting Room

Worth the price of admission. Language warning.

"Everybody in the room seems to know each other. From what I can gather, it's from jail or the halfway house. A gaggle of white trash tweeker chicks begin reading aloud from some sort of pamphlet about clitoral stimulation. While this goes on, a group of crusty black women alternately praise and threaten violence against their children."

h/t Nurse Kelly

The Duality of Abscesses

I had the honor and pleasure of draining two disparate examples of skin abscesses during a recent shift, back to back. There seems to be a spectrum of boils, but for convenience sake, I'll divide them into two categories representing the polar opposites:


1) The thin-walled raised bubble, nearly painless to drain with an abundance of free-flowing pus ready to gush forth with a gentle stab of the blade. Step back!

Draining one of these babies is about as much fun as I can have in the ER, unless the drug reps bring chinese food.


and


2) The inflamed, indurated abscess; flatter and somewhat woody, this is really just a cellulitis with some scant pus interspersed. Universally painful to anesthetize, difficult to de-loculate, and disappointing in the amount of bounty obtainable. This class of abscess is often amenible to a trial of antibiotics, allowing a couple of days to ripen or defervesce if the patient is reliable and willing. Even if some pus is obtained with a needle aspiration beforehand, I've almost always wished I hadn't cut into this type after all is said and done. But I've occasionally been surprised.

The difference in feel between the two is sort of like the difference between slicing into a tomato and an orange.

(these aren't my pictures, btw, I stole them off the internet)

Is it Worth it?

Nice post by #1 Dinosaur.

"I assert that it is not about the money. Nor even about the lifestyle, really. At the end of the day, the week, the year, the career, it is about the life lived. Medicine is about a life lived impacting the lives of others. To call it Noble is old-fashioned, out of style and downright hokey. None of that changes the fact that it is true."

I enjoyed Sid's reply too.

No Time to Breathe

Every shift is madness these days.

Letter to the Impatient Patient

Dear Mr. Taipei:

I hope your "sinus infection" has improved since your ER visit. Despite your absence of fever, nasal congestion or cough, I understand why you might want to take an antibiotic at the first sign of a scratchy throat. Knowledgable medical consumers like yourself "don't want it to turn into strep" like it has so many times in the past, so the early administration of antibiotics is a must. Unfortunately, in this country, folks like you can't just go to the pharmacia and buy some ampicillina yourselves.

Bummer.

Instead, you had to take three hours out of your busy night to wait in a crowded emergency department with a bunch of people even sicker than you, if you can possibly imagine such a thing. Given your "Type A" personality, that wait must have seemed interminable. The frequent lookey-loo behavior you displayed as well as your angry trip to the nurses' station to loudly express your displeasure made that quite clear, rest assured.

You must not have noticed the sign on the wall that explained the triage procedure, or perhaps you thought that it didn't apply to important people like you. Or maybe you just didn't understand the word "acuity." Yes, I really do have patients here in this very ER with heart attacks and strokes, and no you cannot see their charts. I can't believe you even asked.

I realize that it would only take me a few seconds to write you an unnecssary antibiotic prescription, but it would take at least a couple of minutes to listen to you bitch about the waiting time some more, a couple of minutes to hear your littany of woe, a minute or two to actually examine you, and 5+ minutes to do all my charting.

I'm required to do all of that stuff before you can leave with your prized placebo, and I'm just not willing to make the little girl with the wrist fracture, the elderly lady with the syncopal episode or the guy with active chest pain wait any longer than they have to already just so you can be discharged in only a minimally less angry condition than your current state.

As I've said to those before you and will say again to many after you: "If you're sick, you'll stay." Excuse me.

chart notation: patient not in room at 0135. LWBS

Best wishes,

Scalpel

Diving Tigers

For those of you who don't read Ace of Spades every day, you should.

Original series of photos here.

Flea Gone

Best of luck getting through this, Flea.
I hope you emerge victoriously and come back stronger than ever.

Scamming the Scammers

Nigerian scammers trying to trick foreigners into sending them money are nothing new. You've probably seen their e-mails or at least heard about their schemes. This website is dedicated to turning the tables on these criminals. The participants reveal many examples of incredibly elaborate and hilarious responses to these e-mails, ultimately coaxing several of these scammers into humiliating themselves and spending some of the money they have stolen in ironic role-reversals.

One such result is this; a Nigerian scammer reinactment of the famous Monty Python Parrot sketch. It's really pretty funny on it's own merits, but when you consider the context in which it was created, it's terrific. The scambaiter tricked the scammer into creating this video by promising to pay him a large scholarship.


The background story is here.

Or, the short version:

"Six months ago, this wretched human being contacted me to explain he was moments from death as a result of the ravages of Esophageal Cancer. He had led a bad life. All he wanted to do before joining our dead parrot in the great big bird cage in the sky was to distribute his wealth to deserving charities... at a cost of course.



Obo battled on bravely with my requests, and eventually managed to carve a copy of my own head. Having failed miserably to protect my head in transit, it was partially eaten away by a hungry rodent (photochopped).


After apologising for the screw-up, Obo agreed to create another piece of artwork for me, this time in the form of a 17 foot tall painting of a book cover. As well all know, this was a complete and utter disaster, and Obo was ordered to complete yet another project which he did with great success. All this despite being weakened by the ravages of cancer. Ladies and gentleman, we have a hero on our hands!

Obo must be flushed with a feeling of success, and great anticipation of the thousands of dollars coming his way. Shall we spoil his party...? Shall we?"

Well done.

Beyond the Threshold

Any situation that requires an ER physician to go outside and retrieve a patient is usually going to be complicated and time-consuming, and I would wager that it is also more likely to end badly. Here are some examples with which I am personally familiar:

1) Two police officers unload an agitated psychotic crackhead on the ramp. Naked, sweating, yelling and struggling violently, he is a handful to say the least. Make that 10 handfuls: a beefy male ER tech is restraining each leg, the two officers are securing the torso and neck, and a male nurse has the pelvis when I finally go outside to see what I can do. This guy has five strong men on him and he's still bucking and kicking. Suddenly, he stops fighting. Is he playing possum? I check for his pulse, finding nothing. We carry him into the ER and begin CPR. He remains in asystole and fails to respond to any interventions. Another patient struck down by a "rare and controversial condition."

2) I hear a commotion at the ambulance ramp and run down the hall to see what's up. Lots of yelling and chaos. A young woman is in the back of a private auto surrounded by a small group of onlookers. Is she delivering a baby perhaps? Unfortunately not. She's been shot in the chest and dies despite our aggressive efforts to save her.

3) A woman is brought in for altered mental status, and that assessment seems to be on the money. A quick chart review shows a recent admission for cocaine overdose. While we are trying to verbally calm her down and assess her, she says she needs to pee. Good, we need a urine sample anyway. As the nurse is walking her to the bathroom, she breaks away and runs right out of the ER, across the parking lot, and faceplants into the bushes. A tech and I drag her back inside.

4) A psychotic suicidal young man is being transferred to a psychiatric facility. The EMS team arrives to transport him, but they seem uncomfortable and clueless. The patient has been calm the entire time he has been with us, but you can tell he is boiling inside and ready to blow. The ambulance crew mess around for quite a while, asking too many questions and stalling with paperwork and phone calls. When they are finally ready to transfer the patient to the EMS stretcher, he instead runs out of the ER and climbs up on the roof of a nearby parking garage, his elderly father following him. The police finally subdue him, red lasers illuminating his chest. He is transported by the police to the psych facility.

5) Shift change, 7:15 am. One of our ER nurses is walking out the door of the ER after a busy nightshift and is run over by an intoxicated driver who is backing up way too fast, in a hurry to be triaged for his low back pain. Our nurse thought she was done for the night, but she ended up staying in the hospital far longer than she had planned. A**hole patient-wannabe was triaged to jail.

Quote of the Night

Tonight's winner is from the still-quite-intoxicated young man who borrowed his friend's new motorcycle and wrecked it, suffering an open fracture and a nasty road rash in the process. He didn't take kindly to my suggestion that one shouldn't operate a motorcycle after having anything to drink, much less the large quantity of alcohol that he had obviously consumed.

Nor did he appreciate my suggestion that a helmet might have prevented the significantly disfiguring facial scars that will ultimately enable everyone he meets to forever remember him as That Dude With the F***ed Up Face.

Well, I didn't really say that. I just suggested that he should always wear a helmet when motorcycling. I made up that last part. Nevertheless, he obviously wasn't in the mood for any preventive medicine discussions:

"Are you going to lecture me, or are you going to fix me?" he snarled.

Well, actually, I'm going to do both. I'm good like that.

Nurse, can you get me a scrub brush please?

Foot in Mouth Disease

As a longtime sufferer, I've learned to hide my affliction for the most part. But around 4 am the brain fog sometimes rolls in, my defenses are weakened, and my cover is blown.

I learned years ago to never ask a woman if she is pregnant, or even worse, when is her due date. You only make that mistake once. Or if you're like me, twice.

But yet I've had a few awkward moments with age-mismatched couples. There is nowhere to hide when you assume that an older woman is a man's mother instead of his wife. Or that the little hottie with her slightly older male companion is his girlfriend instead of his daughter. And then I learn that she's only 15. Yikes, now I'm Akon. I guess I should have read the chart before I came in. I blame the milk hormones!

If a guy comes to the ER accompanied by another guy, it's usually safe to assume that they are partners...unless they are brothers. Guys just don't come to the ER with other guys. Unless they are both drunk, that is. With two women together, all bets are off. It's funny when they volunteer the fact that they are sisters before I have even sat down. I always appreciate the clarification, but it makes me wonder if it's because they can spot my disease so easily. I'm self-conscious like that.

A couple of weeks ago, my condition flared up again. I had asked the secretary to page Dr. O'Donnell, a lady doctor whom I had never spoken with before. When I took the call, the person I was speaking with sounded like James Earl Jones. Of course it was 4 am, so neither her voice nor my brain were functioning properly.

"Dr. O'Donnell?"

"Yes, this is Dr. O'Donnell."

"Oh, I'm sorry. I was trying to reach the female Dr. O'Donnell."

"This is she."

Ouch.


Then I did it again. A woman accompanying her son suggested a specific antibiotic combination that was perfectly appropriate and coincidentally exactly the combination that I had in mind.

"Are you a nurse?" I asked.

Fortunately she was, but that ill-advised assumption could have been embarrassing. I'm really not an idiot, I just have a disability that makes me look like one sometimes.

EMTALA Scam

This ought to be illegal. From the Houston Chronicle:

"Zee Klein wasn't about to just let her (91 year old septic demented) mother die, no matter what some hospital committee decided. But instead of waging a high-profile fight against the hospital, she decided to get her mother out on her own.

It wasn't going to be easy. For one, Medicare wouldn't cover (her mother's) care if she were transferred to Christus St. Joseph, the downtown hospital where a doctor had agreed to take the case. Her coverage for her particular diagnosis already had been exhausted at Memorial Hermann.

Further complicating matters, (her mother's) condition was deteriorating fast — by the time the hospital's futility committee ruled, she was in respiratory distress and her kidneys were failing. Doctors wrote in her chart that the discharge was against their advice.

"The patient was unstable," Castriotta said. "Given how sick she was, doctors felt her release would be dangerous."

The moment wasn't lost on Klein.

"She looked like she was in the throes of dying," said Klein, 68, who had previously cared for her late husband when he suffered a stroke and numerous heart attacks. "We didn't know how long she had."

Still, Klein had a plan. She would have her mother transferred back to St. Dominic nursing home for several hours, then taken to St. Joseph's emergency room, where federal law would require she be admitted.

But would she make it? (Her mother's) condition was so precarious that paramedics gave her oxygen through a respirator and stood ready to take her to a closer emergency room if it looked like she wouldn't survive the drive to St. Joseph.

On the afternoon of June 26, (her mother) was discharged from Memorial Hermann and started the journey..."

read the rest

No Mocking Allowed!

"They were supposed to be saving lives, not mocking them."

Two paramedics made an outrageous 50-minute tape on the job that shows their crude interactions with hookers and bums - and a nasty running commentary making fun of patients, neighborhoods and the FDNY, as reported by the New York Post.

The pair was forced to resign last week, but the public had no idea just how badly they betrayed their badges.

The disturbing revelations included:

• Running derogatory comments
  
• Mean-spirited pokes at the homeless
• Nasty pranks on drunks
• Sleeping while on duty
• Shocking prostitute breast exposures
• Raunchy lewd jokes at the expense of patients
• Photographing patients without department permission
• Personnel mocking their departments and their jobs
  

Gee, I've never done any of those things.

For those of us who might be characterized as mean-spirited mockers of homeless drunk prostitutes and other assorted interesting characters, anonymity is our friend. We should cherish and honor our friend, never betraying him, or else the PC police might smack us in the head with their humorless baton.

"They played it for a load of laughs, but it wasn't a joke once it went high up," an FDNY insider said.

Exactly.

Not a Drug Seeker

A middle-aged gentleman presented with a complaint of "cracked ribs." He had slipped in the bathroom the day before and just wanted to get checked out. The interesting part was that he drove 8 or 10 hours just to come to my ER. Hmmmmm....suspicious.

He didn't have any bruising, but he was a bit tender to the touch where he said he hit the counter. His X-rays did show a nondisplaced rib fracture without complications.

So we discussed the standard discharge instructions and precautions for chest wall injuries, and I offered him some pain medication, which he declined. "So why did you drive all the way here?" I asked him.

He said that he had just bought a new convertible and was excited about breaking it in.

"It's perfect weather for top-down driving," I agreed. "I've got a ragtop myself. But I'm sure you passed many ERs on the way here. Why us?"

He said that he had been a patient here several years ago and that he just liked our hospital. And he drove the whole trip with the top up. He declined to take any prescriptions, claiming that Motrin would be all he would need. He was planning to drive all the way back home the same day.

He was one of the nicest patients I have ever treated. But I really think he was from another planet.

Butterfly

This reminded me of someone today.

She Throws Poo

Nice rant by Monkeygirl.

Weirdest Link Ever

I love Technorati, because I love seeing who is linking to my posts, and I find some interesting blogs that way.

Like this link, from this blog.