How rude!

From a recent complaint letter:

"Dr. Scalpel stared at me when I talked."

Maybe I should learn how to type into the computer while taking a history like some of the younger docs. It might even save a couple of minutes per patient and allow me to see a couple of extra patients per shift.

But it just doesn't seem natural.

I wonder if those docs get letters complaining that the doctor never looked at them?

Quote of the Day

Neil Entwistle was convicted in Massachusetts today of murdering his wife and 9 month old baby daughter. He faces a sentence of life in prison without the possibility of parole.

Prosecutors had argued that Entwistle was deeply in debt and unhappy with his sex life.

"I wonder how he'll like it now?"
- Shepard Smith, Fox News Anchor

On Treating Tigers

Tiger Woods won the 2008 US Open golf championship despite playing with a torn ACL and two stress fractures of his left tibia. He earned $1.35 million in prize money for that heroic effort, which will also probably increase his already stratospheric endorsement income next year (in 2007, he pocketed an estimated $100 million in endorsement deals alone). Now he's about to undergo surgery to repair his injuries.

When a 32 year old soon-to-be billionaire superstar seeks medical treatment, I doubt he has to get a referral from his PCP or approval from an HMO pencil-pusher. But as the John Ritter case revealed, when a rich celebrity suffers a disastrous medical outcome, the potential liability far exceeds any insurance coverage or assets of the treating physicians.

Sure, the Orthopedist will get to prominently display a signed picture in his office waiting room of Tiger shaking his hand, and he will likely benefit from the prestige of having such a high-profile patient. And I'm sure Tiger will pay his bill in full. But what is a reasonable fee for taking on the enormous liability risk of treating such a patient? (UPDATE - here is his Orthopedist)

And how would you like to be the ER doc who evaluates Tiger a week or two post-operatively when he is just passing through your part of the world on his Gulfstream V? And his leg is a little sore.

I'd frame the AMA form with his signature on it for my office wall.

Quote of the Weekend

Courtesy of a commenter on Malkin's blog:

“We in Germany cannot figure out why you are even bothering to hold an election.

On one side, you have a bitch (Hillary) who is a lawyer, married to a lawyer.

Alternatively, you have a lawyer (Obama) who is married to a bitch, who is also a lawyer.

On the other side, you have a war hero (McCain) who is married to a good looking woman, who owns a beer company.

Where is the contest here?”


Danke schön!

Advice to Interns

This column was originally posted in July of 2007.



For the benefit of the new interns, I'll now present my own perspective on internship.

I like to think that my own internship was more like this guy's than the type being advocated amongst some of my fellow medbloggers these days. I was a mediocre medical student, smack dab in the middle of the bell curve, but I ultimately became the best intern in my large program. "How could that be?" you might ask. Simple...I worked harder than anyone else. If you finished medical school at the top of your class, you are ahead of the game and you probably are already anticipating your cushy Dermatology lifestyle. Otherwise, if you want to be successful, you are going to have to turn it up a notch.

Here's a newsflash for you....the most competitive post-residency positions (whether they be Chief Residency slots, rare subspecialty fellowships, prestigious academic appointments, or deluxe private practices) tend to accept the very best residents rather than the slackers. The best residents, in turn, tend to be those who were the harder-working interns rather than the clock-punchers. This first year can really set the tone for your entire career.

On a non-call day, when everything is done then you might as well leave...but preferably not before the attending does. On call nights, there is always something to learn. I read about the medical conditions of my new admissions whenever I had time, because the most effective learning occurs at the point of contact. Memories are hard-wired when you can associate a medical condition or technique with a specific patient situation. I identified residents and attendings who had outstanding skills that I admired, and I learned as much as I could from them. But you aren't learning anything if you aren't in the hospital.

Extra effort counts. Come early, stay late. Be ultra-aggressive about tracking down results of labs and studies. Take the specimens to the lab yourself if it will speed things up. I did my own wet preps of cervical discharges. I went to the micro lab at midnight to personally gram stain the sputum of a couple of my new patients to impress one particularly venerable old-school attending. Obviously, this was before JCAHO screwed everything up, but nobody did those things back then either. I was hardcore.

I stayed up at night on call in the ICU to hand-draw graphs of the anion gaps and electrolyte trends of my DKA patients so I could post them outside the patients' doors before rounds. I spent extra time talking to families and planning discharges. I picked the brains of my fellow residents to find out what the special (quirky) interests of my next month's attending were, so that I could shine on the first day of rounds by demonstrating my newfound interest in inverse ratio ventilation or the nuances of pulmonary artery pressure measurement. One particular attending forbade the mention of trade names, so if a sleepy intern said Lasix instead of furosmide or Atrovent instead of ipratropium bromide, rounds would come to a halt while he got pimped and chastised. I wasn't that guy. Learn what your attendings want, and give it to them without their having to ask you for it. Your job is to make their job easy, and in doing so you will be amazed at how much you learn from the experience. If you hate your job, it's going to show. Be energetic and enthusiastic.

The first two months of internship everybody's pretty much just trying to stay afloat, but by the third month I knew my patients better than anyone else on the team, and I would arrive as early or stay as late as it took for me to make sure that they were well-cared for. I never called in sick the entire year, nor have I ever missed a shift since then.

When I trained, there were plenty of slacking interns. They were easy to identify because they didn't know shit about their patients, and it showed. They got embarrassed by their residents and attendings because they were worthless and weak. I wasn't that guy. I was the guy the residents and attendings wanted on their team. And yes, I was (and still am) married, and my wife was very understanding. Hundred hour plus workweeks are indeed difficult, but it's only for a year. Deal with it.

This first year as a physician is the foundation for the rest of your career. You can use this time to learn more about being a doctor than you did during your entire four years of medical school, or you can bitch and moan about how sleepy you are and how much abuse you are suffering at the hands of your cruel taskmasters. Your choice.

There are plenty of average interns out there. Don't be one of them. Use their mediocrity to make yourself look excellent by comparison.

The Dreaded Hand Tissue

An unfortunately common practice around these parts is for patients to hold onto a Kleenex for a prolonged period of time. Not a thin, billowy pristine one fresh out of the box, nor one carefully folded for convenient storage just in case it's required. No, I'm talking about the dreaded hand tissue, molded into a crusty tubular shape by the combination of absorbing various bodily secretions and applying what's left of Grandma's grip strength.

Now I don't know about you, but when I'm done with a Kleenex I throw it away immediately. The sole purpose of such tissue is to use it to collect stuff that you don't want to get on your hands. Otherwise you'd just blow your nose in your hand and wipe it on your jeans, right?

These patients missed that memo, it seems. They clandestinely hold onto their germ sponge until it's time to shake hands with their doctor, then they meekly transfer it to their left hand. Sometimes.

Oh, thanks, I appreciate that. You should see what was in MY hand a few minutes ago, lady.

Jedi Mind Trick

She was a pretty typical drug seeker, or so it seemed. There were multiple visits to our ER over the past few weeks, including one on the previous day. Fortunately she'd already had quite an extensive workup, and she had been given adequate prescriptions for powerful narcotics and even a few alternative analgesics. Her husband had called triage looking for her, and he told us that she had been going around to various ERs to obtain narcotics and that she'd just left another hospital across town. It seemed that there really wasn't going to be much that I could do for her except to have an unpleasant discussion.

I asked her the standard open-ended question, "So what can I do for you today?" and she told me her litany of woe without mentioning any of her recent ER visits, perhaps hoping that I hadn't reviewed her prior records. She even requested Dilaudid 4 mg IV, saying that she was a big lady who had built up quite a tolerance for narcotics over the years. She was unfailingly polite and seemed almost embarrassed to ask for her drug of choice, as if she didn't really want it.

When I mentioned that her husband had called, she wasn't upset at all; in fact she seemed relieved. We discussed her pain, her addiction, her family, and her options for more appropriate management of her condition (and her life).

Despite receiving no medications whatsoever during her visit, she thanked me and complimented me by telling me that I was the best doctor she had ever seen.

Sometimes what you want isn't really what you want.

Happy Fathers Day

photo credit

Hello?

"Dr. Scalpel, call on line 1."

Shit, I'm busy as hell and I don't have time for a phone call. Hello, Dr. Scalpel here.

"Hey, this is Dr. Huckfead over at Wickdeed ER. I'm seeing this lady over here that you guys did a CT scan on last week, and I need you to pull it up for me. Her name is Deborah Peel."

Who are you again?

"This is Dr. Dick Huckfead at Wickdeed ER."

Do I know you? What kind of doctor are you?

"I already told you I'm over at Wickdeed ER, what the hell kind of doctor do you think I am? I'm an ER doc."

How should I know? You're calling me when I'm busy and acting like I should know who you are and do you a favor. Most ER docs know that because of HIPAA guidelines, we need a release of information form signed by the patient and faxed to medical records before they will send you a CT report. I can't help you, Huckfead.

Click.

Best Bike Ride Ever

I went on a bike ride with my daughter today, and we noticed a bird flopping around on the ground in some distress. I wanted to leave it to the fate of nature's will, but she vetoed that idea, insisting that we try to save it.

I approached it slowly, and it hobbled away escaping through the bars of a fence. So we rode around to the other side of the fence and found it hiding under a bush. As we tried to catch it again, it flew up into a tree.

"See, it can fly. I guess it'll be OK," I said reassuringly.

Then it fell to the ground. So we had to ride around to the other side of the fence once again, where I was able to capture it fairly easily. It has a damaged left wing and a chunk out of it's butt, probably after having narrowly escaped from a cat, I would wager.

So I carried it in my right hand, steering the bike with my left hand all the way home. There is a local lady who is an expert in animal rescues who takes in injured animals and nurses them to health, so we'll bring it to her tonight.

Needless to say, my kittehs are very interested in our new pet. We made a little nest for it in one of their cat carriers.

19 Years

19 years ago I married the love of my life. We've been together much longer than that, though, since I was a sophomore in high school 26 years ago.

She was a senior cheerleader at another school, I was a skinny punk who drove a 10 year old station wagon and worked as a fry cook at Grandy's, but I had big dreams. I met her the very first weekend I had a license to drive, at the age of fifteen.

We met at a McDonald's, believe it or not. I eventually followed her to college, and she hasn't been able to get rid of me ever since the first night we met.

Happy anniversary, sweetie.

Appendicolith

Abdominal X-rays are usually normal or nonspecific in patients with appendicitis, but sometimes they can be helpful. The circled area shows a calcified structure in the expected location of the appendix consistent with an appendicolith.

The term appendicolith is preferred over the less specific terms, coprolith and fecolith. Approximately 10% of patients with acute appendicitis have a radiographically visible appendicolith. One third of surgically removed appendices, however, contain an appendicolith.

The calcification may form around any type of nidus, including a piece of vegetable matter, swallowed foreign body, or even barium. The appendicolith tends to be round or oval, smooth, and laminated. The size varies, but stones in the l-2 cm range are common with stones up to 4 cm in size having been reported. The location is usually in the right lower quadrant, but the pelvis, right upper quadrant in the case of retrocecal appendix, and even the left upper quadrant may be the site.

I can't vouch for those percentages. I've seen a bunch of appendicitis but only a handful of these, and none was so obvious as this one. Maybe I need to look harder.

The CT images from the same patient reveal a dilated inflamed appendix with a calcified appendicolith.




Here's a cool ultrasound video demonstrating a similar finding.