Offensive, Defensive Medicine

Case: 54 year old male with intermittent bulge to right inguinal area accompanied with intermittent,  sharp pain.

Class? Diagnosis? Treatment?

Class, how should this be diagnosed?

Reality. Internist has an idea... does KUB.... it may show a nephrolith. Internist prescribes antibiotics and steroids. Refers Urology.

Urology is not sure.... orders CT scan. CT does not show stone.

Patient sent home. Still in pain. A week later goes back to internist with picture of said 'bulge'. Internist has more clear idea. Refers to General Surgeon #1. General surgeon #1 thinks he knows. Refers to General surgeon #2 who disagrees with General surgeon #1 but agrees to operate anyway. Is surprised there is a CT Scan that has been done. Inquires as to results of scan. They are negative. He operates anyway and discovers, three weeks into course of illnesss...

Class?

And what did we learn?

Tears in New Jersey

"Yeah mom, I'm like, SOOOOO bummed.... I mean, first I don't get into Princeton and now this! Those hicks down the road are SO obnoxious! Can I please get a ticket to come home tomorrow? I mean, we camped out for three days! The after party is just SO NOT HAPPENING! Please mom???? Can I get dad to take me to Bloomingdales?"

Ah, the delicioius, sweet nectar of a Dookie's tears. A beat-down in Cameron on national TV. Delicious. All the fat, big-haired, cystic acne plagued Jersey girls are pounding shots and pounding ugly Jersey guys and, like the last time I was there, probably burning dorm furniture.

Duke, the University of New Jersey in Durham. It's your safety school and you worship a pagan god with a bad haricut. And your god just got waxed.

Obama Pisses in the Pool

Hate it, just hate it when I end up being right. But you know our service members really should pull more of their own weight. Compared to government union workers I mean. 

Addicted or Dependent?

addiction  ad·dic·tion (ə-dĭk'shən)
n.
 Habitual psychological and physiological dependence on a substance or practice beyond one's voluntary control.

dependence  de·pend·ence (dĭ-pěn'dəns)
n.

1.  The state of being dependent, as for support.
2.  Subordination to someone or something needed or greatly desired.
3.  A compulsive or chronic need; an addiction.

After a discussion with a co-worker earlier this week, I have come to a grim realization.  Many in my line of work, myself included, are addicted.  Or are we dependent?  I’m wrestling between the two definitions.  It doesn’t help that when I reference the definition for the word “dependence” its definition includes the term “addiction.”  The thin line I have used at work to distinguish between the two is this: does this person have a legitimate condition which led to the use of this “drug” in the first place? 

I am ashamed to admit that I cannot clearly identify whether I have a psychological or physiologic need for my drug.  I’ve been a user for 18 years, on and off!  I don’t know if I could ever stop.  Even if the drug starts destroying my body, which it feels like it has, I’m not sure I could quit.  I could change drugs, but worry that I wouldn’t get the same high.  Not to mention that this drug is so easily accessible.  Other drugs would cost more, or I would have to look harder to find them.  If I switch to a new drug, it might be harder to get high.  I have spent long periods of time without it, but my co-workers will tell you that if I haven’t used in a few days, their first clue is that I look run down.  I become easily irritable.  I stop wearing makeup or doing my hair because I feel so crappy on the inside, I want it to show on the outside.  But when I get my fix, the world starts spinning on its axis again.  Even though a few of the drug’s effects are physically painful, I feel great.  I wake up at 4am because I want to get my fix before clinic opens at 6:30. 

Until recently, I didn’t think I experienced withdrawal symptoms when I didn’t use.  Today, I didn’t use until later in the day.  When I did, it was because I felt like crap.  I’d been dragging ass all day.  I assumed it was because I was up feeding the baby in the middle of the night, but not even a 2 hour nap in the mid-morning helped.  It wasn’t until I went in the garage and got high that I felt right again. 

Hi, I’m Old Trou PA and I’m addicted to running.

PCM - Prescribing Clinical Mayhem?

So my first question, 911Doc, is just how painful your penis enlargement was? 

You see, I have a patient who just underwent a penis reduction recently and his pain requires oxycontin and percocet scheduled.  Yet somehow, the consultant gets to be busy enough to avoid writing scripts for the narcs, telling the patient to follow up with his PCM.  Unfortunately for PVT Pile, his PCM only has a "community college" level education and slept through the 5 minute class about prescribing narcs in PA school. 



So for your enlargement, was the oxycontin enough, or did you end up going with something stronger? 

MDOD Mach 2

When change is in the air it always helps me to consult our spiritual guides, Spinal Tap. Since our awesome contributors of yesteryear have all either gone to prison or fled the country and in order to continue to bring you the absolute best in medical rants from the fruited plain I am pleased to tell you to watch THIS SPACE for two new MDOD contibutors. One is a fellow traveller, a disgruntled ER doc (is there any other kind) who has served in the military, done regular civilian ER work AND academic ER work. She has not chosen her screen name yet but look out, she's got a mean left hook and an attitude that is almost as bad as mine.

Our second new edition is a PA. She serves in one of the branches of our armed forces.... Okay, she's in the Coast Guard, I mean Air Force. Whatever, she's in uniform and she went to one of those taxpayer funded 'academies' that we all hear so much about. I have had the pleasure of working with her at my new guvmnt job and she is a fantastic medical provider who also posseses a stunning left-right combo. Don't cross her, I have seen her employ her academy-learned leadership skills and wow, I didn't know what balls being crushed sounded like but now I do. Eeek.

Okay ladies, chime in anytime, and don't mind Frank, he's probably rubbing one out right now just thinking about your first posts. Frank, go easy on 'em huh?

Ladies, I cede the floor to you.

More ER Docs Going Solo....

Some time ago I posted THIS. 

A good friend / ER doc just posted THIS.

And the universe inches ever closer to absolute zero. (very dramatic eh?)

Blogging My Surgery - Finis.... (I hope)

Eschars form at surgical sites, burn sites... they are scabs, deep ones, and sometimes when they fall off they start bleeding by pulling away the edge of a vein or an artery to which they are adhered.

The classic case for ER docs is the 'post tonsillectomy bleed'.... usually with kids... its seven days out from surgery and the scab pops off and BOOM, bright red pulsatile bleeding occurs and you better be ready with a good airway team because time is of the essence. It's always a trip to the OR for cautery or whatever the ENT docs are doing these days.

So this happened to me. In all seriousness, I won't be very specific, all my surgeons and docs did a great job, I'm not trying to nail anyone, I just had an infrequent but known post -op complication of massive bleeding after a small eschar popped off a high pressure vessel up in my oro-naso-retro-supra pharyngeal area. I survived and am doing well and there's only the remotest chance it will happen again in the next two weeks so I'm feeling pretty relaxed. PTSD much?

Rather than tell the story bit by bit I thought it would be more interesting to ask what would have happened to me if I were not an ER doctor who knew, the instant this thing popped, just what to do. See, I don't live near any MECCA and my local hospital had no one on call the night this thing went. But I knew all of this and was able to game the system.

Because of EMTALA, the life saving care I needed a few days ago was only available an hour away by helicopter. Our local hospital, now completely incapable of taking care of any surgical emergency after hours (and most surgical emergencies during operating hours) has simply become a way-station, picking the low hanging fruit of sick medical patients with insurance.

The complicated cases must go away because the specialists have gone away and they have gone away because they don't appreciate working for free more than twenty or thirty times a year.

Knowing this and while spewing vast amounts of bright red blood into my sink, I was able to instruct my life-partner (and ex-girlfriend) to say to the 911 operator "My husband is bleeding out.... We need an ambulance now.... the hospital needs to have trauma blood ready to transfuse.... Medic-Flight needs to be called now...." And then she pulled out the doctor card when the high school graduate on the other end of the line started asking things like, "...is the bleeding more or less than a teaspoonfull????"

Then she was able to speak directly with the local ER attending who knew me and knew this was the real deal and ALSO knew immediately that I had to be flown away as soon as possible.

And the local ER was great. They started tanking me with blood and, miraculously, the bleeding had slowed to a trickle, so at this point I was feeling very dizzy, but very good about my chances of making it to where they cold actually fix me. And obtw, JCAHO, your mandatory questions did get asked and were somehow just as important as the real issue at hand, and so for you JCAHO, I answered that I DO NOT feel safe at home, that I was NOT suicidal but, in fact, HOMICIDAL, and that I had lots and lots of guns in the house. Still waiting for the safety benefits of this mandatory JCAHO shit to accrue to me. Waiting..... Hmm, maybe those questions are worthless wastes of time.

Anyhoo. The Medic-flight crew wanted me to sit very still as they got me down to the place that still does complicated stuff. If that miraculous little clot were to dislodge then they were going to turn into a flying blood fountain with the flight medics desperately trying to get an airway in me at 4500 feet with me choking on my own blood. One of the nice things of this excursion was that my hero-clot stood his ground. Way to go Hercules!

Down at the place where they still do medicine and surgery that is hard I was a fairly routine case. The attending surgeon peaked in at one point and the Chief Resident and third year resident fixed me up. Nice work ladies and gentlemen. Really great.

And hey, anesthesia guys, I was just there last week and you fell for the "I'm allergic to succinylcholine" line again! It paralyzes me dudes! Every time! Glad you thought it was funny too. Oh, and nurse in the second ER, sorry about the "you guys don't have a Foley big enough for me" comment, but I was feeling it a bit, you know, realizing, I was probably not going to die.

So here I am. Walking around gingerly, trying not to sneeze or cough. Waiting for the chances of this popping off again to go close enough to zero to go back to my normal routine, and thanking God that I'm typing this, and wondering, just a bit, what would have happened if I did not know exactly what was happening to me when it happened, did not call ahead and get everybody from EMS to local ER to Medic-flight prepped for what was coming, and did not get lucky with a good weather night for helicopter transport AND get lucky with the availability of a bird.

In other words, what if I was Joe Schmoe? Joe would probably be dead, and he would probably be dead due to EMTALA. And we are trying to turn the whole deal into the 'model' built from the worst piece of medical legislation ever passed in this country.

But to end on a positive. Seeing what I used to do full-time through the eyes of a truly emergent patient made me proud to have been a part. You Medics and Nurses and Docs who continue to do this.... you are simply the best. I am proud to have played on your team. RW, you are a saint.

Must Sleep (blogging my surgery day 7 ??)

Just got home from my adventure. Can't stay awake. The adventure started with a sound, a bruit, proceeded directly to me becoming a bloody fountain and yelling for my wife to call 911, the sound of an ambulance, the sound of a helicopter, and to the sound of me hocking up bloody chunks all last night. Because of the hocking up bloody chunks I did not sleep. But I'm going to try again now and then I'll fill in the blanks.

Don't Blog Your Surgery (post op day 6)

Guesses? Oh it's a good story so do guess! More info when I have more than an iPhone.

The Death of the Individual (post surgical day 5)

I wish I felt well enough to try and do this justice.

Our country is eschewing personal for corporate responsibility. This is not news. It is, however, tragic.

Medicine, once populated by rugged individualistic types who both made tough decisions, performed difficult procedures under pressure, and took the consequences of failure, is now being populated by 'teams'.

Example: After my surgery I felt like shit, and that may sound silly to say, but YOU SHOULD NOT feel like shit right after. In fact, right after is usually the honeymoon period when the local anesthetic is still cooking, the general has just come off, and you are getting some pretty good drugs.

Well I felt so shitty I asked them, 'what did you give me?' and the answer was 'droperidol for nausea and .....'

Droperidol is great for nausea, but it makes you feel like SHIT. It's essentailly a short acting Haldol and we used to give it like candy in residency to get people to STFU and quit spitting on us and it worked great. Then it got black-boxed by the FDA for, supposedly, it's potential to generate dangerous heart rhythms.

So I wake up and feel like shit and simply want to go to sleep. I try, but I keep waking up choking. I paged the nurse and she came in and I pointed out to her that not only was my pulse oximeter not connected, that I was not on a monitor either and didn't I get droperidol in the OR?

Her answer?? "Sir, I am a CHARGE NURSE. The care team comes by to check vitals every four to eight hourse."

Glad they didn't find me cold and blue. She didn't even process my question, she just answered with the 'it's not my job' answer. It's the care team... the care team will take care of it. SHIT.