Poop Strong?

Monkey Girl, up on all things internet, has brought to my attention a cause that we at M.D.O.D. can support. We have given up on the 'take back the night' marches, and the 'race for the cure' runs, and the 'wear a ribbon against war' fad. Here is something all of us here are interested in and can endorse. We encourage you to do the same. PoopStrong... For the Children. File this one under Complimetary and Alternative Medicine. Besides, Manny Poopsalot, CEO and founder, has paid us lot of money to place this testimonial on our site. We are, after all, whores for money and for good, strong poops.

I celebrate myself, and sing myself.

I’ve been patting myself on the back so hard the last few days I feel like an auto-erotic respiratory therapist. Here’s the story:

A young guy comes in to our clinic with some complaints of who-knows-the-fuck-what (I’m a pathologist, do you actually think I know the patient’s history? Please.). Anyhoo, he gets a needle biopsy of a retroperitoneal mass they find on a CT scan. The case is assigned to one of our pathologists - a smart and experienced fellow from the old country. He’s not sure what it is and he shows the case around to several other pathologists who are stumped and ultimately the case is sent to an outside, nationally recognized “expert” for an opinion. So, the case is stained-up the wazoo (we have certain markers called immunohistochemical stains that will highlight specific cell types – aiding in classification of tumor type) and shown to everyone on Earth who knows anything about pathology (I’ve told myself one million times: do not exaggerate!). Well, no one has a good idea of what it is but several theories / guesses are floated, “clinical history” is sought from clinicians, conferences ensue and the entire world is wallowing in a morass of self-doubt and hopelessness.

Enter: me.

I was out the day the case came into the department and had not seen the slides. On their return from the “experts”, my colleague brings the case to me and puts a slide under the microscope. I glance briefly at the thinly-cut section stained pink and blue by hematoxalin and eosin. I think for a yoctosecond and declare triumphantly: “Has anyone fondled this guys nuts?”. Blank stares. Slowly, looks of understanding. And then, finally, awe. “It’s a metastatic seminoma. Go check out this guys balls.”

Another mystery solved; another life saved. “Great men are meteors that burn so that the earth may be lighted.” -Napoleon.

New Zealand

New Zealand has a socialized medical system. It's a lot like the U.K.'s or Canada's. Do you want this? Just askin'.

P.S. Thanks to an 'anonymous' comment in the prior light-hearted post we are back to the business of being a purely medical blog and fun will no longer be allowed. We are all physicians here, not people.

Apocalypto

Comments have been made here that the apocalypse is nigh. They have had to do with the college football season. This morning, while innocently watching ESPN SC Rundown, I saw, what I count, as the third clear sign of the apocalypse.

Brad Daugherty, formerly of UNC Tarheel basketball fame (and some who-cares NBA pro fame), was waxing poetic today about Jimmy Johnson's (apparently) unprecedented NASCAR 'season'. Johnson is the 'Nextel Cup' champion this year and is, I guess, a sort of athlete or something. See below to understand the sport that is NASCAR.

I would insert a *yawn* here but WHAT THE HELL?!?! Daugherty is a 6' 10'' cager for goodness' sake. We've got women commentators on the football sidelines (and thank goodness they are mostly hotties), we've got a male in the Michigan flag corps, we've got U of La- Monroe beating the Tide in Tuscaloosa, we've got Notre Dame versus Duke FOOTBALL as a nationally televised treat with many believeing Duke would win, we've got hoopsters talking about NASCAR.... the day of the Lord cometh like a thief in the night. Be prepared.


NASCAR Coach Reveals Winning Strategy: 'Drive Fast'

Your Tax Dollars at Work... EMS Style (plus bonus feature!)

Click title and take some phenergan before watching (thanks Brian and Jennifer and Monkey Girl).

And just to continue the theme, this patient comes to every ER in the country. Oh, and this one.

Momma's in Triage

I joke around with my nurses about this, but the more I think about it, the more it makes sense. Put my mom in triage, and watch the ED become an ED again. You know, like the old days on Emergency when they would wheel into Rampart with a diaphoretic construction worker they had just hung D5 on. (They always used D5)


You see, although she has no medical training per se, what she does have is some common sense, experience (she raised 7 kids, and before that her own family after her mom died), and balls. No, she isn't a hermaphrodite, but she is stubborn as a mule, and crazy like a fox-or maybe just crazy. And for better or for worse, she usually tells people how it is, or at least how she sees it. And in a community like ours, word would get around quickly that a " crazy lady is in triage, and we better find some other care, or better yet, go to our doctor (imagine that)".


Here's why it would work. She spent the better part of 27 years raising 7 kids, all of whom lived to graduate college. We were poor but did have insurance, as mom worked as a teacher full time. We got all of our immunizations, routine checkups were done, and believe it or not we survived all the normal childhood illness, sometimes with 3-4 kids sick at the same time. Occasionally we went to the doctors office, and even more rare was the ED visit. Probably 10 TOTAL visits for 7 kids over 27 years. These were usually for broken bones, turning yellow (my brother became very jaundiced with Hep A), lacerations or partial amputations. I guess she realized what was and was not an Emergency, or maybe just read the definition in the Dictionary- an unexpected situation (common colds and runny noses are expected) or sudden occurrence (back pain from a rear end MVA in 1994 is not sudden) of a serious and urgent nature that demands immediate action.


Now, there would be checks and balances, and if she was unsure about whether someone had a sudden occurrence of a serious and urgent nature that demanded immediate action she would ask one of the nurses on duty that would also take vitals. But my guess is she would be pretty good. She would require the "it's a spider bite " folks to bring in the "spider". She would tell the penis drip folks to put on a condom and go to the health dept. Most parents (usually just the mom at our ED) would be told to go home, hold and love their child and give Tylenol for the fever, and yes, there will be nights you don't get to sleep since you made the conscious decision to spread your legs and allow a sperm torpedo to inject you, and no I won't have the doctor give your child something to "get them to sleep". She would give the chronic pain folks a "life's not fair" speech so long and irritating they would never come back. But for most people passing through the door she would simply say, "what the heck is wrong with you to bother my son with this BULLSHIT?". (She may say bull dung).



Is it possible that she would miss something? Sure, but we all do every now and then. If you look at zebra illnesses, many are not an emergency at the initial visit anyway and require follow up visits. Is it possible hospital revenue might drop a little if you turn away paying patients. Possible, but I think it would be worth the risk to allow the focus back on EMERGENCIES (see definition above from American Heritage Dictionary-Second College Edition). But life is full of risks. Could we save lives if the speed limit was 35 EVERYWHERE (42,000 deaths last year). I suspect so. Could we reduce deaths if smoking was illegal EVERYWHERE. I suspect so. But these are not going to happen -you know, that personal responsibility thing and freedom to do and live as you please are still alive and well in this country. That responsibility also includes taking care of yourself, and seeking care at state hospitals, Christian clinics, and the like if you have no money or insurance. Yes, this may take a little effort, but again, life isn't fair. Patients that momma gently "redirected" would be referred to a clinic, family doctor, or health unit. My guess is that if you go back in time and follow people from school age and evaluate the decisions they have made ON THEIR OWN, you'll probably find out they made some bad ones or choose to pay for something else other than insurance (plasma screen, Kool menthols, meth). I shouldn't have to pay for their bad decisions and neither should momma.


Now sit back, be a fly on the wall, and watch momma go to work. Heck, she'd probably do it for free.



Finally I am starting an M.D.O.D. book club. These are not recommendations like Okras book club, this is mandatory reading. (I like calling her Okra)


This time I will start with One Nation Under Therapy by Christina Hoff Sommers. It points out a great deal about what's wrong with our touchy feely bullshit PC culture.


And The Politically Incorrect Guide to Global Warming and Environmentalism by Christopher Horner. Basically Al Gore is a dumb ass windbag eco-socialist.

q D

I committed an unpardonable sin tonight.

While in a hurry to write orders on a patient with community acquired pneumonia, I ordered "Levaquin 750mg IV q D". The "D" of course meaning "Day" as it has for for the 17 years I have been writing it, and the 40 or 50 years other docs have been using the same abbreviation.

About an hour later while trying to repair a complex through and through laceration to the ear (with cartilage involvement) on a bipolar patient with severe anxiety, I got an urgent phone call. So I removed my gloves, broke my sterile field, and picked up the phone.

"You used the q D abbreviation on Mr. XXXXXX's admit orders" I was told in broken English.

"So what? And who is this?" I replied.

It was the pharmacist and he refused to send the med because the order wasn't written as q Day. My perfectly legible "D" is of course considered unapproved by JCAHAO and so in the "best interest of patient care", they refused to send up his antibiotic, and placed an urgent call to me during a complex lac repair!

Turns out that I couldn't just give a verbal order to change my D to Day, I had to personally change the order....so the floor refused to accept the patient because the orders weren't "complete" until I finished the lac repair and could go change them.

One more example of how government encroachment into medicine HARMS and DELAYS patient care in the interest of "patient safety". We put two patients at risk (granted the risk is low, but it was unnecessary) in order to make them "more safe". This is just absurd.

I'd Rather Do it For Free

Thanks to GruntDoc for bringing this article to my attention. ERs are closing and some of the reasons why may surprise you.

Hypertension

I am curious and would like comment from others.

One of my PET PEEVES (and yes, there are a lot of them) is blood pressure. We get these people all day long sent to the ED because their blood pressure is "high". A few weeks ago, the dental assistant wasn't going to even let me see my dentist because I hadn't taken my meds that day and I don't like dentistry....so my pressure was 167/101.

Tonight, I had a typical scenario. A patient with blood pressures ranging from 170's / 100's was sent to the ED by his chiropractor. Turns out that they guy's arms had been tingling for 2 weeks (coincidentally about the same time the chiropractor started using some traction device that stretches the guy's neck). But TODAY, his blood pressure was high and he was rushed to the ED.

Of course, every headache patient has an elevated pressure, and most of the "total body tingly" patients have an elevated pressure. Our nurses freak out when I try and discharge anybody with a high pressure, and one local EMS service even gives sublingual nitroglycerine to anybody with an elevated pressure! I just don't get it.

Hasn't the evidence been pretty clear for about 15 years that urgent treatment of blood pressure is dangerous and contraindicated? (unless the diastolic is over about 130 or there is any evidence of end organ damage).

I get concerned when the patient has chest pain, shortness of breath, or neuro symptoms, but otherwise, I couldn't care less about the blood pressure. It's an outpatient workup, and treatment.

I try to educate patients, but I might as well try and educate the shrub in my front yard.

I get these people all day long who check their blood pressure 6 times a day and come to the ED the minute one reading is "high". By the time I see them, they've convinced themselves that they have all kinds of symptoms, and the blood pressure just must be the cause.

What do you guys do? (I don't mean Etotheipi.....I'd assume 0/0 is his normal patient).

A new one for me!

After this long you'd think I've seen almost everything. Yesterday EMS calls bringing in a trauma victim from a PLANE CRASH! Say what??!! A freakin' single engine plane crash! I've never seen a plane crash victim/survivior! Guy was pretty FUBAR, but will live..No great pics, just the usual assortment of broken shit and an HI..
Anybody else out there seen one of those? (being in the Armed Forces, God Bless those men and women, disqualifies you)

Second Opinions

What's the deal with the ED being used for second opinions?

Friday night, almost 50% of the patients I saw had been seen for their problem within a week of their ED visit. I didn't find or change any treatments on any of these folks.

One was a guy had months of abdominal pains. He had been admitted by GI to the hospital next door and had all of the appropriate labs plus an ultrasound, CT scan, MRI scan, EGD, and ERCP...all of which were negative. He came wanting a "different doctor" and "Demerol" plus a repeat of all of his tests!

Another patient was a child with otitis externa. He had been seen by his PCP that morning and started on oral antibiotics AND Floxin drops, but within 12 hours he just "wasn't better" and had "severe pain" (he was asleep at the time of exam). The parents seemed completely shocked that I told them that it might take him a couple of days to get better! They wanted him admitted until he was well.

It was so fun and interesting to be the "second opinion doctor" that I didn't have time to see the football player who was injured.

What a pain! Thank God for EMTALA to insure that these people could be evaluated in the ED whenever they wanted.

Maggots are People Too.

A maggot is a fly larva that enjoys feeding on dead flesh. They look sort-of like large grains of rice that wiggle.

If you have been in medicine for a few years, you will probably have seen maggots chewing on some guy’s foot ulcer. This is sounds pretty nasty, but in truth, maggots can be helpful. They will clean away dead tissue and prevent infection. They have been used for millennia for wound debridement and are still used today in some settings. As recently as WWII, in the days of limited antibiotic availability, wards of soldiers would have maggots applied to open wounds, saving life and limb.

I recently got a foot amputation specimen in the pathology lab. This had a deep heel ulcer extending to the bone (don’t get diabetes people!). I cut into the wound and hundreds of maggots poured out. My instinct was to puke, but then I recalled my admiration for these humble creatures. I sectioned and sampled the foot then placed it in a large jar of formaldehyde. My respect for fly larva was about to grow.

Formaldehyde (or Formalin) is a chemical agent used for fixing tissues. This roughly means that it stops meat from rotting. It turns human tissue firm (M.D.s will recall the feel of the bodies in gross anatomy – in a non-sexual way, we hope) and disinfects by killing organisms. In fact, it is such a good disinfectant that - at least according to the texts that I have read – everything is killed with the possible exception of prions (these cause the spongiform encephalopathies such as ‘mad-cow’, wasting disease of elk, kuru, fatal familial insomnia, scrapie, Gerstmann-Straussler-Scheinker and Creuzfeldt-Jacob disease. These are called ‘spongiform’ because when you cut up the brains of people and animals with these conditions, they have holes like a sponge – so, aside from not getting diabetes, please don’t ritualistically eat the brains of the dead like the Fore tribe in Papua New Guinea, ok!).

Anyway, two days after I put the foot in formalin, I went back to pull out an old specimen and I saw something moving in one of the adjacent jars. When I looked closer, it was the maggots swimming happily around, like a miniature koi pond filled with animated rice grains. Again, I gulped the vomit from the back of my throat; my heart filled with love for these beautiful infant flies. I thought to myself: ‘cockroaches are pussies’, and went back to work.

Halloween

Not to steal any attention from Etotheipi's MDOD post, but I was wondering if there are any good Halloween stories out there? I took my 11 year old by the nursing home/rehab center to visit my Mom. He was dressed as the Grim Reaper. Several of the residents tried to follow him out. Guess they thought it was their time!