Waffle-Master

ED docs and radiologists have a strange relationship. For that matter, I guess most docs have a strange relationship with their radiologists. The radiologist sits in a dark cave (as opposed to the well-lit cave favored by pathologists) or at home in front of a high-resolution video monitor, reads films and scans, reports back to the ordering physician, and never sees or lays hands on the patient. They don't own stethoscopes. They are great at what they do, and, even though I read every X-ray and, increasingly, most CT scans, they are just much better at finding stuff than I'll ever be and I couldn't do what I do without them. Neither could the surgeons or the internist or the orthopedists. That being said...

The dig on the radiologists is that they are notoriously Clinton-like in their reads. For instance, I might order a CT scan to look for kidney stones and, with the report about the presence of absence of stones, the radiologist is likely to tell me about 5 or 6 other "interesting" anomalies, often termed "ditzels" or "lucencies" or "hypodensities", which I then have to explain. Any of the above might represent the early manifestations of cancer or prion associated disease so it's not something we can just blow-off.

Most are great and know what I care about, but some, well, some are not helpful at all. Some truly do represent the internationally recognized symbol of radiology, which is a weasel dressed in camouflage, sitting on a fence, next to a hedge, across the street from a bank, eating a waffle.

"Waffle-master" is a term that we give to these commitment-o-phobes. When a "waffle master" is reading films we have actually worked it out to rotate the report taking amongst our providers. It is that painful. A "waffle-master" calls a minimum of two times on all studies, and one has actually called six times to add "ditzels" and "whatnots" to an already non-diagnostic read. The burden is thereby shifted to us to explain these thingamajigs to the patient and to make sure that appropriate follow-up is arranged. Quite a trick when the follow-up recommendation is usually for a similar study to be done in three to six months and the patient is either from another town or has no primary provider. A "waffle-master" will then recommend "clinical correlation" which is just a fancy way of saying that they are hedging and all responsibility is now ours. The best we can do then is to say to the patient, "Well, it's probably nothing but could be cancer so please arrange this follow-up."

The needle-in-the-eye, however, is reserved for the poor doc coming on at 6am. If a "waffle-master" is on for rads, the bleary-eyed ED doc is sure to receive five or six reports on plain films from the prior shift where the ED doc has not seen a "ditzel" or "lucency" or "hypodensity" and he or she must pick up the phone and call the discharged patient at home and inform them that they might have, but almost certainly do not have, cancer.

New Worst Names Ever

Seen recently in our ED (names slightly altered, but you get the picture) ...

William Caramel Glaze
Rainyday Smith
Heavenlee Jones
XxZavyier Frank

Mug shots available soon from the local police... it's inevitable.

You'll Shoot Your Hand Off

A Haiku:

NAIL GUN. SAFETY FIRST!

"WHERE THE HELL IS THE TRIGGER"?

'POW'! "DAMN-SHIT-FUCK-DAMN"!

Double Protection

Well, his first mistake was driving drunk. His second mistake was crashing his car. His third mistake was spitting on everyone and fighting with the paramedics and with us. His fourth mistake was continuing with the fighting and spitting and writhing around on the board. His fifth mistake was crashing his car in a town without a trauma surgeon. His sixth mistake was sustaining a head injury. His seventh mistake was pissing off the police so much that they decided that after he was treated (wherever that ended up being) he would go to jail for a while. So, perfectly appropriately, he was paralyzed with succinylcholine, was intubated, had an NG tube placed into his stomach, had a nice big foley placed in his ding-dong, and was sent down the road for a complete trauma evaluation. I don't think he was badly hurt but we'll never know. I do know that God protects fools and drunks and this guy was both so the odds are with him.

At Her Bohemian Road Nurse Majesty's Request- 911Doc's Meme

My dear friend Bohemian Road Nurse has 'tagged me with a meme'. From her website I gleaned the following...

The rules of the meme are as follows:
You simply list eight random facts/habits about yourself. And feel free to write a little bit about those things if you'd like

Tagging me means that ETOTHEIPI and Schrodinger's Cat are tagged as well. This seems likely to produce a lot of crap from them, but, for now, I will simply write my own crap. Here goes...

1. I love college football. Football is the greatest game ever invented by mankind. All of you who disagree are idiots. Cheerleaders are great too but seriously, if you are a dude and you are a cheerleader, then you are at least really weird if not a closet homosexual. I know, I know, you get to travel with all the hot cheerleaders etc... but I still think you have cake in your pocket.

2. On the sexes: Men and women are different. That's the way God made us. All attempts to minimize or ignore this end in wailing, gnashing of teeth, and women's semi-pro football (which we have just down the street- it's terrible) or women's boxing (which is an affront to everything good and holy).

3. On Government: People are all flawed and we all have free will and hence the need for government. Government works best when it maintains a behind the scenes presence and allows for the flowering of human achievement and accomplishment by maintaining order by the rule of law. Government should fashion a safety-net for its citizens but not a safety-couch for anyone who happens to wander or sneak into the country. Right now we have a safety La-Z-Boy recliner with wide-screen HDTV for all. The huge bureaucracies responsible for this recliner elevate mediocre people with mediocre ideas to great positions of power. Generally, people are either of the mind that they are the one's that can or should fix their own problems or they are of the mind that it's the government's job. The latter type of people are all chosen by a secret computer to man the many superfluous posts at all government bureaucracies or they are chosen to be on disability. As the 83rd permutation of this rule my hospital is now on double secret probation and may be forced to close because one of the aforementioned flunkies found a patient chart which was corrected improperly. Someone scratched through an entry instead of drawing a single line through it and initialing it.

4. On Guns: I own guns. If you decide to rob my house or do other nasty stuff to me or my family and you succeed in making it past my very large dog then I will shoot you happily, and, if you are still moving, I might shoot you again until you stop moving. Then I'll try really hard to resuscitate you after I walk calmly to the phone to call 911. I'm full service.

5. On My Career: Emergency Medicine is the best possible job for me and the worst possible job for me. As you can see from above I like folks who are "internal locus of control" people, people who take responsibility for themselves and their situations. When I see these folks as patients they are generally very sick and, generally, I can make a big difference for them. When I see the La-Z-Boy crowd, probably 65% of my patients, there's not much I or anyone can do for them. Hence, I am perpetually presented with people who are absolute wastes of carbon (products of our current societal engineering schemes and absent or drugged-out parents) without any insight into their problems who believe I should fix them immediately for free. Believe me, I have many problems and I am far from perfect, but if you call me on it I will listen and try to improve and all that stuff. Anger and pain is therefore a direct and daily result of my job. The other problem regarding Emergency Medicine for me, besides feeling like I'm bailing on the Titanic, is that I do not handle the randomness of my schedule well. I take a sleep medicine most nights, and the sleep disturbance, combined with the La-Z-Boy patients, will probably drive me out of the ED soon. Too bad because I'm good at this job and I don't know what else I would do. It's clearly bad for my health .

6. On Fairness: Life is not fair. Don't expect for it to be. Case in point. I feel like I have reached the pinnacle of a very high mountain doing what I do. I will never be rich from it and will not retire early. Second case in point and less on the self-pity side, lots of nice people die right in front of me and usually from no fault of their own. Car crashes, drive-bys, whatever. Life is not fair. I also believe, however, that there is an afterlife, and I believe it will be more fair than any of us would wish. True justice should scare the crap out of you.

7. On Respect: If there is a group of people less deserving of respect than today's college professors then I don't know who they are. Wait, I've got it! Celebrities! At least the college professors (only a vanishingly small percentage of whom have ever held a job outside academia and a vanishingly smaller percentage of whom have served in the military) have "book learnin.'" Why do people give a rat's ass what Leo DiCaprio thinks about "climate change", or what (or whom) Paris Hilton is doing, or what other glittering jewels of colossal ignorance think about anything? Did they even finish high school? And what is it with the cognoscenti today? Most are educated far beyond their intelligence. The people who carry advanced degrees and have some rudimentary knowledge of history but still believe that just one more trillion dollars spent on education or health care or welfare or whatever the next great fix-it is will do the trick? They carry, just beneath the surface, a belief in their own superiority and the belief that most ordinary folks just can't do it without their help. I hate them. The only people I respect before they earn my respect are people in the military, doctors, and the clergy.

8. On Coca-Cola: There is nothing better after a good sweat than an ice cold coca-cola.

BHR, I have a feeling not much of this is up your alley but thanks for the invite. ETOTHEIPI? 'Cat? The world awaits.

Secret Location (Mini Confab)

I Will be joining Schrodinger's Cat at the secret location in the Nevada desert. I expect to do some jackalope hunting and give money away to rich people. Report to follow.

Secret location

To whom it may concern

I will be gone next week to a secret location in the Nevada desert for further medical training. As I understand it there is no electricity there and therefore no computers. I have heard tales of gambling and debauchery, but I am sure these are just tall tales. I expect to learn a lot from the curriculum, which is as follows:

1. How to say no to narcotic refills without losing a friend.

2. How to avoid loud obnoxious family members, AND increase your press-ganey scores.

3. How to hypnotize parents into believing their child does only have a virus and not the black plague.

4. Tear away scrubs: good or bad for morale?

5. The 500 lb. pelvic exam: A new approach. (really looking forward to this one)

6. Emergency care under an unfunded federal mandate: what we do every day and why it's only going to get worse.

7. Selective hearing, jedi mind tricks, soul blocker spray, and other means to avoid a deep depression and homicidal thoughts after your shifts.

As you can see, this will be very educational and I should return a better doc and stronger person.

The Cat

The "Vanishing Probe" Sign

If you come in to my ED after placing a shotgun over your heart and pulling the trigger AND I take the ultrasound probe (pictured here on a very nice sonosite machine) to look for heart activity AND, after taking off the bandage that covers the wound, the ultrasound probe DISAPPEARS into your right and left ventricles, then you are DEAD. No, AngelFlight crew, there were never any pulses even with CPR- you are liars or fools. I hereby dub this the "vanishing probe" sign of death and it should be recognized with other sure indicators of death like rigor-mortis, decapitation, fixed and dilated pupils with asystole in three leads, and vaporization in an atomic blast.

Crisis

The American mainstream media operates in a perpetual crisis mode. The planet is sick, Anna Nicole dies, bombs here, bombs there, climate change, cell phones cause cancer, eat this, don't eat that etc... Nevertheless, as you can see from reading this and other blogs about Emergency Medicine in the United States today (most notably Charity Doc's "Fingers and Tubes in Every Orifice"), we feel we are at the breaking point. I do not work in a major trauma center anymore though I did train in one much like the subject of this article on MSNBC.COM. This article is a no holds barred window into the reality today in Emergency Medicine. It's hard to believe if you haven't had the bad fortune to be a patient in an ED lately, but one day you will likely get a peek into our world, and it is not pretty. Please click the link in the above text to read about Grady Memorial in Atlanta. This IS the reality at trauma centers, and, increasingly, at every single Emergency Department in the country. And to once again beat a horse, in the current health care debate there's lots of blame to go around, but the dirty little secret it that NO ONE dares to mention that patients themselves must be made to bear at least some responsibility, both financial and otherwise, for their own health care. Add that in to the equation and maybe we can get somewhere.

THIS IS A MUST READ!!!

Be Alert (for me strangling someone)

I went into the ICU last night to intubate a patient for the surgeon and I saw this sign on the door to the patient's room. Now I know crap like this exists in every workplace and it is generated by some well-meaning safety nannies, but it doesn't mean I have to like it. Just a quick quiz here: What does this sign mean? Give up? Hint: It doesn't mean "be alert".

I was wondering about this as the nurses prepped the patient for the intubation. I felt the need to exclaim at that point to anyone who would listen, "Wow, what a great sign! If this weren't up here I was just going to come in here and fuck around, but now, wow, I'm going to be extra special careful when I paralyze this guy and stick a tube down his trachea!"

After getting thoroughly pissed off at this sign I wondered why it had pissed me off. First, it distracted me from the task at hand because I actually had to think about what it meant. Second, this is not a bee, it's a wasp or a yellow-jacket. Third, the thing is stoned, look at his eyes for crying out loud! Fourth, his legs are amputated. Why? Fifth, if this was meant to be a clever play on words the word is "bee" not "be", otherwise the whole thing just doesn't flow. Finally, some paper shuffler somewhere spent lots of time creating this 'patient care initiative' and now all us stupid nurses and doctors and techs have to 'be alert' when we could otherwise be comatose.

So the answer about what this means is that it is posted as a reminder in patient's rooms who are at risk for falling. Seems that we don't want just anyone to see a sign in plain English that states that the patient is at risk for falling for fear of offending the easily offended. Now this is gargantuanly stupid. I therefore spent a few hours thinking of how this might be improved and I came up with this sign...

THIS PATIENT IS AT RISK OF FALLING.

SWARM!

What can I say? Saw this sign today. Evidently there is now a swarm of ANGRY hymenoptera on the floors. I called the Orkin guy. A little more investigating uncovered that this is actually an ACRONYM which, if memorized, will be just super helpful.

Beds should be kept in lowest position
Evaluate the environment for obvious hazards
Electrical cords should be kept out of walking paths

Ask staff for assistance when getting your family member out of bed
Lighting should be on to improve visibility
Equipment should be in locked position etc...
Remove any clutter to provide unobstructed walkway
Toitleting should only be done with nursing assistance

Again, I put my feeble brain to work and came up with a more short and succinct sign to place in these patient's rooms.

CAREFUL! THIS PATIENT IS AT RISK OF FALLING

Once in a While...

Once in a while all the years of training and practice make a difference in the blink of an eye. Once in a while the patient dying is young and otherwise healthy. Once in a while we make a good save.

First I must tell you that the patient in this post was diagnosed by the triage nurse and then my charge nurse acted right away to get her back and I merely did what I was trained to do, but boy, with a good result it sure feels good.

Betsy is 27 and she was pregnant with her first child. She was eating dinner when she had a sharp pain in her abdomen. She quickly became weak and ill and, being a hardy sort, didn't want her husband to call the ambulance. He insisted in getting her to us and he pulled up in the ambulance bay with her in the passenger's seat. She attempted to get out of the car but collapsed on the pavement. She was rolled in to the ED and my charge nurse told me that a doctor was needed in bed 11 because the patient likely had a ruptured ectopic pregnancy.

I came into the room to see a young girl slumped in the wheelchair with eyes open and looking as pale as Casper the ghost. Her systolic pressure was 60. Training took over; two large bore IVs, stat type and cross two units of packed red cells (and by the way be ready to give trauma blood in a pinch), normal saline wide open, ultrasound to the bedside, all the abdominal organs floating in fluid, page the OBGYN stat, pain relief, quick speech to the patient and her husband, quick bimanual pelvic exam, OBGYN in the room in five minutes, confirmatory trans-vaginal ultrasound at the bedside, operating room consent, labs sent, blood pressure responding to saline, get those piercings out (had to remove the labial piercing with wire cutters from the maintenance tool box), patient rolling to the OR, and one hour later she was in recovery from her ex-lap and unilateral salpingectomy and evacuation of her ruptured ectopic pregnancy. She was in the ED for ten minutes. She had two liters of blood in her abdomen and would have died if she had waited just a few minutes more.

I went to see her a few days ago and she and her hubby were sitting in their room watching Seinfeld and laughing. She looked great. She still has one functioning fallopian tube and should be able to have children. Now this is what we train for; this is Emergency Medicine (and nursing, and OBGYN). She never once asked for pain medicine God bless her.

It's a Tumah

Just got a special delivery from the OR: a 65 pound ovarian mucinous cystadenoma (a benign ovarian tumor). The lady sort of looked like someone with a 130 week pregnancy. To illustrate, hold your arms out in a circle in front of you like you are giving an air-hug to someone fat. That's about the size of it.

I know what you are saying: "ewww!", followed by, "what the f##k?!". Of note, the record for one of these things is about 350 lbs.!

She apparently was a wee bit chunky and decided to try Weight Watchers. News flash: it didn't work. She went to the doctor who said: "ewww, WTF!?!, get that parasitic alien life-form out of your belly, you freak!!". (I paraphrase)

They took it out intact in the OR and we had to lug it down to the loading dock to get an accurate weight. It was a big hit with everyone and I have a series of unpublishable Abu Gharib-esque photos with it (e.g. thumbs-up, pointing, smoking a cigarette; a bunch of dudes nude in a pile - oh, wait, that's from the weekend).

When we opened it, it filled a large sink with brown, mucous-ey fluid. I had the pleasure of grossing the thing, which involved sectioning it extensively and taking microscopic sections to look for cancer. And, yes, it was warm.

Pimpin' Ain't Easy (except for this guy)

To be fair, this patient was nice, but really, what can I say about this shirt? This is kind of like the bumper stickers that some of my high school classmates used to have on their cars: "I Love Bong Hits" and "In Search of the Eternal Buzz" come to mind. Perhaps a baseball cap with a neon flashing sign that says "Arrest Me" would complete the picture? And oh by the way, I did get permission to take this picture.