Watch your Language

I had a moment today that would make Etotheipi proud.

Our head nurse was talking with some tight assed looking lady as I started my shift this am. The tight ass looked like a typical clip-board carrying high heeled nurse that only appears in the daylight.

About the same time I got to the desk, one of the nurses knocked over a big cup of ice water which spilled over a couple of charts and onto the floor. I quickly reached out and grabbed the cup saving almost a teaspoon from pouring out.

As a way to "impress" her fellow clip-board nurse, our head nurse pointed a finger at me and said: "That's why you don't leave cups laying around without lids on them"!

I turned to face her and informed her "That wasn't my goddamn cup, I just reached out to catch it".

To further impress this unknown person, our head nurse again brought out the finger and said "watch your language in patient care areas".

I couldn't resist! I said: "I'm sorry. You're right. I should have said 'THAT'S NOT MY FUCKING CUP'"!

Man did that conversation come to an abrupt ending!!!

I later found out that the clip-board carrying tight ass was some senior VP of something. She reportedly wasn't very pleased with me and didn't find my attitude very positive (or humorous). I've worked at this hospital for 3 years, and I've never seen this bitch before. I'm not too impressed with her importance.

The point remains.....it wasn't my cup!

The Pus Palace

http://www.youtube.com/watch?v=2OK8TZ-OV7c

http://www.youtube.com/watch?v=FXfMA5WEODc

Youtube won't let me imbed the above posts.

Conversations with an anon (hopefully a future named and useful contributer to our humble blog) made me wonder.

Years ago, when we first started seeing MRSA, we went through tons of positive cultures. By the time the cultures returned, the patients were better. So, many of us decided to stop spending $50 bucks a pop to diagnose something we already suspected and had treated. We were wasting a fortune on useless cultures.

So, here's my current practice. If it looks and smells like MRSA, I don't culture UNLESS it's a diabetic, chemo pt, child, septic pt, located over a joint, or there's something else complex or unusual about it. If it smells anaerobic or looks different, I go ahead and pop the culture. In this manner, I probably only culture about 20% of the abscesses I drain.

On a related topic, where I worked before, we almost never put these patients on antibiotics after I&D (unless there was surrounding cellulitis or another complicating factor). When we saw them back, they were doing fine.

At my current hospital, Bactrim and Clinda are standards of care after I&D of the abscess. So, I play along, and I can't tell that there's any better or worse outcomes than in the location where we didn't use antibiotics.

As for Bactroban Ointment, I know some folks who use it for everyone, and others who only use it for patients with recurrent infections, or family/workplace outbreaks.

Here are my questions:

What do YOU do (no "right" answers here):
- Do you culture ALL of your I&D's?
- Do you put them all on antibiotics?
- When do you use Bactroban nasal?

Finally, Do you follow these patients in the ED (like we do), or do you have a place to send them for follow up?

Tanner Food

To compensate for my boring informational post, I thought I'd include one a bit more humorous.

Being the twit that I am, I was in my scrubs the other night after a long shift and I was searching in our refrigerator for something to eat. (refer to dumbass anonymous post in Emergency Physician = Bartender)

I found this container in the back covered with tin foil.....and my interest was piqued.

When I peeled the foil back, I was suddenly disgusted (and slightly aroused too) as this pubic mass of fungi squirted out of the bowl. It was like 70's porno-bush.

I'd say this was a Tanner 5, maybe even a Tanner 6. (for the non-meds....I don't want to "spoil" the surprise...but here's your link: http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=endocrin.box.1059)

I didn't know whether to screw it or eat it since I had a semi-erection and some vomit in my throat. (this part is a joke for all of the anon fungus lovers out there). So, knowing that my inlaws were coming the next weekend and my wife would clean the fridge....I covered it up and pushed it back into the fridge!

Network Docs

WARNING: This isn't a funny or fascinating post....it's informational and boring.

A few years ago, our CMG (contract management group) decided to go "out of network" on all health plans. That meant that any patient who was obligated to use our hospital by their insurance would still get a full charge from us.

I didn't know about it until a friend got a huge bill and complained to me.

It didn't seem fair to me.

Well, now that we're trying to fire our CMG and start our own group, they're appealing to the hospital. Their sales pitch is that we/they make about $800,000/year by being out of network. My response is that cutting out the 30% we send these bastards is slightly more and therefore we don't need them.

I also discovered that the Texas Association of Business is trying to pass legislation that would require hospital based physicians (Emergency, Pathology, Anesthesia) to charge the "in network" rate. Therefore, the CMG argument may be moot.

I thought this was interesting info.

http://www.texmed.org/Template.aspx?id=4228

Emergency Physician = Bartender?

Years ago when I was young I was a bartender in a cool place. I was also a bouncer who got by on my height and weight alone as I have no training in that area. I basically do the same thing now. The pay is better, but my customers are the same.

I was at a local chain restaurant tonight eating some wings and drinking coffee and diet coke. Next to me plopped down a tattooed "townie", about 34 years old, with a very ugly woman that I assumed was his mother. She was not.

He turned to me (I had my scrubs on) and said, "Yeah man, I used to be an EMT and the shit you guys see... whew, it still gives me nightmares." Okay, reasonable. The he ordered, "Hey man, get us a few drinks, we've got places to go and people to do, huhuhuh!"

The ugly woman sidled up close to him and placed her beefy hand on his inner thigh. I threw up in my mouth a little bit.

The patient will be here in a few hours. He is on his way out with his lady friend to paint our very small town shades of red, and will, since he's an annoying little fuck, get on the wrong end of a fist or a pipe a knife or gun. I fully expect to see him in a few hours with a messed up face and much drunker.

The only difference here is that he will have paid for his drinks. He will not pay for his hospital bill.

Outcome?

What do you think would happen if I pointed a 12 gauge shotgun at my foot and pulled the trigger? Well, now the patient has a BKA and now he knows what would happen.

Dance Your Way to Disability

Great comedy is borne of tragedy. So says the Bible (or Shakespeare or someone important). What is shitty comedy borne of? Pitiful comedy? Absurd comedy? Perhaps it is born as the love-child of stupidity and laziness?

Patient (smiling and chatting with friend in room while flailing arms and legs; sitting on bed without falling off): "I can't stop shaking."
Me: "How long has this been going on?"
Patient: "Well it happened from 2003 to 2004 then it stopped but it's back again."
Me: (quickly considering neurologic crocodiles like Huntington's Chorea and fighting instinct to call 'bullshit'): "Who is your neurologist?"
Patient: "I don't have one, they kept sending me to psychiatrists."

The patient had been fine-tooth-combed at our regional zebra-diagnosing-center and had, in fact, been seen by a few head shrinkers, all of whom believed that this patient had a "non-organic" problem. "Non-organic" is a a handy cop-out for the doctor that doesn't want to end up in hour long depositions sitting with his attorney across from the plaintiff's attorney (and plaintiff in white neck 'brace'). And, to be fair, there is convincing evidence the somatiform illnesses are produced purely without a 'decision' by the patient.

"Malingering", however, is still diagnosed at the end of the 3 million dollar workup trail if the super sub-specialist has the balls to write it down. It occurs in the presence of secondary gain to the patient (i.e. a monthly disability check or a big legal settlement), AND, with a conscious decision by the patient to pursue this secondary gain by faking symptoms.

In the course of evaluating this admittedly very pleasant patient I asked her if she could walk. It seemed to me that if she tried she would smash her hands into walls and step in front of buses and such. She allowed as she could walk and I held out my hands to test her gait. Oh for a video camera at that moment! She made me look like a good dancer and, as my colleague stated to me afterwards, she has a great career in front of her in the tap field. She did a semi-perfect soft shoe all across the floor while following my gentle direction. Strangely, she was able, during this duet, to softly grip my hands.

Enter the neurologist who almost bust a gut laughing. Enter the ativan. Cue the sleep. Cue the CT Scan (negative). Cue the discharge paperwork. Cue the $5000 unpaid bill. Cue hours and hours of tap-dancing jokes.

Ladies and gentlemen. If you are going to fake an illness, don't pick one like schizophrenia or movement disorder. Go with the tried and true... back pain, neck pain and the like, otherwise you will end up exposed if not embarrassed.

Find more videos on www.findinternettv.com.

How'd They Get This Past HIPPA?

Found this little gem of a video on my favorite college football blog, Every Day Should Be Saturday, it shows the effects of PCP on a young, stupid human, and the effect of the young stupid human on the doctors and nurses of an Emergency Department somewhere. There is always a patient much like this one who sucks the resources of the department dry while we try to care for other patients who didn't choose to do stupid stuff to themselves. Enjoy, and dig a little deeper in your pockets, you are paying for this guy's care.

*addendum: if the youtube credits are to be believed, the dirtball in the film is the person who put the video up on the net. this is either a well done fake or a real live dirtball who can afford a car (per the paramedic's history he was driving), killer tats, fine hood-ware, a computer, and some knock-down 'illy', but not medical insurance- the ER is free dude! :) *

A Tree Grows in Brooklyn...or something.

We get a lot of colon biopsies to look at. This is due to a huge effort by all the professional societies involved in gastroenterology to shove a tube up everyone’s ass. It serves a dual purpose: screen for cancer and make GI scope-jockeys incredibly rich. I’m all for it.

The Japanese have led the charge on this practice. You have probably heard the well-known American expressions: “Grass on the infield: Play Ball!”, or: “Old enough to pee; old enough for me”, or: “Old enough to eat; old enough to be eaten”. Well, in Japan the ancient saying goes: “Old enough to shit; old enough to have a flexible colonoscope inserted to your terminal ileum, then drawn out slowly while taking biopsies of suspicious polyps”. Believe me, it sounds much more clever and pithy in the original Japanese.

I got a polyp to look at under the microscope the other day and, like one might expect, there was some fecal material along with the tissue. This is usually due to a “poor prep”, a.k.a. “I ate a corn muffin and 20 munchkins before coming in today”. Amazingly, it is possible to microscopically identify what that person ate in most cases. Sure, there is a lot of digested sludge that is basically a mass of bacteria and degenerated goo. But, if you are lucky, you may see a leafy vegetable; some steak; and, of course, CornNuts®. Anyway, this poo was different. There was some sort of seed structure that looked unusual. I showed it around and was greeted with shrugs (how is shit NOT interesting!?). I probably could have dropped it there but I actually know a botanist, so I gave her the slide. A couple days later she called me and said, “It looks weird because it is germinating”.

The dude was growing a bean sprout in his colon. I’m thinking: New England Journal of Medicine: “Ass-plants: a case report and review of the literature”. Move over Jonas Salk, step aside Louis Pasteur; I’m going to Disney World, bitches!

Presbycusis and Dementia

A couple of nights ago, they brought in a 92 year old man from a nearby geriatric psych unit. He had fallen and sustained a 2cm laceration on his face. The poor old guy was deaf as a door nail, and presumably quite demented since he was an inpatient at the psych ward for those whose true age lies only in carbon dating technology.

As I worked on the guy, I explained what I was doing (by yelling so he could hear me). I was kinda bored, so I started asking him about World War II (Dr. X will recall that this was the war in which our respective "motherlands" kicked Nazi ass). The old guy told me in very lucid details about his experiences as an infantry soldier across the Pacific theater ultimately being stationed in Japan as a Military Policeman (MP) after the war. He then told me all about how he used his GI bill to obtain his educational degrees and then worked for years in education and educational administration.

As we talked and yelled back and forth at each other, I was struck by how seemingly normal this old dad was.

I finished my suturing, and he asked me if there would be a scar, I assured him that his wound would not scar (I'm just that good). "So, my face looks normal now?" he asked. I explained that he had 6 small sutures above his eyebrow, as well as some swelling from the fall and the injected Lidocaine, but once it was healed in about a week, it should look normal.

"Boy are my Mom and Dad gonna be surprised!" he exclaimed.

As I left the room laughing, I whispered to my nurse "yeah, they're going to be very surprised. In fact I'll bet the first thing they say is 'Hey, what the fuck are we doing still alive'!!!"

For all reasons to love EM, the stories are by far the best reason.

Musings

A couple of weeks ago, the newspaper's sport's section ran an article looking back on the Dallas Cowboy's season. I thought that the headline was an excellent substutite for our "GYN ROOM" sign.

It lasted a few hours before someone finally became offended and replaced it.

As of this writing, I'm still waiting for my letter from the administration telling me how my little attempt to lighten the mood was "inappropriate".

Not an exciting aspirin story

The other day I almost hit for what I call the cycle, the body sound/smell/fluid cycle. Went to one room and a little lady whose 90 year old dad I was examining let out a tremendous fart (stinky too). She did say excuse me. Then the next young lady burped in my face while saying "ahh". (tonsil exam). In order I then drained a volcano of pus, swiped vaginal secretions, and checked the poo of a GI bleeder. As I sat quietly waiting for the incontinent chronic vomiter to come in to the ED, I reflected and gave thanks for all the glory, and glamor, one wonderfully stinky shift can bring.

This following is not medical (except for the death and injuries to the victims) but this conversation possibly was maybe overheard last month:

Secretary picks up phone- "Hello.....Oh my God!....I'll turn it on right away."
She picks up another line - "Mr. Garagos, turn on the TV, there was a tiger attack at the San Francisco Zoo!"
Mr. Garagos-"Oh, that is horrible, those poor people."
He picks up another line, and calls his wife - " Honey, call the Mercedes dealership. Tell them I do want the ball-sack warmer. If they have any questions, tell them tiger, dead kid, zoo. They'll know what you're talking about."

OTC Meds Can Kill Ya

File under "I wouldn't have believed it until I saw it."

There are lots of humans out there that I am amazed made it to adulthood. Witness one in particular...

A fortyish gentleman came in to see me the other night a full two months after being bitten in the foot by an Akita. His leg was swollen, red, and painful from the toes up to the knee. The infection had been evident a few days after the bite and by the time this gentleman figured out that it might be time to see a physician the question on my mind was whether we would be able to save his leg or not. The leg was tense and weeping pus. Make sense so far? Good.

This is where the ER rule that one must always think of the worst possible diagnosis first comes in handy, then again, it doesn't. This is actually where our specialty intersects with veterinary medicine. ER docs are often in the position of veterinarians as many of our patients are unable (due to stroke, baseline mental retardation, intoxication and the like) or unwilling (patients in police custody for example) to give us the whole story.

Then there are the patients who are not, technically, mentally challenged, but are, nonetheless challenged. This particular gentleman was all set for admission with a vascular surgery consultation to assess the viability of his badly infected leg when the following exchange occurred...

Pt: Doc, I think I broke my ankle.
Me: Why do you say that sir?
Pt: 'Cuz when that dog bit me it rolled on my ankle and it has hurt ever since.
Me: Well sir, you probably didn't break your ankle if you have been walking on it.
Pt: Well why does it hurt so much?
Me: Because you have a terrible infection and that hurts right there, especially since two months after the injury your bone might actually be infected, and sir, you will be lucky to keep that leg... You should have come in a lot sooner. In fact, you should have come in that day!
Pt: Well, for a while I could take care of the pain at home.
Me: How did you do that sir?
Pt: With stuff I had at home.
Me: What stuff?
Pt: I don't know, aspirin or something...

Hmmmm. Aspirin. Aspirin is a killer and it particularly kills children and old folks. Oil of wintergreen is particularly nasty and even a smidgen of it will kill a child due to its extremely high concentration of methyl salicylate. Athletes have died from skin absorption of salicylate laced balms used to treat local pain. Paradoxically, an acute ingestion of aspirin is, oftentimes, a lot less dangerous than chronic salicylism. It's a difficult diagnosis to make, especially the chronic form, and is often the culprit when elderly folks die, as physicians don't think to check for it and the patient doesn't think to mention it. It's just aspirin right? They sell it in huge bottles for $3 right? Even when the diagnosis is made patients often still die. A good summary regarding aspirin toxicity can be found here.

Back to my patient...

Me: Sir, do you have a ringing in your ears?
Pt: What? (just kidding). Yes.

So the simple cellulitis patient had a random aspirin level of 90 (very high). Three hours later, after the patient showed an alarming decrease in his mental status, I had intubated him, and placed him on a ventilator. I scanned his head to check for cerebral edema, which was not present, and then placed a dialysis catheter in his femoral vein.

He went to the ICU, sedated on the ventilator, and was emergently dialyzed. Three days later he remains on the ventilator. I have no idea if his leg will survive because the critical care team can not get him off the ventilator and don't know if he will survive. His two pack a day smoking habit is not helping in this regard.

Yet another example of the challenge of being in the ER. If I had not been curious about the 'broken ankle' comment, this man would have died and even an autopsy might have missed the problem. He may still die. Really, I was so amazed that he had waited so long I didn't hope to gain any diagnostic answers from this question, I was merely trying to get more information so I could tell his story later with the complete list of bad decisions he had made. (Yeah, I was going to make fun of him with other docs and nurses. Sorry.) His death could easily have been ascribed to sepsis, which he has, and his lab work was eerily normal. Chronic salicylism. Danger! Both he and I were lucky that night. Very lucky.

We Have "Sold Out"

Since the anonymi have pegged us, correctly, as being money-grubbing, SUV-driving, uncaring earth-destroyers, I figure the cat's out of the bag and we might as well profit from it. Accordingly we are now accepting advertising at our discretion. Contact information is posted to the right on the top sidebar. We will be out of pocket for a few days as we attend a combination NASCAR, football, country music, bowling, home-brew drinking, endangered-species hunting, killing, and grilling festival.

Too Delicious Not to Post

Just received the following email.

Definition: Political Correctness

Political Correctness is a doctrine, fostered by a delusional, illogical, liberal minority and rabidly promoted by an unscrupulous mainstream media, which holds forth the proposition that it is entirely possible to pick up a turd by the clean end.

Crippled Child Slips on Bannana Peel, Hilarity Ensues

ETOTHEIPI's hilarious story about an 800 pound cadaver reminded me of something I saw back in the late 70s in what passed for an Emergency Department in the CCCP.

I was 'working' there one day when a young boy with crutches (from a childhood bout of polio) hobbled back to a treatment area with some bullshit illness. I mean you could just look at him and tell he was full of shit. One of the previous patients had left a banana peel on the floor, which is very strange, as bananas were as rare as toilet paper in the Motherland at that time, but there it was, and there he went. Wham! Blood everywhere. What a mess, the little asswipe.

Nothing a few stitches and a cast didn't fix but I could barely keep a straight face trying to take care of him. His parents were Uzbeks, the worst kind, and both had congenital supra-tentorial ano-cranial inversion, so it's not surprising their little urchin had many problems. That's what inbreeding of inferior races will do. I don't think any of them had bathed in months, and their sob stories about lack of food and money were all lies and we told them so.

As the child was trying to leave on his crutches, a drunk man stumbled into him and grabbed the little boy's hair and pulled him to the ground. Boy was that funny! It was lucky the drunk man was not hurt, but the child broke his fall.

The parents were distraught but we told them to HTFU, and that their kid's problems were all their fault. You should have seen their faces! We had them booted from the hospital by the police and we never saw them again. It still makes me laugh. I think they got sent to a gulag.

Ah, the good old days!

это будет шутка вы идиоты

Thanks Dr. Plaster (from Emergency Physician Monthly)

I do not personally know Mark Plaster, MD, but he writes a monthly collum for EP Monthly and this one is a gem.

Best of 2007, MDOD Style

I just listed my favorite posts from 2007... the list is on the right sidebar. The sad reality for me is that almost everything everyone else wrote is worthy and maybe 25% of my stuff is worthy. Now back to work.

Just had an 87 year old woman, who looks 60, tell me her 'secret'. Her 'secret', which she proceeded to demonstrate to me, is to 'exercise her face' in the shower every day. This involves making faces for a few minutes. As she contorted her face to demonstrate these exercises I thanked God, for a minute, that I am in this job.

Correlation Does Not Imply Causation

My New Year’s resolution for 2008: shout down and belittle idiots who make statements such as the following:

“Cell phones cause brain cancer! I read it in Time!”

“High-tension wires cause cancer! My sister’s friend got leukemia and so did her next- door neighbor! They live half a mile from power lines!”

“Breast implants cause cancer! My cousin’s friend had implants and got cancer! She’s dead now!”

“St. John’s wort cured my friend’s uncle’s prostate cancer! They wanted to do surgery and make him impotent and incontinent! Doctors are jerks and don’t understand non-traditional remedies!”

Enough.

Anecdotal evidence like this is retarded. When you next read in a newspaper or popular magazine about a ‘study’ that shows fava beans and patchouli oil may lower ‘bad’ cholesterol, I want you to stop and think before spewing your idiocy to everyone. Especially me. Yes, I am a doctor - but guess what, when you ask me if I heard about that amazing fava bean study, I’m going to kick you in the teeth.

By the way, have you heard about global warming!? It was the third warmest day in recorded history in Moosejaw, Saskatchewan! I’m not even kidding!!! Please study the attached diagram. Fucking corporations!!!

Happy New Year!

Upcoming in the next week or when I get around to it... a 'favorites' list for 2007. Please feel free to vote for one or more posts in the comments section here.

Congratulations to the intrepid London Ambulance crews! Same shit, different country.