Yes, The President will let you have your gallbladder removed...

Am I the Only One That Worries?

Sometimes I wonder if I'm the only doctor that worries...  I fear I might do the wrong thing for a patient, and I worry that I could do things better.

I worry because I care.  I really want to do the right thing and sometimes wonder if I'm really up to it.  

I've seen and known doctors that never worry.  They never think they do the wrong thing.  When I was in med school and residency, I used to admire these doctors.  I used to revere their confidence, and longed for the day that I, too, could be so sure of myself and every decision I made treating my patients.

Well, that day, for me, has never come.  I have come to realize, however, that these doctors that are so sure of themselves are usually not very good doctors.  I think many of them have learned to hide their incompetence behind a veil of arrogance.

I asked one of my attendings that I truly respected once just before I finished residency if that feeling would ever go away...  He put his hand on my shoulder and looked me in the eye and said, "If that feeling ever goes away, that's when you really need to start worrying."

What were you taking this medicine for?

Yuck!  One other complication of being fat is that things tend to get lost in fat rolls...

I had this lady once who was so large she couldn't walk.  When you're that large, and can't get up, you certainly can't wipe your ass and clean yourself... 

While examining her, I noticed that she had a pretty severe fungal skin infection within her fat rolls, or "pannus" as we like to call it.  When I lifted up one roll, I found a prescription bottle stuck within the roll...  After peeling it out, I looked at the label and realized she hadn't told me that she was taking this medicine...  Well, actually, she hadn't taken it in about 2 months.  At least that's how long ago the prescription was filled, and it was almost full.

She didn't know what that prescription was for, or why it was prescribed to her.  Apparently she hadn't been taking it.  

What a surprise.

Things people have put in their ass that they probably shouldn't have...

Welcome to 2008... I haven't posted in a while... Not for lack of stories to tell, but lack of time in general for me to sit down and type...

I understand that people need to do things to spice up their sex lives, but I'm still amazed at things people stick up their butts. Most of the time, these items are so large that patient's have to go to the operating room to have them removed. While plain old vibrators are the most common "foreign body" I've seen, it's always interesting when they're the battery operated kind and are still on... You can hear the hum when you walk in the room, and the vibration travels nicely through the soft tissues of the abdomen to the abdominal wall. I also love the x-rays that show a perfectly focused abdominal x-ray with the blurry phallus in the middle...


I also had a guy come in with a cordless phone inserted antenna down... Yes, an actual cordless phone with the thick plastic kind of antenna that's attached (not the telescoping metal kind)...


Then there was the "ship in a bottle!" That one was unique. It was a small ship-in-a-bottle, but a ship-in-a-bottle none the less! It was made of blown glass, and the ship inside was blown glass, too. You could actually make it out on the x-ray which was pretty funny.


One other that stands out as unique, was "3-potatoes-in-a-condom." They weren't Idaho bakers, or anything like that... they were more like New Potatoes (you know, the smaller kind)... But, they were potatoes. And, there were 3 of them. They were all inside a condom, tied at the end into a knot so none of them would fall out.


These cases are hard... they are very funny in a sick sort of ER humor kind of way. The key is to laugh after the patient has left the emergency room...

I've come up with some VERY simple rules that everyone should follow in case they get an urge to shove something up their ass in the heat of the moment...

1. DON'T use anything thicker than the largest crap you've ever produced in your life.
2. DON'T use anything with sharp or jagged edges.
3. DON'T use anything that has the potential to break or shatter into little bits that are sharp or have jagged edges.
4. DO use something that has a base that is quite larger than the diameter of whatever it is you're shoving up your ass.
5. DO use LOTS of lube.

This is NOT McDonald's...

...and it's not Starbucks either... 

If you want to be served in the order in which you arrived, please do not go to an Emergency Room.  Please go, instead, to McDonald's or Starbucks.

...Surprisingly enough, you will sit in the Waiting Room for some time while we take care of the 65 year old lady that came in after you clutching her chest having a heart attack...

...Your child WILL wait a few minutes while we resuscitate the 9 year old girl that was found floating in the pool...  And your kid with the hockey puck injury to his leg doesn't trump the patient we're doing chest compressions on---- even if you did get to the ER first...

...No, Ma'am, you probably DON'T really wish that you're husband needed CPR, too, so that he would get some attention...  He's been coughing for 2 weeks and you decided to bring him in Sunday night at 10:00pm.  I think he can wait 30 more minutes while we try to save someone's life.  

There is a national standard for triage in the Emergency Department that puts patients in one of five categories... Imminent, Emergent, Urgent, Semi-Ugent, and Non-Urgent.  Imminent and Emergent patients are brought into the ER immediately upon arrival and placed in a bed.  Imminent patients require full immediate resources or the patient will die within minutes, or they are already dead and we need to try to bring them back to life.  Emergent patients are likely to deteriorate rapidly to Imminent status if there is no immediate intervention.  Urgent patients are sick, but not likely to die in the near future and we have time to do testing to sort out what is wrong with the patient.  Semi-Urgent and Non-Urgent patients should have waited to see their doctor in the morning or should have gone to a clinic.

The vast majority of patients seen in Emergency Rooms are semi-urgent and non-urgent; these patients usually get discharged from the ER and go home...  The patients that really need to be in the ER are the Urgent, Emergent, and Imminent patients.  The Emergent and Imminent patients are the ones that should have come to the ER long before they did.

So, you don't get a bed and get to be seen by a doctor just because you got here first.  We take care of the sickest patients first.  

We also know that you may feel like you're sicker than someone else we bring back before you, but we are pretty good at what we do.  And, yes, we are qualified to make the decision of who is sicker and who we need to take care of first...  When you've had years of nursing education and training, and several years of nursing experience, then you, too, can sit at the triage desk and make these decisions, too...  

In the mean time,  please have a seat.  We'll call you when a bed is available...

"Chief Complaints" I hate to see, Part 1: Fall from standing.

There's quite a few of these, so I thought I'd separate them into parts...

One of the "Chief Complaints" that really makes me cringe is when I see it on a chart is any patient over 80 years old with "Fall from standing."  If you're over 80, apparently, standing is a dangerous activity.  You wouldn't believe how many people over 80 years old fall from standing.  It's usually never a good thing, either.  It's usually at least a broken hip, broken ribs, intracranial bleed, or something else just as bad.

• Broken hips lead to deep vein thromboses that progress to pulmonary embolisms 
• Rib fractures or rib contusions rapidly progress to pneumonia; and full blown pneumonia in the elderly is never a good thing
• Intracranial bleeding is never a good thing in any patient, but in the elderly usually leads to permanent impairment

Even if these patients survive the initial injury; it's quite often the initiating event that leads to a rapid decomposition in this patient population.  I can't tell you how many elderly patients show up in the Emergency Room on death's doorstep that were "completely normal 3 months ago before he fell."

They tend to not do well...

I remember my first year out of residency.  It was the middle of January and I picked up a chart; "Fall from standing,"  "Hip pain,"  "87yo F."  And, of course, I thought, "this poor woman, her life is slowly beginning to end..."  Needless to say I was pleasantly shocked and surprised when I walked in the room... This very sweet woman was sitting in a chair in the room reading the newspaper.  As I walked into the room after knocking, she peered at me over the rim of her reading glasses and over the top edge of the newspaper...

She had been skiing in Colorado with her family 2 weeks prior to her emergency room visit, teaching her newest grandson how to ski...  She slipped and fell and hurt her right hip.  She came to the emergency room because it was still hurting after 2 weeks and wanted to get it checked out.  She was also more than a bit irritated at herself, because she didn't fall skiing down the hill; she fell while level skiing to the condo they were staying in after a full day of skiing when her ski hit a dry patch of dirt...

EMTALA

There's a federal law called EMTALA, the Emergency Medical Treatment and Active Labor Act of 1986, requires that all patients presenting themselves to an emergency department Must receive a "medical screening exam" to assess the presence of an "emergency medical condition."  If an "emergency medical condition" exists, then the hospital must provide "stabilization" or transfer to a hospital that can provide stabilization if said hospital doesn't have the capability or capacity to provide said stabilization...  All this must be done regardless of the patient's ability to pay.

The problem is is that the law does not define "medical screening exam" or "emergency medical condition."  And each hospital has had to interpret what these terms mean.

Some patients are pretty savvy and try to abuse the system.  They also assume that this means that emergency room treatment is "free."  It is, of course, far from free...  It is more expensive that any other outpatient treatment.  And, since they don't have insurance, they'd rather come to the ED where we don't ask for cash up front, than go to an outpatient clinic and pay $100 or less to see a doctor.  

This is why it costs so much to go to the Emergency Room...  All these people coming in for their "free" visit to the doctor.   And,  why emergency rooms are so overcrowded in this country and it takes hours to see a doctor after you arrive...

I can go on an on about this, but just wanted to get some initial words down about the subject.

One complaint per customer, please...

O.K., why can't people just have one complaint and/or one problem per visit to the emergency room?!?!

One little old lady came in today for an abscess.  She was very sweet.  I drained her abscess, gave her antibiotics, and got all of her paperwork ready for her to go home; instructions on what to look for, prescriptions for antibiotics and pain medication.  I even told her to come back to the ER in 2 days so we could check her infection to make sure things were getting better, which I never do...  When the nurse went in to discharge her, she found that she'd been having chest pain for the last 15 minutes.  I went in to talk to her...  No big deal, just this nagging "pressure" kind of pain under her left breast (nowhere near where her abscess was, unfortunately)...  On further questioning, "Oh, yes, this IS just like the pain I had with my heart attack..."  

Ugh!  So, thus began her chest pain workup and subsequent admission to the hospital...  At least I don't have to see her again in the ER on Saturday...

I also had a patient "checked out" to me at physician shift change.  Easy hand-off.  This guy came in "suicidal" asking for help.  He was waiting for a transfer ambulance to take him to the psych hospital.  His only issue was that he had a history of a heart valve replacement and was on the blood thinner coumadin.  Coumadin levels have to be checked regularly, and the doctor before me had checked his level so he could be "medically cleared" for the psych facility.  OK, we actually monitor it with a blood test called a PT/INR that measures the clotting tendency of the blood, and not the actual "coumadin level," but patients tend to refer to it as their "coumadin level."  Anyway, his level was almost twice what it should be, which essentially means that his blood wouldn't clot very well.  This not only puts him at a high risk of bleeding, but should he start to bleed for any reason, it would take him a lot longer than a normal person to stop bleeding.  Having levels this high is usually no big deal... You just have patients stop taking coumadin for a day or 2 and then recheck the PT/INR.  And this guy was fine...  No problems.  Of course, that is, until about 10 minutes before the ambulance was due to arrive and he decided to go to the bathroom...  And decided to shit a pool of blood in the toilet!

Ugh! So, thus began his lower GI bleeding workup, and rapid reversal of his coumadin to stop his bleeding...  Oh, yeah... we also called the ambulance and told them not to bother coming.  Can't send a guy to a psych hospital and have him start shitting blood in the middle of group therapy...

Another reason to not be an alcoholic...

I've been at this for a while, and have never seen someone hemorrhage so much from their varices.  For the unitiated, varices are like hemorrhoids, but are at the bottom of your esophagus instead of in your anus...  They're the end result of years of hard drinking.

For such a new blog, this is my second GI Bleeding post, but this one was even more impressive than the last one.

The man came in in cardiac arrest, and we were able to resuscitate him and get a pulse back.  The paramedics told us that he had been vomiting blood at home, so we inserted a naso-gastric tube to wash out his stomach and see.  After inserting the tube, we started to suction buckets of blood out of him and had to start a massive transfusion protocol.  After suctioning out over 5 liters of blood, and transfusing over 20 units of blood, the surgeons were considering taking him to the OR and the GI doctors were considering getting out of bed to come see the patient; we decided to use a Sengstaken-Blakemore tube, to try to staunch the flow of blood.  Follow the link to see the diagram of how to insert one of these tubes.  It's an elaborate set up and not done very often--- at least not at our institution.  The tube has to be tied to a football helmet to keep tension on it.  You blow up a balloon at the end of the tube and pull it back so it puts pressure on the junction between the stomach and the esophagus.  Then you blow up a balloon that runs along the length of the tube within the esophagus to tamponade the bleeding.

He ended up getting 54 units of blood while he was in the ER.  There were a lot of doctors and nurses working furiously to try to save this guy's life.  The surgeons took him to the OR, but couldnt find the source of bleeding, so he ended up getting a TIPS procedure by the interventional radiologists.

He died shortly after the procedure; but not for our lack of trying to save him...

The exploding colostomy bag...

This patient showed up in the ER the other day... came in by ambulance. Apparently he called 911 because his colostomy bag exploded. On further investigation, I found out that not only does the guy have a colostomy, but is HIV positive, is homeless, and recently moved into the area from another city in the state. I also found out that this was not his first visit to our hospital. He'd been here almost twice a week for the past several weeks, and the nurses all knew him well already. I'd been away for a while, so he was new to me... He was also showing up at other emergency departments in the area as well; all for his exploding colostomy bags...

The thing about colostomy bags is that they tend to fill up with shit and need to be emptied once in a while...

Just like a water balloon; if you let them fill up, they tend to explode. Now picture a bag attached to your body, over-filled with shit to the point where it explodes... Now you can imagine what this guy looked like.

The nurses went in to get him cleaned up, and I started to do what I needed to do to get this guy taken care of. When they were done wiping the large clumps of shit off his body, we were going to get him to the decon room to let him take a shower. He was new to town, and hadn't been "plugged in" to our HIV clinic; so I called the social worker to come see him and get him an appointment. I called the general surgeon, so I could get him an appointment in the surgery clinic to evaluate his colostomy for possible reversal, and I called the ostomy nurse to come see him and teach him how to care for his ostomy site and to get him some bags so he wouldn't let them explode on himself anymore...

Unfortunately, once the nurses wiped most of the shit off of him, they attached a clean colostomy bag to his ostomy site, and with that, he wanted to go "home." They came to get me to intervene, and I asked him why he wanted to leave? He said that all he needed was a new bag and he was ready to go. I explained to him, again, all the things we had in the works for him... shower, social worker, ostomy nurse, a supply of bags, the surgery clinic appointment... He said he didnt' need any of that and he just needed to go.

Then I realized it... He didn't want our help. He just wanted to keep calling 911 when his colostomy bag exploded and have them bring him to us to clean the shit off of him and give him a new bag.

So I told him, very calmly I might add, that it wasn't appropriate for him to just leave. I said, "You're still covered in shit, we just were able to wipe most of it off. There's still shit underneath your fingernails... and we're trying to get you over to the shower." He was still in bed butt-naked with just a sheet over him. "I've got the Social Worker on her way to see you and the Ostomy Nurse is on her way to see you, too. We're trying to get you clinic appointments so that we can take care of you."

"I don't need any of that," he said. "Just get me out of here." So, I told him that was fine; we couldn't force him to do anything he didn't want done, and he was certainly welcome to leave. I also told him he was welcome to leave butt-naked and without the new colostomy bag, at which point he went ballistic.

He screamed at me in a high shrilly voice,  jumped up out of bed and started running out the door crying... Naked.  Except for his colostomy bag.

The nurses didn't know what to do... I told them to let him go. The police outside would certainly stop him, so he really wasn't going anywhere. Can't have a homeless man running around the city naked with an exploding colostomy bag.

I don't think it's appropriate for us to continue to enable this man's behaviour. He's taxing the EMS system by calling them for a non-emergency, and he's wasting the time of the Emeregency Department staff and the hospital's resources when there is appropriate outpatient care readily available.

The nurses eventually caught up with him and gave him a hospital gown... He left with the hospital gown and the new colostomy bag.

He'll be back when it explodes...