Pride

November 15th, 2006

I suppose I have been guilty of all the mortal sins at one time or another (lust having been a particular favorite) but an early lesson for me in treating patients at the Mecca was “practice humility at all times, or expect to get your ass handed to you… often.” So I have remained diligently humble and open minded so that if nothing else I do not allow Pride to affect my judgement as it is not only the root of all mortal sin but also the root of all medical mistakes. In a case a few months ago, however, my old nemesis Pride came calling once more and this time for some inexplicable reason I embraced it… although I am not exactly sure why I did, nor why it is still on my mind.

First, some background about the ER in general. The ER is the fishbowl of the hospital; every physician in every specialty feels it is their God given right to not only dump patients onto the already overburdened ER but to also mandate how each patient is treated in regard to their specialty. The latter nearly always in hindsight and usually without scientific evident to back it up. The ER staff must constantly answer to other departments about “why we gave antibiotic x instead of y” or “why we called general surgery instead of internal medicine for a diabetic foot”, et cetera, yet many times when we call in the middle of the night for an opinion or because a patient requests a specialist the answer is “do what you can for them and send them to me next week”. (See the Dookie chute post)

Not too long ago the Mecca was having major problems retaining surgical subspecialists. Orthopaedics, Plastic Surgery, and Neurosurgery were all in extremely short supply. The plan was to treat patients as usual only consulting the above specialists (after hours) if surgery is needed. Well it wasn’t long before old Trenchy met up with a patient who insisted upon having a plastic surgeon consulted for a minor problem. 

It was a Saturday morning shift in July and the triage nurse brought a chart to me specifically saying, “you don’t want the intern to see this (remember they start on July 1)… this lady has a scratch on her face and they want a plastic surgeon.”

“Dammit.”

So I put down my coffee, put on my clean white coat and went in with my super-caring-see-I-am-actually-bright-and-speak-English-ER-doctor routine. Greeting the nicely dressed middle class couple I realized within about 30 seconds that the 1.5cm laceration on the lady’s cheek would probably heal best with a simple dab of neosporin and it was also about that time that my evaluation was interrupted with, “thanks and all but we really just want you to call a plastic surgeon.”

Trenchy: “I understand yall are worried about the cosmetic outcome… we COULD place an adhesive glue over the wound but stitches are really not necessary and could make the wound worse in the long run.”

Husband: “well great, just call a plastic surgeon to come tell us that and we’ll be on our way.”

Trenchy: “It is not just that simple to get a plastic surgeon involved… we have a shortage of specialists right now and they are only consulting for problems that require surgery.”

Wife: “HONEY… I don’t want some JOKER IN THE ER WORKING ON MY FACE!” (I don’t know how to write in staccato)

Husband: “don’t worry, he won’t be… (to me) listen, we are not here to argue with the ER doctor, just call whoever is on call.”

Trenchy: “listen, I am trying to help you… if I call the plastic surgeon on call you will get someone with alot less experience than me.”

Husband: “is he a surgeon?”

Trenchy: “yes, a surgery resident.”

Husband: “then call him.”

So I paged the plastic surgery attending hoping beyond hope that he would come down and speak to my irksome patient. It happened that the attending and resident were both in surgery together and I talked with him by speakerphone…

“It sounds like a load of bullshit Trenchy… you know we are shorthanded and  your Department Chief said yall would handle this kind of crap for us… I have 3 cases today from all the shit you consulted us for overnight…”

“I know sir, but they are insisting on a plastic surgeon, won’t let me touch them…”

“and you say it’s 1.5cm and doesn’t need approximating?….. God dammit, I’ll send the resident down… but I WILL be calling your Chief about this on Monday.”

Beautiful. Get in line.

So about a hour (and a dozen dirty looks from the happy couple) later the unsuspecting surgical intern be-bops down to the ER, glances over the chart and walks into the hornet’s nest… emerging back out of the room like a scolded pup within minutes.

Intern: “they told me they want a plastic surgeon.”

Trench: haha “well you ARE the one on for plastics, dog.”

Intern: “yeah, but they asked how long I have been a doctor and then the wife told me to ‘get the hell out’ .”

So I took a deep breath a went back into the room.

Trenchy: “listen… I spoke with the plastic surgeon, he is NOT coming down here for this. I really wish you would let me help you. It would take two minutes.”

The wife gave me a “pssk” scowl as I spoke and I soon agreed to try to call other plastic surgeons that were not on-call to see if someone would see her in the ER.  None of the calls being returned, I faced them once again.

“No plastic surgeons are calling me back… I am sorry that your expectations have not been met but honestly they were incredibly unrealistic for what we have to offer. I really don’t know what else I can do for you.”

At that point the husband asked for a phone book and they spent the next hour calling plastic surgery offices to no avail. In the meantime, the ER had really begun to get busy with particularly ill patients for a Saturday and I had basically expected to see them simply walk out as so many others do when our services are far below what is expected. Alas, I would not be so lucky… the husband motioned me back into the room.

“Listen, could you tell us a little more about the surgical adhesive that you would like to do?”

I was stunned. They had been in the ER for 3 hours. I had been amiable all morning despite their ridiculous expectations and patronizing attitude. I suffered humiliation (and probably rightly so) from a colleague to bow to their demands, and now this? My Pride could take no more. That ghastliest of sins not only had me in it’s grip, it began to control my speech.

“I’d say if you can find a plastic surgeon, you may want to ask them about that but honestly… simple cleaning and treatment with neosporin while it heals and you probably won’t have a visible scar in six months or so.”

“So you aren’t going to glue it for us?”

“No sir, I performed a medical screening exam as is required by law and called plastic surgery like you asked… I am no longer involved in your care, but the nurse can clean it up and put some neosporin on it if you would like.”

To the staffs great relief, they immediately storm out of the ER.

I still live by my mantra, but these days I keep Pride in my pocket, for just such an Emergency.


Fight Doctor

November 12th, 2006

Boxer Richie Melito.

I loved boxing as a kid. Growing up in the 70’s and 80’s, I lived in an age when television entertainment was a “choice” of three channels and during many weekends the options were basically fishing shows, Hee Haw re-runs and ABC’s Wide World of Sports.  The latter of which could take a redneck kid, for an ephemeral moment, out of the trailer park to experience skiing in the Alps, surfing in Hawaii and most importantly epic rounds of boxing. Jim McKay took me to exotic locations like Manilla, South Africa and New Jersey to see the greatest names in the sport battle it out; Ali, Frazier, Norton, Duran, Leonard, Hagler… and not for a hundred bucks a pop, it was as free as watching Captain Kangaroo. Screw needing 3 channels, the agony of defeat was all I ever needed.

So years later, when the redneck trailer park graduate was offered the opportunity to be the ringside “fight doctor” for a few small regional bouts, I leaped.

Bobby Mitchellwas smooth in a smarmy, small town boxing promoter kind of way, but I admired his work ethic. At the fights he seemed to be involved in EVERYTHING, you could just sense that he was clearly running the show at these local events and that had a lot bigger plans for the future, a LOT bigger. One thing is for sure, if he ever manipulated me I never knew it. If I stopped a fight, he’d say “thanks doc… good work.” When I stopped a pregnant woman from boxing, ruining his under-card he’d add “good call… you’re the doc.” Honestly, I am no easy judge of men but I liked Bobby and I have known people with his kind of drive before; we have not heard the last of Bobby Mitchell.

I was the ringside physician at the infamous Melito vs. Curry fight in which Curry was paid to take a dive. Eddie Curry seemed to me to be rather old to be taking on the younger, larger Melito. My pre-fight exam of Eddie revealed the wounds of years of boxing… I had questions about his peripheral vision, testing him several times. Knowing the tricks of the trade, Curry eventually faked his way around my exam and I cleared him to fight. In retrospect I think he felt bad about the ruse, “this boy can’t hurt me Doc, you’ll see.”

After the first bell, the difference in the opponents became obvious. Curry seemed to instantly transform from a tired looking middle-aged mill worker to a spry veteran fighter with a skip in his step and a pop in his gloves. Melito, physically impressive at first glance, looked like a B movie actor attempting to play the part of a fighter. It was hardly a De Niro-like performance. He had no foot movement after the first 30 seconds, seemed ridiculously over-confident and could not anticipate Curry fast enough to land a jab much less a solid shot.

Curry began to wail on Melito near the end of the first round and I, the once starry eyed redneck kid turned naive and supposedly impartial ringside doctor found myself moving my fists every time Eddie connected on his nearly stationary opponent. Curry’s great rally was short lived, however, as Melito’s phantom jabs took him down in the 3rd. At the time, Curry’s fall really did seem way too easy to me, but then it was the first fight I had witnessed in person and as I rushed into the ring to check on Curry all I could think of was the vision in his left eye. “He must have not been able to see from his left”, I thought. The idea of a predestined fall never crossed my mind.

As it turned out Curry was fine, as a matter of fact he suffered only a small area of swelling under his left eye, amazing, in retrospect, for a 45 year old fighter. Melito, on the other-hand, looked like hell. I instructed his management to take him to the Mecca and I phoned a colleague to suture the lacerations on his face and ice down his swollen nose. I think everyone in the room that night realized that Melito would get killed if he ever fought a real opponent… except perhaps Melito himself, but then what can I say? I may have been the only one at ringside who didn’t see that the fix was in.

An important note here; I make no claim to be a better man than the participants in the fix. In fact knowing what I know now, I would’ve gladly handed Curry twice his under-the-table purse to have seen him put Melito down on the canvas.  

All in all though I enjoyed my brief stent as the “fight doctor”. These days though I have 300 cable channels and after witnessing an obviously gravid woman attempt to fight for a few hundred dollars I don’t have the stomach to watch much boxing. Oh, and after seeing 30,000 patients, I’m a lot less gullible.


Remember

November 11th, 2006

It’s never too late to get your Flu shot……. er……. uh actually we had two cases of Influenza-A today so I reckon it is too late for some.


I Can See the Headline Now…

November 8th, 2006

“Florida man shot while passing through SC”

Free Image Hosting at www.ImageShack.us

PS- Several people have emailed and did not get the joke… none of the aforementioned people actually clicked on the picture, aw, screw it… it’s not that funny anyway.


To Whomever

November 7th, 2006

found my blog by searching “smoking weed after having stents”.

Listen:
As long as you are on a platelet inhibitor like Plavix then hey man, no problemo… but dude, give it a rest for a while, wait 30-60 days for those stents to epithelialize and make sure your blood pressue is under good control. The REALLY IMPORTANT THING is to be sure of your source… none of that crack dusted shit and crack by itself it is a gnarly stent disrupter… dude, a scene that you want NO part of.

Come to think of it, just grow your own to be sure… one of my buds just gave up long term liquor use to grow the herb and his shit is totally together. Otherwise don’t forget to eat healthy when you are getting your munch on and watch those crazy lipids man… they are playa hata’s.

P.S.- If the man DOES somehow come down on you… simply clutch the left side of your chest with your right hand and just say, “uh, chest pain… and I have stents dudes.” You’ll be livin large again in no time.


Adrift in the System

November 7th, 2006

As another Election Day comes around I thought that I should perhaps make todays post have a political leaning… something that stirs up thoughtful debate, spurs us to action or simply shines just a glimmer of hope for the Great American “democratic” process. After deep and thoughtful consideration, however, I got nothin… just Jorge.

Jorge is a 22 year old man who came to the United States about 4 years ago to work as a painter. He came with a large group of his family who all work in the home building profession and while I have not discussed the topic with him personally, the records note that it is pretty clear that they are here illegally. He speaks no english.

Jorge has had “kidney trouble” for many years but about 4 months ago he stopped being able to urinate and became deathly ill with confusion, vomiting and severe chest pain. Having no physician and no insurance to turn to, he showed up at the Mecca for care and a few simple tests later it was quite clear that his kidneys had failed. With no kidney function the toxins that human bodies produce everyday built up in Jorge’s system to extreme levels leaving him at death’s doorstep. Indeed a natural progression that has invariably lead to death in humans since we were swinging by our tails… that is until we smart monkeys invented hemodialysis.

Hemodialysis (HD) is the process in which blood is removed from the body and then filtered through several semi-permeable membranes to remove several key metabolic toxins and electrolytes that are the byproduct of normal human metabolism… the science is pretty sweet actually. It is ,however, no cake-walk; imagine going to a dialysis center three times per week to sit for hours while your blood is removed, filtered and recycled into your body. Meanwhile certain unfiltered metabolites, drugs and toxins still build up in your system and you stay chronically exhausted from anemia, suffer nausea, cramps and untold other daily ills, not including the constants risks of life threatening infection. HD patients invariably seem to steadily deteriorate over the years and there are several that we see frequently at the Mecca that look literally like zombies.

Back to Jorge…

Jorge had an unbelievably complicated course during his initial diagnosis and treatment as he had several life threatening infections and ended up staying in the hospital for about 3 months at a cost approximating half a million dollars. Part of the complicating factor of his stay was his illegal status. Social workers at the Mecca contacted the Mexican consulate and were able to arrange a hospital transfer for Jorge but because he had not developed kidney disease while he was employed in Mexico he would have to pay for his treatments. Since he has kidney disease now as a “pre-existing condition” he would not qualify to receive insurance. The combination of his lack of insurance in Mexico and his LACK OF ANY FAMILY LEFT IN MEXICO has caused him to be unable to return there.

On the otherhand, the fact that Jorge is an illegal alien precludes him from receiving health care funding in the United States. (Nearly all Americans on HD, receive Medicare to cover the incredible expense of the treatments and care from Nephrologists.)
So the plan for Jorge, as met out by the decision makers at the Mecca, is to leave him adrift in the system. When he begins to experience symptoms related to the build up of the toxins in his blood, he is to check in at the Mecca ER and then he will be transferred to a dialysis bed, seen by the nephrologist on call, undergo HD and then be discharged.

So far, we have been seeing Jorge in the ER about 3 days per week.


How did I not think of this?

November 6th, 2006

I could put up a link, but I have to give props to my man at Medgadget. World’s fastest condom.


Zero Degrees of Separation

November 5th, 2006

Free Image Hosting at www.ImageShack.usI met Kevin Bacon on the sidelines of the Carolina game last night; a very approachable dude and his assistant was pretty cool too. I cannot imagine living a life in which every-time you step out into the open someone wants to take a picture with you or get an autograph... poor Kevin, even Cocky asked for an autograph.
I simply annoy people by talking to them:

Trenchy: “hey man, I didn’t know you were into college football”

KB: “yeah, I am, but I don’t get to many games”

Trenchy: “well, this is not our best crowd… we usually have 85,000 plus…”

Assistant: “this is awesome… the whole town is here”

KB: “yeah this pretty loud…”

Arkansas scores, goes up 14-6….

Trenchy: (throws hat) “dammit, where’s the containment?”

KB: “yeah it is not looking good…”

Trenchy: “thank you sir may I have another?”

KB: “aha… good one.”

Trenchy: “dude, that is the best movie ever.”

KB: “thanks… good luck stopping these guys”

Thanks Kev, but no such luck; we were playing like we were Footloose.


Trainwrecks.net

November 2nd, 2006

Wow, I thought I was hard on myself until these people with nothing better to do than troll blogs offered this tid bit on me…

  • “Snowball said,

    on November 1st, 2006 at 2:31 am

    Knock knock! Who’s there? Trench Doc. Trench Doc who?

    You know, Trench Doc! That selfless rural M.D. whose devotion to the craft of modern medicine is exemplified by such feats as letting a patient die and blaming it on the nurse, chortling away as his favorite resident calls a patient a cocksucker, assessing the likelihood of a sexually transmitted disease diagnosis based on the patient’s pubic hair grooming habits, high-fiving another doctor who arranged to dump all his patients complaining of pelvic pain onto a critical care resident on the grounds that real doctors don’t treat skanks, and, finally, laughing in the face of an AIDS patient.

    Proof that if you suspect your doctor of being a douchebag… you’re probably right.

    Nothing too wrecky going on in the comments, probably because most of the med-blog audience is off reading doctors who can write about medicine without whining about all their dirty fat slut patients all the time. ”

  • At first I thought, “wow, people actually read and mock blogs for entertainment… that’s pathetic”, but then I realized that we are talking about humans here… there is no bottom to the pathological well. However, I have considered that perhaps I would get more therapy out of this if I would write more about the angst of spending 2 hours talking to a woman who just watched her daughter burned alive in a car fire,  the quiet bravery of a certain kid with leukemia, how I couldn’t sleep for a week after I coded three children in one shift… ah, screw it… so I’m a douchebag,  anyone want to hear about the guy who put a Granny Smith Apple up his ass?
  • and in my defense… that patient who died tragically because of incompetence did not have Trenchy’s name on the chart (for liablity insurance purposes)… remember, Snowball said “douchebag”, not “incompetent douchbag.”


    Pediatrics at the Mecca

    October 28th, 2006

    Another Peds shift on a Saturday.  I singled out one kid and told him he could pick  anything he wanted to watch on T.V. (all rooms have to watch the same thing)… and thank the Lord he chose football; he is a good kid.

    One thing about this place though… It will help you reset your priorities in a skinny minute. If you are alive and your children do not have cancer, then you are greedy for asking for ANYTHING else.