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Incredibly Busy

It is one of those days. Patients continue to pour in one after another and just when you feel that things are truly getting dangerous with two or three patients at risk of dying someone who is even sicker rolls in. The feeling I get on shifts like this is a sick uneasiness. Like getting caught on my skiff in 10 foot swells; no longer wondering if it will capsize but which wave will strike it just right.

Our nursing staff is younger and more inexperienced than I have ever witnessed. Most of them working in the critical care areas have been out of school for less than a year and most of the nurses in charge are clueless. Seriously. Scary clueless.

In my 8 hours we saw…

A dialysis pt. with fever. A dialysis pt. with fever and hypotension. A dialysis pt. with fever, hypotension and confusion. A 77 year old man with altered mental status. A status epilepticus. An 80 year old with abdominal pain and fever just discharged from the ICU. An 85 year old with chest pain that just left another hospital today at 5pm with intractable angina and idiopathic gastrointestinal bleeding. A Fourniers gangrene (scrotum gangrene) that went to the OR. A gun shot wound. Another gun shot wound. A large scalp laceration with profuse bleeding. A liver laceration from a car crash. A spinal fracture from a car crash. A large subdural hematoma with 4cm of brain effacement. A persistent bradycardia requiring transcutaneous pacing. A 75 year old with COPD and altered mental status. A pyelonephritis. A 79 year old with fever and altered mental status. An overdose. An infectious tenosynovitis that went to the OR.

Of those, we had 2 intubations and 9 central lines… two of which were performed in an open hallway.

We would have seen more but there are no hospital beds, so when I left tonight at 11pm, the above listed patients were still in the Mecca’s ER. The finger amputation and the rest were waiting in the lobby, with little hope of being seen tonight. The patients who were not admitted waited for over an hour to be discharged as the young nurses were barely able to keep up with the vents, lines and medications muchless the discharges.

I also covered the psych Pod; Committed four people, sent two to rehab and went fishing for one hard to find “vaginal” paperclip that turned out to actually have been placed in a rectum.

Liar, Liar

Somewhere, in some file at the Mecca-ville courthouse there is an transcript of a court proceeding in which a young Trench Doc was called to testify in a murder case. Inscribed on that twentieth century document for anyone to see, in perpetuity, is the following Trench Doc quote:

defendants attorney: “so doctor, please tell me… why would you order such a test when the patient had clearly stated to you that they had not been using drugs or alcohol.”

Trench Doc: “because sir, it may be news to you and the court… but ALL patients are liars and it is up to me that they do not receive the death penalty for that offense.”

By CARLA K. JOHNSON, Associated Press Writer Fri Feb 16, 1:33 PM ET
CHICAGO -

There’s an open secret in medicine: Patients lie.

They lie about how much they smoke and whether they’re taking their medicine. They understate how much they drink and overstate how much they exercise. They feign symptoms to get appointments quicker and ask doctors to hide the truth from insurance companies.

“Doctors have a rule of thumb. Whatever the patient says they’re drinking, multiply it by three,” said Dr. Bruce Rowe, a family doctor in suburban Milwaukee. “If they say two drinks a day, assume they have six.”

Hippocrates, the father of medicine, is said to have warned his students around 400 B.C. that patients often dissemble when they say they’ve taken their medicine. TV’s fictional Dr. Gregory House repeats the same message to his crack team: “Everybody lies.”

But lying can lead to expensive diagnostic procedures and unneeded referrals to specialists. It also can have disastrous results.

“I definitely learned my lesson. I could have ended up in a coma,” said Michael Levine, a 28-year-old financial adviser in Los Angeles, who lied to a specialist he saw for a wrist injury. Misguided pride, he said, kept him from mentioning the Xanax he was taking for anxiety. He didn’t think the doctor needed to know.

“He wasn’t my regular doctor. He was treating my wrist,” Levine explained.

The doctor prescribed the pain reliever Vicodin and Levine took it on top of Xanax. The next few days vanished in a cloud of grogginess. Levine slept through ringing phones and alarms and woke up exhausted. His wrist pain was easing, but he could barely function. Eventually, he stopped the Vicodin, returned to the doctor and, under questioning, confessed.

“The doctor said, ‘Why didn’t you tell me? I never would have prescribed you that,’” said Levine, who now realizes how easily he could have overdosed and died. “For the future, I will always ‘fess up.”

Why do patients lie? The examination room itself is an environment that discourages honesty, said Los Angeles psychiatrist Dr. Charles Sophy.

“You’re naked in a gown and you have a guy standing there clothed, with a coat on and there’s all sorts of things in his pocket. And you’re sitting there, basically naked … that makes it hard to come clean,” Sophy said. On top of that, the doctor may be rushed.

Researchers say patients often lie to save face. They want to be “good patients” in their doctors’ eyes. But that’s a misguided and risky practice. For example, a woman who doesn’t want to admit she smokes and then is prescribed birth control pills is at greater risk for blood clots.

Some researchers estimate more than half of patients tell their doctors they’re taking their medicine exactly as prescribed when they’re not. In reality, they don’t like the side effects, can’t afford the pills or didn’t understand the instructions.

A study by researchers at Johns Hopkins School of Medicine found a big gap between what patients said and what they did. Researchers looked at how patients with breathing problems used an inhaler equipped with a device that recorded the date and time of use and compared that with what the patients said.

Seventy-three percent of patients reported using the inhaler on average three times a day, but only 15 percent actually were using it that often. And 14 percent apparently deliberately emptied their inhalers before their appointments to make it look as if they were good patients.

Some doctors are seeking approaches that encourage more honesty. Dr. Zach Rosen, medical director of New York’s Montefiore Family Health Center, asks his patients a series of questions to determine whether they’re taking their medicine.

“I ask, ‘What medications are you taking?’ At first, I just want the names,” he said. “They say, ‘I’m taking X, Y or Z.’ Then I’ll say, ‘That’s great. How often are you taking that medication?’ … Then I’ll say, ‘Are you experiencing any problem in taking your medications?’”

Asking several questions takes more time. But the approach elicits better, more honest responses than a single question, Rosen believes.

Doctors also should avoid phrases that sound judgmental, said Nate Rickles, an assistant professor of pharmacy at Northeastern University. There’s a big difference between “Why aren’t you taking the medication as prescribed?” and “A number of my patients don’t take their medication as prescribed and they do it for a variety of reasons. What do you think might be going on with you?”

When alcoholics seek detox treatment from Dr. Akikur Mohammad, an addiction specialist at the University of Southern California School of Medicine, they must tell him exactly how much they’ve been drinking so he can give them the right dose of medication to treat withdrawal.

“I tell them, ‘You can lie to your friend, you can lie to your family members, but you came here for help and your report will determine the treatment plan. If I undermedicate you, you may have seizures and die,’” Mohammad said. Despite the warnings, patients still sometimes mislead him, he said.

Cyndi Smith, a 45-year-old Weight Watchers leader in suburban Chicago, admits her own lying past when it came to questions about her exercise and eating habits. She says she lied because she was fooling herself.

“You convince yourself of certain things and it becomes true, when in reality it’s not,” she said. If her doctor had questioned her more thoroughly, she says she might have told the truth.

“I think doctors could be a little more point-blank,” she said. “And we need to be a little more honest.”

Why those of us in the Trenches care so much… not.

 

New data proves what the harden old timers have known for years… No matter how hard we try, we can only care so much at one time.

Kevin Carter, the photographer who won the Pulitzer prize for the snapshot on this post is a classic example. The image was one of many that were shot while he covered the horrors of war and famine in Africa. Carter was flooded with inquiries about what eventually happened to the child but he really had no answer since he did not stop shooting photos to offer aid; apparently he even seemed puzzled by the interest raised in that particular photo over the many other tragic scenes he had documented.

Then a mere two months after winning the Pulitzer he ended his own life.

From Yahoo News…

SAN FRANCISCO—While a person’s accidental death reported on the evening news can bring viewers to tears, mass killings reported as statistics fail to tickle human emotions, a new study finds.

The Internet and other modern communications bring atrocities such as killings in Darfur, Sudan into homes and office cubicles. But knowledge of these events fails to motivate most to take action, said Paul Slovic, a University of Oregon researcher.

 

People typically react very strongly to one death but their emotions fade as the number of victims increase, Slovic reported here yesterday at the annual meeting of the American Association for the Advancement of Science.

 

“We go all out to save a single identified victim, be it a person or an animal, but as the numbers increase, we level off,” Slovic said. “We don’t feel any different to say 88 people dying than we do to 87. This is a disturbing model, because it means that lives are not equal, and that as problems become bigger we become insensitive to the prospect of additional deaths.”

 

Human insensitivity to large-scale human suffering has been observed in the past century with genocides in Armenia, the Ukraine, Nazi Germany and Rwanda, among others.

 

“We have to understand what it is in our makeup—psychologically, socially, politically and institutionally—that has allowed genocide to go unabated for a century,” Slovic said. “If we don’t answer that question and use the answer to change things, we will see another century of horrible atrocities around the world.”

 

Slovic previously studied this phenomenon by presenting photographs to a group of subjects. In the first photograph eight children needed $300,000 to receive medical attention in order to save their lives. In the next photograph, one child needed $300,000 for medical bills.

 

Most subjects were willing to donate to the one and not the group of children.

 

In his latest research, Slovic and colleagues showed three photos to participants: a starving African girl, a starving African boy and a photo of both of them together.

 

Participants felt equivalent amounts of sympathy for each child when viewed separately, but compassion levels declined when the children were viewed together.

 

“The studies … suggest a disturbing psychological tendency,” Slovic said. “Our capacity to feel is limited. Even at two, people start to lose it.”

So Mam, what brought you to the ER?

trenchdoc-patient-drawing.pdf

Vasectomy linked to Demetia Risk

< Dammit. I told her it was like forcing me to have a lobotomy!

Chief Complaint

We here at Trench Doc have a new favorite chief complaint and indeed a new favorite 3rd year resident.

Chief Complaint: “Patient states back pain for 2 weeks, was admitted to 2 other hospitals with out relief. States that he will be suicidal if we do not control his back pain. Patient states he is a Chiropractor and knows what pain medication he needs.”

I have to be frank; rarely do I respond positively to manipulative patients. In fact, if I determine that they have a borderline personality disorder then one of my primary goals (along with medically sound management of course) is to piss them off to the point that they never return to the Mecca.

My resident took a very healthy approach, however. It is one that I have attempted but not once have been successful with. He simply worked the patient up appropriately and then had an intervention confronting the patient about his narcotic use and convinced him to agree to go to drug rehab.

Kudo’s to both the doctor and patient and shame on the Trench Doc for his jaundiced expectation of a favorable outcome.

Another Fine Mess…

I have found that some patient complaints only occur in the ER after I have worked a night and then a day and then another night ; only when the coffee pot is empty, all the death and destruction have subsided and the closest thing that I have to any spare energy is the blood on my shoes. Then and only then do I get to have this conversation.

Paramedic: “this is Ms. Annie, her complaint is constipation for over a week.”

Me: “huh? oh, yeah… hello Mam.”

Ms. Annie: “hello docta… oh, I am feeling better now.”

Paramedic: “she took several laxatives ove the past few days without relief… but then she uh, kinda got relief on the way in the ambulance.”

Me: “yeah… we can tell.”

Ms. Annie: “I just need a bath and yall can take me right back home.”

Me: “yes mam.”

Thank God I am not a nurse.

Quote of The Week (caution: Non Medical)

 

On renewable energy:

So many religions say we’re waiting around for the savior to come, but… when you shave in the morning and look at yourself in the mirror, you’re looking at the savior…. this is the most important story of our time. Solar pwer definately works. Wind definately works. Nuclear is already producing 20 percent of our energy supply. Geothermal can work in some places. We can harness tides. it’s not going to be one thing; we haveto do work on all of them. And this is not just for the environment. We need to do it for the economy and our security.

The greatest transfer of wealth in the history of the world is going on right now, bewteen countries that don’t have oil and those that do. Billions of dollars are being transferred every month. If we had another oil boycott, the U.S. economy would come to a halt, and so would the military, because it also runs on oil. This is an enormous threat. We need to respond with same kind of determination we did in WW II. Detroit went from building cars to building tanks overnight, and that’s what we have to do with energy. By the way, this won’t be bad for the economy. It won’t be a sacrifice. It is the best thing we could possibly do for the economy.”

  - Ted Turner (Jan. 2007 Men’s Journal Interview)

Damn right Uncle Ted. Damn right.

Time for Action

This weekend I am lucky to have assembled nearly every physician blogger in the United States, as well as many others with questionable credentials who have agreed to participate, for a Symposium on healthcare funding. Together, we fully expect to have a very workable plan that can be used to prevent the impending collapse of the Nation’s healthcare system and provide a long term solution to the steadily spiralling costs of healthcare.

Good luck, and let us all beseech the blessings of Almighty God upon this great and noble undertaking.

Update 1- We have agreed to call the meeting the Joint Decision of Web Associated Doctors Symposium or JD-WADS. Please return for further updates.

Update 2- By a two-thirds majority we have decided upon a multi-tiered system, the basis of which is Governmentally funded basic care for all Americans (Tier A). Tier A care will be funded by taxes on wages, gross sales at Wal-mart and tariffs on any non-metallic or solid wood goods imported from China.

 It is clear to the symposium members that such a plan must include at least immunizations, prenatal and postnatal care, preventative care and medication coverage to provide the following: amoxicillin, doxycycline, aspirin, metoprolol, glyburide, captopril, B and O suppositories, fluphenazine decanoate, clozapine, lithium, bupropion, alprazolam, sildenafil, finasteride and phenterimine.

Update 3- Above the Governmental Plan, (Tier B) Americans may choose to purchase health insurance on their own from companies that provide such. Employers will no longer be required to provide insurance for employees but will be taxed to aid in covering the cost of the Tier A patients. Tier B subscribers will be allowed to tax deduct premiums and a percentage of deductibles. Insurers will be limited-profit companies with profits regulated by a Governmental agency similar to utility companies.

Update 4- After working the numbers, it appears that we will also be able to work in all Sexually Transmitted Disease treatment into Tier A and can allow tax credits to farmers growing corn to help with the Mexican tortilla shortage. Mexican immigrants deemed to be illegal however will still not qualify for benefits but, of course, remain eligible for the Tier B tax credits should they choose to purchase insurance.

The Arkansas contingent has also asked that we reconsider the Wal-mart and Chinese tariffs and a special committee has been formed to crunch those numbers.

Update 5- The Committee report suggests cancelling the Wal-Mart/ Chinese tariffs. Those Tier A funds will now come from the Department of Education by condensing elementary education to 12 years ending in the 11th grade. As well, all liability awards will be taxed at 50% and the proceeds will be added to the Tier A fund.

A second committee has recommended the banning of organized labor within insurance companies as compensation for forcing them into “limited-profit” status. In return the New Jersey contingent has asked that the state be allowed to research and report on forming into an independent territory that could self govern but recieve Tier A benefits. Somone then noted “uh, kind of like Puerto Rico”,stunned we realized that we had not considered Puerto Rico in the previous so numbers both motions were then tabled.

Update 6 (Day 2)- The Symposium would like to thank everyone for the great effort put forth yesterday. Overnight we were able to re-crunch some numbers and it seems that more people are employed by drug companies in Puerto Rico than we thought. So with that many Tier B’s the numbers should be fine. In a related note we would also like to thank the fine folks at Lilly for somehow finding out about the symposium and sending breakfast and lunch to each of our 32,000 homes today. Wow.
The first order of business is the “New Jersey question”. We feel the need to stay away from Constitutional Amendments so that congress can easily pass the results of our symposium with minimal reading time by congressional aids, so the idea of limiting organized labor must be sacked at this time. However, we have agreed as a concession with the insurance companies to place the 12th graders left over from the “Wal-Mart Compromise” into indentured servitude for 1 calendar year as restitution.
An issue has arisen, however, as noted by Mr. Ira Lipschitz of the Trail Lawyers contingent: “we must protest most vehemently the plan to place American children into a form of slavery by the insurance industry and of course any taxes on liability awards is strictly prohibited in the Unites States Constitution…. surely this ‘Symposium’ is a farce.”

Update 7- An idea co-sponsored by Kentucky and California has been voted down. We simply, as a whole, do not feel that “throuroughbred horses and cats” health coverage can fall under Tier A while being paid for by increasing tobacco and alcohol taxes. The Symposium has asked them to re-submit the plan with funding that does not include any increase in taxes on those items. Apparently hidden in the wording of the proposal was language that would have amended the Constitution allowing “any governor of California related to a former president by marriage” to run for President of the United States. Again, I ask the Symposium, please refrain from Constitutional Amendments. Since tempers have flared on the issue we will take a one hour recess.

Update 8- A great deal was accomplished once all parties came back to the table. Our numbers find that Tier A services can further include cancer treatment, hemodialysis, coronary bypass surgery, organ transplantation, elective abortions, birth control, the California/Kentucky proposal and some plastic surgery procedures if we limit NICU admissions to 28 weeks minimum gestation and legalize marijuana (taxing at 50%).

Furthermore we have determined that there is no such Constitutional issue with liability award taxes. However, we have made an agreement with the Trail Lawyers that will eliminate the 11th grade in primary school and will redirect “that energy” as “experience compensated clerks, to be used as each individual attorney sees fit for the calendar year.”

One other change is the substitution of tadalafil for sildenafil and finasteride, as the former gives more “bang for the buck.”

On behalf of the other WADs across the nation I offer a hearty thanks to all the participants who worked so hard to work out the details of the JD-WAD Symposium and of course special gratitude to Senator John Edwards who will be working so diligently to bring this compromise plan to fruition.

 

 

 

You’re a Manimal!

 

Several residents have inquired recently about why I occasionally refer to them as “a Manimal”, so I suppose it is time for a thorough yet concise explanation.

As an intern my chief resident on my surgical wards was a classic balls-to-the-wall, cut-to-cure but nearly burned out fifth year resident. Upon realizing that he and I were cut from the same cloth, he frequently sent me on missions to stamp out fires that could potentially save him a great deal (or likely any amount) of work. Each time that I was successful I would be hailed on our rounds with a hearty cheer…

“haha, Trenchy walled off another admission, what an ANIMAL!”

Before long, the chant quickly mutated to “The Animal” and by the beginning of my second year of residency I was simply The Animal; a title that I held in high regard during the next few years of our training. Now, you non-medical types may not quite comprehend the psychopathology involved at this point but at least try to understand this:

In medicine, having a reputation as a sharp, no-nonsense, skillfull practitioner of the art is critically important… having the same said of you in the dog eat dog world of residency training is the ONLY thing that matters. Frankly, a reputation like that is power… it is to be nurtured, kept holy, treasured.

“Listen, if The Animal says it’s appendicitis, then it’s appendicitis… screw a Cat Scan, call the OR.”

Our training period was in retrospect, more ephemeral than we ever realized though and The Animal, along with scores of other nicknames and stories, faded into our collective unwritten lore as the years rolled by. It would be unusual though that the Trench Doc would forget such an important part of his time at the Mecca nor any obscure 1980’s television product that features a doctor who can morph himself into any animal. Thus, anytime a resident excels under the Trench Doc’s tutilage (and since there can be only one Animal) it is likely that the hallowed halls of the Mecca will continue to echo…

 ”you’re a Manimal! ”

God Bless the Mecca.