29 October 2006


One of the frustrating things about working in the ER is that you so rarely get follow-up on a patient you have seen. They leave the ER and it is as if they cease to exist. And when you do get follow-up, it's usually a bad thing -- "Remember that chest pain you sent home yesterday?" So today I was pleased to get follow-up on one of my patients from yesterday's post. It was Patient Number 5, Chronic Abdominal Pain Lady.

Now I didn't realize that it was her at first. For one, the name on the chart was different. Also, the details of the presentation were slightly different. When I walked into the room, though, I noticed that she looked very familiar. Then I saw the external jugular vein on her neck, a very distinct large and bifurcated vessel that I had had to cannulate to get blood off her the day before. (BTW, how sad is it that I didn't recognize her face but did recognize a vein?) At first, I played dumb and got some details from her. She recognized me and tried to give me a close approximation of the previous day's story, getting a little flustered when I pointed out that she had told the triage nurse something very different. I made an excuse and left. The admitting clerk approached me and told me of not the one but three other names they recognized her as having used. They all had social security numbers, dates of birth, phone numbers, and addresses which were identical, except for an occasional flopped digit.

I went back in and explained to her that I was happy to screen her for an emergency condition, and treat one if it were present. I also pointed out the . . . irregularities in her registrations. I did not accuse her of anything, but I said that I was concerned about her dishonesty. (Even when you have someone busted, it's wise not to overcommit oneself.) Predictably, she escalated and became angry and threatened to sue me and stormed out.

Ah, victory. I hate (really hate) having an adversarial relationship with patients. But it's hard not to savor a clean win when one comes along.

28 October 2006

Oh, the pain of it all! Oh, the pain!

With Apologies to Dr Zachary Smith. . .

The first seven patients I saw today were in the ED for:

  • Dental Pain (ongoing for three years)
  • Back Pain (third visit in one month, 18 in 2006)
  • Migraine Headache (six visits in a month, and second ED visit in 18 hours)
  • Back Pain (this one was legit)
  • Chronic Recurrent Abdominal Pain (ran out of Oxycontin and doctor "out of town")
  • "Cyclic Vomiting Syndrome" (in which only narcotics stop the vomiting)
  • Oxycontin withdrawal
Sometimes I wonder why I bother. I occasionally wish my job demanded something more than a valid DEA license, and decision-making skills beyond "yes narcs" and "no narcs." It just drains the carpe right out of your diem to start the day off in a series of ugly little dogfights over drugs with people whom, to put it charitably, you have concerns about the validity of their reported pain.

Now please don't jump to conclusions here. Pain sucks, and in the common event that I know to a reasonable certainty that someone is suffering, I am quite free with the narcotics. That's a big part of my raison d'etre. The problem is that increasingly, it seems that the chronic pain complaints far outnumber the acute pain complaints, and treating chronic (or recurrent) pain in the ED is fraught with difficulty to say the least. You don't know the patient, they come to the ED over and over for the same thing, they are demanding (both in terms of time expended and emotional energy), some are dishonest, there always seems to be some barrier to treatment which requires ED therapy ("Doctor out of town," "Lost prescription," "Only a shot works," "Threw up my pills," etc), and there is never objective evidence of physical disease.

These folks are colloquially referred to as "drug seekers." I wasn't trained in how to deal with them, and haven't seen any good educational/research on the topic. That which I have seen seems to have been infected by the Pain Thought Police, whose first law is that "Only the patient can tell you if the pain is real," and whose second law is "All pain is real." (You can see the problem there, at least from my point of view.) So of necessity, my approach to these folks is sort of ad hoc.

Off the top of my head, I would describe most of the "problem patients" as falling into a few distinct groups:
  • Malingerers: Want drugs for diversion or recreational use
  • Organic pain superimposed on narcotic addiction
  • Organic pain superimposed on psychiatric condition
  • Minor injuries in individuals with poor pain tolerance
  • Primary psychogenic ailments
These probably comprise 80% of the repeat visitors we see for narcotics. I commit heresy -- The Pain Thought Police would have us believe that organic pain and narcotic addiction can never co-exist. Any ED doc will tell you the truth. The real problem for me is that there are a couple of other categories:
  • True organic pain of long duration
  • Acute pain in a narcotic-habituated individual
And my job is to sort out the wheat from the chaff, so to speak. I try to find a way to say "no" to the first group of "seekers" in a manner that is therapeutic, honest, defensible, and not too much of a pain in my ass, while acurately sorting out the occasional individual who looks like a "seeker" but in fact is "legit."

It sucks. You wind up feeling judgemental and mean, you have to make people cry, and when you are wrong, you feel absolutely horrible -- and you always have that nagging doubt in your head, "Was I too harsh?" This is honestly the most emotionally challenging thing I have dealt with as an ER doctor -- not as hard as having a child die on you, but more of an every-day sort of low-level emotional parasite. Some ER docs say "Why bother?" Give 'em what they want -- it's easier and everybody's happy." No complaints to administration that way, either. We euphemistically call these docs the "candy men," but in truth I feel like a more honest appellation would be "pushers."

When I came home, my wife cheerfully greeted me and asked brightly, "So how many lives did you save today?"

Oh, the pain of it all. . .

[PS -- Don't miss the Follow-up to this post.]

25 October 2006


So Barack Obama is going to run for president? Or maybe not. He's too young, too inexperienced. He should stay in the Senate. Or, he's charming and visionary and the perfect anti-Hillary and a wonderful communicator who just happens to be black. He should run.

I don't have a firm opinion. Though when I saw his DNC speech I turned to my wife and said "That man is going to be our next president." So maybe I'm a prophet.

Hilzoy over at Obsidian Wings has a fascinating rundown of what Obama has actually accomplished in two years as a freshman senator in the minority party. I am a little surprised, and if anything it increases my sense that Barack is a guy with real future as a politician, and that I am glad he's on our side. Whether his future is in the Senate or White House I don't know, but based on what we've seen, he seems likely to do a great job wherever he is.

Oh, you should go check out the link, if only to see the little picture in the upper-left of the screen. Hysterical.

Stay the Course

When your policy has failed, you can either change the policy, or change the name of the policy. Anybody care to guess which the Bush team chose to do?

24 October 2006

Terrorized by a small child

I was at the YMCA locker room changing before Karate, and a little boy was there, naked, maybe six years old. I couldn't see anyone else around, though there might have been someone lurking in the rows of lockers. The little boy came up to me and said, "Is it a bad thing if somebody touches my privates?"

Alarm bells started going off in my head. "Um, yes. Yes, that is a bad thing. Nobody gets to touch there." I looked around nervously. Still nobody there. But I was terrified that someone would come in and overhear part of the conversation that I, a strange adult male, was having with a naked child, mistake me for a pedophile, and call the cops. The kid followed me around the locker room, strangely insistent on the topic. Mostly he asked the same question over and over in slightly different phraseology.

The ER doctor in me did wonder if there was a reason the kid was asking this question. Should I ask him? Should I tell someone? Who would I tell? How does one go about that? I decided not to, mostly based on the tone the kid was using -- the same sort of fantasy tone my son uses when he torments me with hundreds of random questions. There was no affective hint of anything other than a little kid rambling on.

So I hid. I bravely went back to the bathroom and locked myself in a stall. In fairness, I did need to use it, so it wasn't an act of pure cowardice. When I came out, I saw the kid had attached himself to some other guy and was tormenting him with repetitive questions, mercifully on a different topic.


Funniest movie ever made or reprehensible piece of crap?

You decide.

23 October 2006

4 AM Ramblings

It's a little strange how your perspective changes when you are a parent. Something about the power of visualizing your child in the position of any other child who meets with an accident or untimely demise makes the emotional impact of images and thoughts of that type an order of magnitude more potent. The interesting thing is that I find it is not just limited to cases where there is a simple parallel between my kids and the victims. For example, I've been literally sickened by the carnage in Iraq and in Lebanon for quite a while. But I find that my empathy has extended even to the adults. Particularly the adults who are being kidnapped, tortured and murdered in massive numbers. I can rationalize the death of a soldier in a firefight -- the act of kidnapping an unarmed, helpless civilian and toruring him to death seems inhuman to an incomprehensible degree. I feel sick when I think about it, and it's because I am empathizing with the victims. I don't think I would have viewed it the same way before I had kids. I was a lot more dispassionate in my outlook then.

21 October 2006

Obesity is a malignant disease

Dr "Bard Parker" over at A Chance to Cut has an interesting abstract of the recent literature surrounding obesity in trauma. It may be from the Journal of Proving the Intuituvely Obvious, but is worth a look. Nobody in health care would even shrug at the notion that really heavy people are a nightmare to care for, simply on a practical basis. This is the first time I have seen severe obesity linked to short-term mortality.

In short, the heavyweights were 7 times more likely to die in hospital than similar non-obese patients with comparable injuries. They had more infections, spent more time in the ICU, had more central lines, more episodes of organ failure, and spent longer on a ventilator. (To which anyone who has spent time in an ICU responds "duh.") Intubations and tracheostomies are more difficult, and central line placements are more challenging in the obese.

I can vouch for that personally. I am pleased to report that I have three succesful, first-pass intubations in 500+ pounders in the last two years. (One survivor.) Last year we had a young man in his early twenties who weighed over five hundred pounds who expired after a motor vehicle accident. To this day I do not know what his injuries were. He did not fit in the CT scanner, so we had no real way of assessing him. He died of respiratory failure right in front of our eyes. It was terrible; he came in awake, talking and very afraid. He could only breathe sitting up, and even then his respirations were ineffectual. He slowly became somnolent. After great deate and with great trepidation, we intubated him, successfully (no simple matter). But we were unable to ventilate him effectively, and he coded and expired. I would presume there were internal injuries which contributed, but we were never able to ascertain that. It was a bad thing.

It seems like we see more and more of these cases as time goes on. Sad.

16 October 2006

Distorted Beauty

Dove (yes, the soap/cosmetics company) has an amazing video here, at their "Campaign for real beauty." It's worth thirty seconds of your time. I might add that it's a really nice thing for a cosmetics company to focus on. Good for them.

15 October 2006

The risks of notoriety

I am at the national convention for ACEP, the American College of Emergency Physicians. I enjoy coming because it's always full of engaging lectures and really lets me reconnect with the reason I am an ER doctor, lets me refocus my thinking and develop my vision for where I and my practice are going.

It's also a lot of fun, and I get to reconnect with old friends from residency.

So today one of my partners and I were walking into the hotel, and ran into the director of my residency program, who was talking to a half-dozen of the current residents. He waves me over, greets me enthusiastically, and introduces me to the residents. "This is Shadowfax," he says, "He graduated from the program in 2000."

One of the residents blurted out "The Shadowfax?" Another follws it up with "Oh man, I've heard about you!"


"Er, what exactly did you hear?" I managed to weakly croak.

"I was talking to Dr Jones, and he told me about the time you walked into a room for 30 seconds, walked out and said, 'This kid has Kawasaki's and needs to be admitted for IVIG. This is the most interesting thing I am going to see all day. I'm going home.'"

"I heard about you used to do spinal taps with your eyes closed," chimes in another. "They said you preferred to do it by Zen."

I had some very vague memories of the incidents. They sounded familiar (though somewhat inflated in the telling). The stories, to my great discomfiture (and the poorly suppressed amusement of my partner) went on for a while. I was more than a little surprised that I had been remembered at all, let alone in such detail. It's a big academic program, and I didn't cultivate any close relationships with the faculty, so I kind of expected to be forgotten. I guess I did make an impression.

That's a good thing, right?

How to frame the debate

Make it personal.

From Majority Action. Powerful and effective. I have lived for so long in dread of the "wedge issues." The wedges have been used so powerfully and brutally, almost exclusively by conservatives, that I have developed an almost-reflexive aversion to them. The pathetic inability of the progressive movement to counter them made me pull my hair out. I know there are moral complexities to this issue which by far exceed what can be conveyed in a 30-second commercial. It's sad that american discourse has come to this. But it's nice to see the progressive side finally get into the game.

12 October 2006

September Fund makes a funny

From Harold Ickes' September Fund.

Impending Democratic Landslide?

I remember too well the late October polls which showed that Kerry was sure to beat Bush and I have vowed to never put so much of my hopes into polls again. But this is certainly encouraging. Constituent Dynamics has put out a huge slew of polls today -- 48 districts. The results do not look good for the GOP. (Cool interactive poll -- check it out.)

If you look at only the races where the Democrats lead is outside of the margin of error, the Dems are already at 218 seats, which is the magic number needed for Speaker Pelosi (TX-22 is considered a certain pick-up and was not polled). There are another 20-25 races which are toss-ups. If there is no "Democratic breeze" blowing and we only split the remaining seats, the Democrats will control the House 228-207. If we do better than predicted, the margin could be even larger.

Now there is only one poll that matters, and that's in 25 days. Whether this is a huge win, a win, or a loss will depend on the ground game -- and the Republicans have the best ground game. They've beaten us with it before, and I have seen them close the deal too many times for me to take anything other than transitory pleasure from this sort of polling data. But it is encouraging.

04 October 2006

Meanwhile . . .

Sex scandals that bring down bloated, corrupt, corpulent Speakers of the House are fun and all but let's not forget. . .

23 US Servicepersons have died in Iraq since Sunday.

George Bush has blood on his hands and this is why we stand against him.

The Republican Assault on Charge Nurses

So here's an increasingly rare comment on an actual health care related topic.

The NLRB, heavily dominated by Bush Appointees, voted along party lines yesterday to reclassify millions of US employees as "supervisors" who are by that definition, ineligible to join unions, organize, or engage in collective bargaining. This case revolved around a Michigan hospital's attempt to break their nurses union, and the result is that somewhere around 800,000 nurses (and about 7 million workers in other industries) are stripped of the protections offered by a union without truly being members of management.

It's no suprise, coming from the most virulently anti-union, anti-worker administration in living memory. These are the same folks who opportunistically used the passage of the Department of Homeland Security bill to engage in a little union busting.

35 days till daylight.

01 October 2006

Strange Ironies

Noted civil rights lawyer Glen Greenwald points out an odd distinction with regard to Republican Congressperv Foley's cybersex:

[I]n-person, actual sex between Foley and a 16-year-old page would be perfectly legal in D.C. and in most places in the U.S. . . . Despite all the irritatingly righteous (and overheated) "pedophile" language being tossed around, in the overwhelming majority of states, and in Washington DC, the legal age of consent for sex is 16 years old. That means that actual, in-person sex between Foley and a 16-year-old page in D.C. would not be criminal at all (though it likely could have other legal implications).
Interesting but not too significant, since they are not alleged to have done anything more than talk dirty. This is where the felony potential kicks in:
[U]nder the so-called "Adam Walsh Child Protection and Safety Act of 2006" . . . along with 18 U.S.C. 2251, discussion or solicitation of sexual acts between Foley and any "minor" under the age of 18 would appear to be a criminal offense (see Adam Walsh Act, Sec. 111(14) ("MINOR.--The term 'minor' means an individual who has not attained the age of 18 years") and 18 U.S.C. Sec. 2256 (1) (“'minor' means any person under the age of eighteen years").
And who, you might ask, was a co-sponsor and author of some of the language of the "Adam Walsh Child Protection and Safety Act of 2006"?

None other than the honorable representative from Florida's 16th district, Mark Foley.

Hoisted by his own petard.

Your Government at Work

Via Ezra:

With little public attention or even notice, the House of Representatives has passed a bill that undermines enforcement of the First Amendment's separation of church and state. The Public Expression of Religion Act - H.R. 2679 - provides that attorneys who successfully challenge government actions as violating the Establishment Clause of the First Amendment shall not be entitled to recover attorneys fees. The bill has only one purpose: to prevent suits challenging unconstitutional government actions advancing religion.
Original citation.

I hadn't heard about this. I wish I could say I was surprised, but I'm not. Sometimes I think I have lost the capacity to be surprised by these people.

37 days to daylight.