29 June 2008

An EMTALA Primer

Over at NY Emergency Medicine. Go read it -- it's worth your time, especially if you are new to Emergency Medicine.

One thing that bothers me about the EMTALA case law and current enforcement, is that despite the theory that EMTALA was not supposed to be a surrogate for malpractice, the "overlap" between EMTALA enforcement and medical negligence has come to be near 100%, in effect creating a double jeopardy situation for ER docs. Though I have never seen or heard of a case in which a doc/hospital were subject to med mal and EMTALA fines, the possibility is disturbing.

26 June 2008

Breaking: Republicans Filibuster Medicare Fix

From The Hill:

The Senate left town Thursday night for a week and a half after passing billions in domestic spending initiatives and a new GI Bill but falling a single vote short of passing Medicare legislation that would have prevented pay cuts to physicians. [...] The Medicare legislation would have blocked a 10.6 percent fee cut to physicians that is scheduled to take effect on July 1. It failed 58-40, two shy of the required 60, but Majority Leader Harry Reid (D-Nev.) switched his vote to “no” as a procedural move that allows him to bring the bill back up for a future vote. Sens. Edward Kennedy (D-Mass.) and GOP presidential candidate John McCain (R-Ariz.) missed the vote.
Fun fact: McCain has not shown up to the Senate to cast a vote since April. His would have been the deciding vote.

Republicans oppose the temporary SGR fix because funds to pay for it were obtained by reducing the size of the Medicare Advantage plans.

The net effect here is that as of next week, physicians can expect to see that 10.6% cut in compensation from all their Medicare patients. Perhaps there will be a stop-gap fix while a compromise is worked out, or perhaps, as in 2006, the ultimate solution will be retroactive to July 1. The conventional wisdom is that the cuts will eventually be stayed, but once they are implemented, and become the status quo, the higher the likelihood that the remedy will not appear and we will be stuck with the lower rates, or that a fix, if it comes, may be less than initially expected.

24 June 2008

X-Ray Art

This site is worth a look. Lots of artful and fascinating X-ray "photos" of real-world scenes.

For example, a hangared Boeing 777:
I have no idea how this guy gets these images, but they are amazing.

23 June 2008


Way, way way off topic, but the Cubs just finished a three-game sweep of the White Sox, at Wrigley Field.

I'm sorry, let me correct myself:
The first-place Cubs just finished a three-game sweep of the White Sox, at Wrigley Field.

No, that's not quite right either. Trying again:
The best-in-the-major-leagues Cubs just finished a three-game sweep of the White Sox, at Wrigley Field.

Yes, that's it. Ah, that felt good to say. The last time the Cubs had the best record in June was 1908, which was coincidentally the last time they won the Series.

Weird. The Democrats are poised to win the White House, and the Cubs are eyeing a World Series. Someone with a cynical disposition might be forced to wonder how they will each manage to blow it, how they will snatch defeat from the jaws of victory. But not me -- I'm a Cubs fan, and you have to be an optimist to survive as Cubs fan.


In the ER, we don't usually get follow-up on out patients unless they happen to come back in, or unless we take the extra effort to find out how things turned out for the admitted patients. Matt had asked how or if they were able to repair the unfortunate hand featured in this previous post. For your education and edification I offer this follow-up image:

I leave it to the good Dr Bates to provide technical details, as is her wont; suffice it to say that extensive soft tissue injuries -- flexor and extensor tendons -- have left this individual with limited prospects for a functional recovery.

Fun fact: in medical school, Dr Shadowfax was terribly torn between careers in Plastic/Hand Surgery vs Emergency Medicine. Given his attention span (very very short), it is probably a good thing that he chose as he did. But he still quite enjoys taking care of complex hand injuries.

Utter Depravity

So I'm seeing this young 20-something guy, and he's a wreck. Anxiety attacks, withdrawal from methadone, 50 ED visits in 2008 alone (and it's only June -- that's like twice a week!), and he's just begging and pleading with me for some narcotics and valiums. In fact, he was begging for meds since well before I saw him -- he was on a gurney in the hall for a couple of hours while I dealt with some real patients (an incarcerated hernia with dead gut taking up the bulk of my time), and every time I walked by he would clutch at my sleeve weeping and pleading for meds. The nurses were bugging me to just get rid of him already, but I had too many sick patients to break off.

Finally, I manage to clear my plate of more pressing issues, and I go to see him:
Him: "Doc, ya gotta help me. I'm sufferin' real bad. I can't breathe and my heart's about to explode. I been off the methadone for like a week now and it's just killing me."
Me: "Are you vomiting much?"
Him: "No, it's the pain. My whole body hurts, all my bones, and my skin is on fire."
Me: "Sounds rough. How much methadone were you on?"
Him: "Eighty milligrams a day. Been on it for eight years."
Me: (impressed) "That's a lot. Were you in the local methadone clinic?"
Him: "I was for a while, but I got kicked out. Mostly I just steal my mom's methadone, but she got cut off by her pain specialist because she kept running out early."

Now I know that addicts will do absolutely anything to get their fix. They will betray anyone, steal anything, lose their family, lose their home, they'll even whore themselves out for the drugs. So I know and I have seen the awful power that drugs take on the soul of the addicts. I've seen people do terrible things because of their addictions.

But stealing your own momma's pain medicine? That's just low.

21 June 2008

Just for the record

McCain has cultivated his image of a moderate, non-partisan sort of guy, someone who's not as ideological as the rest of the crowd. It's true that he's occasionally been against his party's orthodoxy, but not on one issue: a woman's right to choose. On this, he has been consistent in his belief that Roe v Wade should be overturned:

No disrespect to those who differ on this issue. But if you are concerned about the rightward shift on the Supreme Court, remember that Sandra Day O'Connor was the vote that kept abortion legal, and she was replaced by Alito. Justice Alito does not believe in stare decisis, that precedents (like Roe) should be allowed to stand. Abortion rights hang by a thread as it is, and it's no stretch to say that the next president could appoint two or three new justices to replace the aging liberal members of the SCOTUS.

The Supreme Court recently upheld habeas corpus rights by one vote. We can't afford another president who will appoint more right-wind ideologues like Scalia and Alito.

Elections matter.

20 June 2008

A Public Service Announcement

  • Always assume that a gun is loaded.
  • Before cleaning your gun, please be certain that you have unloaded it.
  • To adequately declare a gun "safe" you should visually ensure that there is not still a round in the chamber.
  • In any event, it is still not a good idea to place your hand over the muzzle.
This has been a public service announcement.

19 June 2008


Tonight was sparring night at Karate; I have sustained the following:

  • Jammed right great toe
  • Contusion, right patella and suprapatellar tendon
  • Bilateral quadriceps contusions
  • Right elbow contusion
  • Left thumb subungual hematoma
Any coders out there? What does that work out to?

(And let the record reflect that I gave better than I got. Well, except for one nasty Sandan who got in some good licks.)

Weird Abscesses

I have seen a lot of abscesses in my career. They're quite different now than they used to be -- in training, in an inner-city program, I used to see lots of IV drug abusers with cutaneous abscesses due to injecting dirty drugs. Those pusbags were hot, red, tense, and exquisitely painful. When lanced, with good local anesthesia, they produced fountains of pus and immediate relief from the pain, and they healed well without antibiotics.

Now, of course, we all know about CA-MRSA, and 99% of the cutaneous abscesses I see are due to this germ. But they look quite different than the "classic" abscesses. Generally, they are notable for a central, shallow pustule, with minimal purulent material, and significant surrounding erythema. You can de-roof the pustule, but you never really get anything out -- just enough to culture -- and evacuating the pus is not sufficient for healing. Antibiotics are always, it seems, necessary.

The MRSA seems different in children, especially infants and toddlers. Those can look similar to the superficial pustules that adults get, but seems to have a much higher incidence of harboring a large subcutaneous collection of pus, which will fountain out under pressure when lanced. The kids seem to be much sicker (febrile, high white counts, etc) and way more likely to require hospitalization.

It's hard to know whether this is a regional thing, or whether I am seeing the typical presentation of the CA-MRSA lesions. Is this consistent with what you all are seeing?

17 June 2008

More on Russert

By now it has been widely reported elsewhere that Tim Russert did indeed die from a ruptured plaque in his Left Anterior Descending coronary artery -- a classic "widowmaker's" MI. Interestingly, CNN reports that NBC did have an AED on site, and that it was not used, because DC EMS showed up at the same time, and that the presenting rhythm for EMS was V Fib. Not a surprise, really.

Medics tried to revive Russert

The only take home message I derive from the case is that stable coronary disease is never stable in the setting of new-onset symptoms. When a small, non-occlusive plaque ruptures and develops an occlusive thrombus, even someone with a recent negative angiogram can infarct and die. Which is why I have a low threshold for admitting patients with chest pain, even those who have been studied recently.

Oz: [...] that creates this referred pain that in cardiology and cardiosurgery we recognize to be angina.

"Cardiosurgery"? Who the hell calls it "cardiosurgery"? I've never heard that term before. It's like those misguided buffoons who call Emergency Medicine, "Emergentology." Get with it.

Keepin' it Classy

As seen at the Texas GOP convention. How did this guy not get thrown out of the building? Are the organizers dumb, or just permissive of overt racism in their party's discussions?

Most (actually all) of the republicans I personally know are decent people who I would assert are not racists and in fact would violently react against any racially insensitive rhetoric. But it's hard to deny that there is a deep, dark racist core to the modern GOP. It's no secret that it was in reaction to to the Civil Rights Act that the Old Confederacy states flipped from being solidly democratic to solidly republican. Reagan ran on a States' Rights platform, commonly understood as code for racial segregation and famously campaigned against "welfare queens," also code for "black freeloaders."

That was 30 years ago, and I had hoped that today's republican party had progressed beyond that. I guess I gave them too much credit. Pat Buchanan recently derided Obama as too "exotic" to win; fortunately a co-panelist called him on it, asking him "What's exotic? Is "exotic" code for "black"? I don't understand what exotic means." and forcing Buchanan to back off of the statement somewhat.

At this point, it's just a matter of time before some republican starts calling Barack Obama "Boy."

16 June 2008

You Know

You know it's going to be an entertaining shift when you pass a multi-vehicle accident on the highway on your way into the ED.

I got there just before the first of many patients did...

14 June 2008

The candidate who can't speak straight

McCain on Social Security, 2004 and today:

I don't know why McCain thinks he can just flip-flop on every single issue and think nobody will notice. Maybe he just talks out of his ass a lot, spouting whatever's in the front of his mind at the moment, and since he's been something of a backbencher in his caucus, there's not been a lot of accountability for his inconsistency. That's a nice thing about being a "maverick": when you're powerless, it's easy to escape close scrutiny.

It's kind of sad actually. I think he once was an independent-minded guy, and long ago, he did have the courage to take on his party's orthodoxy. Now that he has a chance to be president, he's sold his soul and his principles for the chance. Sad.

13 June 2008

Holy crap

Tim Russert collapsed and died at the studio today. He was 58.

Really sad.

He had apparently just returned from Italy. NBC says the cause of death was a heart attack, but I've gotta put my money on a PE.


An obviously distraught (but professional) Tom Brokaw announces the news.

The Magic Cure

There are some patients that you dread having to see. You just know in your heart before walking into the room, that it's going to end up badly -- an argument, a dispute over narcotics, a complaint to administration, something bad -- despite all your efforts to make nice. I saw her name on the chart when I picked it out of the rack, and my shoulders slumped as I recognized the name. I wondered momentarily whether anybody had seen me pick up the chart -- maybe I could slip it back in the rack for my partner to take. But my conscience wouldn't permit that, so I took a deep breath and squared my shoulders, and went bravely into the room.

This lady had a lot of problems. She was terribly addicted to narcotics, on well over 160 mg of oxycontin daily, had intractable headaches, anxiety problems, heart problems, abdominal pain with no clear diagnosis, and all sorts of other psychiatric issues. A challenging patient. What was she here for today?

"Doctor, I'm getting bruises all over for no reason," she said, extending her arm towards me as evidence. "I just started a new blood thinner and I read on the internets that if you have bruising to go to the ER immediately!"

Sure enough, she did have a bruise around her right wrist. It looked as if someone had grabbed her where her gold bracelet was and squeezed really hard. But she denied any trauma. Despite her statement, she really didn't have any bruises anywhere else. I inspected the bruise a little more carefully.

There was no swelling, but the purple-green coloration was pretty typical of an evolving deep bruise. I pulled at the skin a bit, and the bruise moved with the skin, which was a little unusual; generally you can pull the skin across the underlying bruise. This looked like it was in -- or on -- the skin. On a hunch, I got a wet paper towel and rubbed the bruise a bit.

It disappeared completely.

She looked at me in open-mouthed astonishment. Literally dumbfounded. I smiled broadly, "Well, you're cured."

She was horrified, embarrassed, and delighted all at the same time. She covered her face in mortification, and thanked me effusively for being "clever" enough to figure it out. Since she was now cured, I told her she could go home, hoping to get her discharged in that brief window of relief, before she could dream up another complaint. She was so embarrassed that she bolted the ER without even waiting for discharge instructions.

Score one for the home team.

McCain != Bush?

John McCain, for some incomprehensible reason, objects to being continually associated with the Worst. President. Ever. and all of his failed policies. He won't appear in public with Bush. He tries to pretend that he has been some sort of contrarian radical, speaking independently since day one. Someone should clue him in to the fact that the internet exists, and puts the lie to his words:

I love watching the green-background speech because I just find his strange death-rictus smile hypnotic.

(for the non-geeks out there, != is the computer science symbol for "not equal to")

12 June 2008

St Baldrick's Follow Up

The St Baldrick's campaign for 2008 is not over, but since most of the fund-raising takes place around the signature shaving events, the bulk of the gifts have been given. Results at this point:

Shadowfax raised just over $17,000
Nathan's Network raised just under $40,000
St Baldrick's overall is at just under $16,000,000, and on course for their 2008 goal of $18 million.

You may recall that in March I profiled faithful reader and pediatric oncologist EMH (M/N 977). The good news is that today we learned that her research is being funded through St Baldrick's! She writes:

To all the readers who supported the St. Baldrick's Foundation... thank you for contributing the funding that was just awarded for my research!

The funding will support my work for pre-clinical trials in 2 mouse models of medulloblastoma. I will testing the efficacy of a promising oral agent called IPI-926, which has shown anti-medulloblastoma activity in human and mouse medulloblastoma cells. If effective, this drug could move toward clinical trials for children with medulloblastoma.
This, while of course very preliminary, may prove to be of benefit to kids like Henry, who is undergoing chemo and radiation for his medulloblastoma.

I can't tell you how proud and grateful I am for all that we accomplished this year, and to see it translated into real research being performed toward curing these cancers is wonderful. Thanks again to all of you who supported this campaign, and if you are a new reader, you may look at the pictures of my shaved head here, and if you enjoy them you are ethically obligated to click the below link and toss a couple bucks into the pot -- and towards EMH (M/N 977)'s research!



EMH (M/N977) has been outed -- in a good way! She was featured in a very nice write-up over on PZ Myer's uber-science-blog, Pharyngula! Way to go, Beth!

Let's play again: McCain vs McCain

This is fun:

In 2005 and 2007, McCain was in favor of raising the cap on the Social Security payroll tax as part of a hypothetical compromise solution.

On a Feb., 23, 2005, edition of "Meet the Press," NBC's Tim Russert asked McCain if he would support "as part of the solution to Social Security's solvency problem, that you lift the cap so that you would pay payroll tax, Social Security tax, not just on the first $90,000 of your income, but perhaps even higher?"
“As part of a compromise," said McCain, "I could, and other sacrifices, because we all know that it doesn't add up until we make some very serious and fundamental changes.”
In 2008, once again, the maverick senator found it expedient to ditch that position and in a remarkable display of chutzpah, criticize Obama for the very same compromise that he supported for several years:
"The Social Security tax cap, he wants to raise from $105,000 to I think
$200,000," McCain told Bloomberg News' Peter Cook. "Do you know how many
employers, small-business people that would mean a 12-percent increase in their
Social Security tax? I mean, this is just -- Senator Obama wants to
raise taxes," he continued. "I want to keep tax cuts in place. And I think
that it’s important that in a time of real crisis, economic crisis in America,
the last thing we want to do is raise people’s taxes now."
Let's score this one: Flip-flopped to pander to the right wing base? Check. Hypocritical criticism of Obama? Check. But it seems incomplete without the McCain mendacity. Where's the lie? Ah, yes, here it is:
Obama and his advisers have said on multiple occasions that he would continue to exempt income between roughly $100,000 and around $200,000 from the Social Security tax while imposing it on income above $200,000.
Deliberate mischaracterization of Obama's actual proposal? Check! A perfect score!

The gift that keeps giving

I swear that they shouldn't let this guy out in public without handlers and a script. He's a walking gaffe-fest. First it was "Bomb bomb bomb, bomb Iran." Then it was "100 years" in Iraq. Then he says "It's not important" when we bring our troops home from Iraq. All of these were foolish, careless things for a candidate on the stump to say. But now he's gone too far, he's made the unforgivable gaffe, he's crossed the line of no return:

He's going to veto beer.

No, really! I didn't even know that was in the executive's authority, but apparently that's his plan:

Seriously, I don't think these "gaffes" are terribly important. Sometimes a gaffe is, as they say, the unintentional speaking of a political truth. The "100 years" comment would qualify there. Sometimes a gaffe is just something which sounds bad, especially out of context; the "not important" line would qualify there. But he is careless with his words, isn't he? I can't wait to see what he says next. Seriously, I think I'm really going to enjoy this campaign.

11 June 2008

Advice for new EM grads

It's that time of year again. New interns will be flooding the wards, and newly minted attendings will be starting their first "real jobs," for some the first "real" job they have ever held.* So I'd like to play Polonius and offer some unsolicited words of advice for all those brand-new Emergency Physicians heading out to their first staff positions.

  1. Make a good first impression. This is critical. Your new partners will form an opinion of you based on their early experiences, and those first weeks on the job are crucial in establishing yourself as a "good hire." Show up on time; ten minutes early is better. Dress professionally; relaxed is OK in the ER, but a pressed white coat or a collared shirt looks better than rumbled scrubs. Smile a lot and even when things are frustrating, keep your temper in check. Remember that in most groups, this is a probationary period to see if you are a good fit for partnership. Put your best foot forward.
  2. Don't be scared. You know how to do this. "New Attending Syndrome" is inevitable, as you first shoulder the sole responsibility for patient care. But have confidence in your knowledge base and don't change your practice style just because there's no supervisor looking over your shoulder any more. If you would have sent the patient home as a resident, then do so as an attending. Once you start practicing scared, it's a hard habit to break.
  3. Learn the local politics. Make sure you know who the medical director is, who the nurse managers are, the medical staff chairs, and the administrators who exert influence over the ER. Are there any existing or recently-resolved conflicts? Any of your new partners who are disaffected? Any specialties or medical staff docs who hate the ER? Any financial disputes within the group? Don't take sides in any ongoing pissing matches if you can avoid it, but make it a point to survey the lay of the political landscape.
  4. Figure out the local standard of care. Every hospital handles stuff differently. Do they admit syncope? Is there a rapid chest pain protocol? Does your group write admitting orders? Who admits GI bleeds? How sick do you need to be to get into the ICU? Conscious sedation?
  5. Don't rock the boat (yet). If there are things in #4 that you don't like, you may not be in a position to effect change, especially until you have completed #3. Establish yourself as a reliable and productive doc before you start agitating for changes in procedures, especially on contentious turf-related issues.
  6. Make the nurses your allies. Emergency medicine is truly a team sport, and the nurses will make or break you. Learn the nurses' names, especially the charge nurses. Bring them food or coffee on the night shift. If they go out in the morning, see if you can come along. Do not flirt or date them if you are single (and especially not if you are married). A sexual harassment allegation is not the way to start your career. Respect their experience and their judgment, and they will save your ass many times.
  7. Get to know the medical staff. Go to medical staff meetings, and go up to the floor to follow up on admitted patients. Read the paper in the doctor's lounge. Show up to the department meetings for other specialties if they are open. They love it when a representative of the ER shows interest and respect by coming to 'their' meeting. Your middle-of-the-night phone calls will go over better if the consultants have seen your face and think well of you.
  8. Get up to speed. As a new doc, you will not be able to move the meat right out of the gate. But there will be a lot of people watching how you manage patient flow, and you do not want a reputation as a slow doc. Keep picking up patients right until the end of your shift and stay as long as you need to to get them dispo'd. Impress people with your work ethic. Pay attention to the number of patients you see daily, set yourself a goal, and track to see how you are performing. Trust me, your employer will be doing the same.
  9. Live within your means. Your income is about to increase by an order of magnitude -- don't go nuts. Buy a smaller house than you can afford, hold off on the BMW for a few years, and build up a cash balance first. You should have 60 to 90 days' liquid cash before you start spending and living large. Make sure you have life and disability insurance -- many residencies offer individual disability plans to graduating residents, and you should definitely sign up if you can. Pay off your credit cards. Start an investment account.
  10. Enjoy life. Most community ER docs work 12-15 shifts a month. That's a lot more time off than residents can comprehend. Reintroduce yourself to your spouse and family. Didn't you use to have hobbies? Go hiking, sailing, or, um, start a blog.
  11. Build a niche. What do you want to do with your career? There are lots of ways to be involved and to grow professionally. Sit on hospital specialty committees, or work in medical staff governance. Become involved in the administration of your group, or local EMS. Work on quality improvement projects in the ER. Learn about reimbursement or risk management. Get on an ACEP committee.
  12. Seek help when you need it. Don't embarrass yourself with avoidable errors; take advantage of whatever resources there are to help you out. If you work in double coverage, don't hesitate to ask your colleagues how things work as issues arise. They know how to navigate the local system and are usually happy to share the insider's knowledge. But your medical director won't be happy about cleaning up your messes, especially if you try to overcome obstacles through force of sheer will alone.
  13. Be forgiving of yourself. You are going to fuck up. It's certain. You're going to be too slow, you will put your foot in your mouth, you'll let yourself be browbeaten by an irate consultant, and you may even harm a patient. These things are part of the game and you can't completely avoid them. Don't get down on yourself when it happens, learn from your mistakes if you can, shake it off, and get back in the game.
A lot of these can be thought of as the voice of experience, or in the department of "do as I say, not as a do." If I were starting over, I'd do a lot of things differently. It's worked out pretty well for me, but had someone given me a similar list at this point in my training, things would probably have been a lot easier, and I'd probably have pissed off a lot fewer people in the process.

Hope this is helpful, and commenters should feel free to add on advice in the comments!

*which is not to say that med school and residency aren't work, just that they are steps towards the ultimate goal of becoming a practicing physician.

Let's Play McCain vs McCain

From the Straight Just Talk Express:

John McCain, 2002 edition:

I am concerned that repeal of the estate tax would provide massive benefits solely to the wealthiest and highest-income taxpayers in the country. A Treasury Department study found that almost no estate tax has been paid by lower- and middle-income taxpayers. But taxes have been paid on the estates of people who were in the highest 20% of the income distribution at the time of their death. It found that 91% of all estate taxes are paid by the estates of people whose annual income exceeded $190,000 around the time of their death.
John McCain, 2008 edition:
Another of my disagreements with Senator Obama concerns the estate tax, which he proposes to increase to a top rate of 55 percent. The estate tax is one of the most unfair tax laws on the books, and the first step to reform is to keep it predictable and keep it low.
Hmm. We'll give him ten out of ten points for "willingness to abandon principle when politically expedient," but you know what would really put this over the top? If he threw in a gratuitous lie to make Obama's plan seem just a little more extreme. Oh, here we go:
Obama's actual plan: Make permanent estate tax with $3.5 million exemption and 45 percent rate.
Nailed it!

This is gonna be a fun campaign. Does McCain know that people have memories and that records of the past exist? Or does he think he can just contradict himself endlessly and nobody will notice? Maybe he just makes shit up as he goes along and simply can't remember all the stuff he's said in the past.

10 June 2008

My Motto

As taught to me by a wise, salty old sea-dog of an attending:

Every patient I see presents to the ER with the same goal: to find a way to die on me and make me look bad. And I hate looking bad. My job is to thwart them.


It's a common perception that, being an ER doctor, everybody and their brother must bug me for medical advice at all times. Strangely, I have found that not to be so much the case. It's in fact quite rare for someone I know only casually to ask my opinion on anything medical. They may ask for "freaky ER stories," but not about themselves. In truth, I also try very hard not to let people know what I do for a living. My standard line is that I "work in a body shop in [name of town]."

My family and close friends do occasionally ask for opinions regarding their own health, but these are all people I am really close to and have a very trusting relationship with, so it doesn't bother me. I may or may not be able to help them or answer their questions, but I have no qualms about discussing it and venturing an opinion when appropriate.

I recently found myself in a somewhat dicey variation on the theme. A high-profile, powerful individual who I knew only professionally called me and asked for some advice. This is a person I have interacted with on multiple occasions, but don't really know very well, and though I am well-disposed towards her, I would not say we have much of a relationship at all. But we do have enough of a relationship (and she is important enough) that it would have been impolitic of me to brush her off.

Worse, her concern was regarding chest pains she had been experiencing. Clearly, after some information-gathering, these were quite unlikely to represent anything serious. But as all ER doctors know, unlikely things do happen from time to time.

So I had to decide: what should I tell her? I could just abdicate all responsibility and tell her to get in to the ER. Safer, simpler, and the "textbook" answer. But I could tell that she did not want to go to the ER and I hated to think that if I sent her in and she endured a negative work-up, she would be annoyed at me for wasting her time and money and disrupting her busy life with a worthless hospital stay. Would her opinion of me suffer? Not an appealing thought. On the other hand, I could reassure her, quite honestly, that the symptoms she was experiencing were probably not serious and doing so, effectively give her permission not to go in. (Which was what she wanted.) She'd be happy with me, and truth be told, she almost certainly would be fine. But such a response just feels intrinsically dishonest, and as a fundamentally paranoid ER doctor, that nagging "what if" in the back of my mind is hard to ignore.

Ultimately, this is what I told her:
You need to understand that I am not going to attempt to diagnose or treat you over the phone. I will, however, give you some background information. The symptoms you describe, in a person such as yourself, are highly unlikely to represent any serious disease. There is, however, a small but measurable possibility that these pains are caused by your heart or some other dangerous cause. If you go to the ER, they will do tests X and Y and Z and will be able to give you a better assessment as to whether you are at risk or not. If you choose not to go in, that is a reasonable choice in this setting, but you need to consider your own willingness to tolerate risk before making that decision.

There was a long silence over the phone. Clearly she was not thrilled with what I had done -- put the onus of the decision back on her shoulders. She thanked me and ended the conversation.

A short time later she sent me a text saying that she was going in.

The next day, at work, I was tempted to look her record up in the computer, to see what the tests had shown. But I was unsure whether that was kosher -- would it have been a violation of her privacy? She had trusted me enough to call me and discuss her medical condition -- does that entitle me to "treating physician" status? I decided probably not, at least not worth the risk and potential bureaucratic headache. I figured I would find out next time we met, which I did, and she was fine, and in hindsight she was quite glad for my advice because it had helped her make the decision that was right for her.

So a happy ending for both of us.

09 June 2008

An Ironic Proof of Concept

I bought a cool generator for our house; a couple of years ago, this area lost power for two weeks in a windstorm. What with me working nights and my bride home alone so often with three little kids I wanted to make sure that there would never be a prolonged power outage. I went kind of nuts and bought a 12,000 watt triple fuel model (I want to be able to power the entire neighborhood):

It runs on gasoline and natural gas, so I can just plug it into the house line and let it run. I feel very manly every month or two when I pull it out and fire it up, just to make sure it's running and to circulate the oil a bit.

Yesterday when I hooked it up, to my surprise I found that it would not start. I realized in short order that the last time I had tested it, I had inadvertently left the power switch on and the battery was dead! After a short time on a battery charger, it was up and running, and I was left, chagrined, to reflect on two thoughts:

  1. It's a damn good thing I had tested it.
  2. How ironic would it have been had there been an outage and the generator itself was dead?
I made double certain to properly secure the device this time...

08 June 2008

The strangest damn thing

I recently saw a woman in her late sixties who presented to the ER with severe shortness of breath. She had a history of COPD, or emphysema, due to a long history of smoking. She also had a history of Grave's disease, a thyroid disorder, which had left her with a mild residual proptosis. What happens in this condition is that for some reason there is accumulation of this gelatinous goo in the orbit, behind the eyeball, causing the eye to be displaced forward. Put simply, she looked a bit bug-eyed.

It was her breathing, though, that had captured my attention. She was not moving air well, and was becoming progressively more sleepy -- a bad sign. A blood gas confirmed that she was retaining carbon dioxide, and at this point it was clear that she was going to need some ventilatory support. In the "old days" I would have intubated her, but lately we've been trying to avoid that with what's called "non-invasive mechanical ventilation," or NIMV. What we do here is strap a mask to the patient's face to create a good seal, and attach it to a machine which blows a little extra air into the lungs every time the patient tries to take a breath. We hooked her up, and she seemed to perk up a bit, and I wandered off to make arrangements for her to go to the ICU.

Moments later, a panicked respiratory tech was grabbing me: "Come quickly! Now! Now! Her eye fell out!"
What can you say to a statement like that? I ran to the bedside, and sure enough, something like this is what I saw:Although it was only her right eye that was out, and it was a bit further than in the picture above. It was actually drooping or dangling just a little bit, due to gravity. Oh yeah, and she was screaming bloody murder and clawing at the face mask. We removed the face mask, and stood there in complete and utter shock. Not really having any clue of what to do, I put on some gloves and gently massaged the globe back into the orbit. Once in, she felt better (no kidding!) and her vision seemed intact.

I figure that the face mask must have been putting some pressure on the nasal surface of the eye socket, and the strap, which has to be cinched pretty tightly, was putting pressure on the temporal aspect of the socket, and with the globe perched a little forward to begin with, it just got squeezed out like a zit!

Needless to say, we did not put her back on NIMV. I let the ICU doc know why she was not on NIMV, and suggested he might want to get an opthalmology consult, and sent her on up.

That was the strangest damn thing I have seen in a long time...

Any coders out there? Is there a CPT code for "manual reduction of prolapsed globe?" I bet there is; there's a CPT for everything. How many RVU's for that one?

I have the greatest job in the world.

07 June 2008

Four More Years

McCain: My presidency will not be a third term for George Bush.

You decide.

04 June 2008


Of a Sort:

03 June 2008

This is our time

Yes we can.

The Victory Speech:

The (ahem) vigorous opposition:

02 June 2008

Found at the doctor's desk

Now why would anybody in their right mind sterilize a reflex hammer? Can you answer me that?!

Although, as I have learned previously, the central sterile supply processing people simply do not ask questions. If it shows up in their bin, they sterilize it.

Nice to have in case I have to do a sterile reflex exam.

An Open Letter

To an unnamed specialty surgeon:

I don't think we had ever spoken before, but when I called you the other day we had the following conversation:

Me: I have a young man here in the ER with a [painful subacute problem in your area of specialty]. I think he's OK to go home today, and I'd like him to follow up in your office.
You: Hmmm. Sound like he's going to need a [series of operative procedures]. How long has this been going on?
Me: Eight months.
You: Wow. Why did he let it go so long?
Me: He doesn't have any insurance and can't pay.
You: Pity. Still, tell him I'll see him Tuesday morning.
Me: Thanks very much.

You could have weaseled and tried to dump this problem on someone else. You could have tried to get me to send him to the county hospital. You could have been a dick and just said no. I have no real leverage to force you to take care of patients like this. I wouldn't have faulted you much had you been annoyed or grumpy about having to do several complex, risky procedures for no pay. Many of your colleagues will take these cases, grudgingly, and in return for their condescending willingness to do their job, they feel entitled to take out their frustrations on me.

But you didn't. You took the case without hesitation, cheerfully, and without complaint. You did the right thing without prompting, begging, or cajoling. I don't know whether you were motivated out of compassion, duty, charity, or if you're just a really nice guy. It doesn't really matter; either way, you made my day a lot better, and certainly that of the patient as well. I'll remember you for it.

Thank you.