Gray Ghost sign

I really love the National Institutes of Health even when I can not figure out how they score my RO1s. They support studies on genetic susceptibility to certain diseases, cancer precursors and interleukins. The things that they don't research are the things that seem to make a typical call night a living hell. There are so many of these but here are a few.

Why do people with tattoos and piercings turn Gray as a Ghost and past out when they see the needle for their IV?
Why is getting the IV often the hardest part of surgery?
Why is it that the patient who needs the NG tube the most, is the one who will always pull it out?
When you go to get a pair of exam gloves out of the box, why do you always get a blob of gloves instead of one at a time?
Why can you always find hemacult cards but no K-Y jelly?
Why do the patients charts suddenly explode like a paper filled A-Bomb when you pull them out of the rack?
Why does the EMR go on the fritz at the exact time you need to check the hematocrit?
Why is it that patients seem to code more often in the elevators and radiology than anywhere else in the hospital?
Why can't hospitals have really big elevators so the ICU beds and all the IV pumps and stuff fit without bashing them and you in the process?
Why do they put carpet in hospitals? (Ever tried to get blood and pus out of one?)
Why do patients seem to only extubate themselves in the middle of the night?
When you are paged, why is it that the person who paged you is never the one who answers the phone?
Why are patients who come to the ER with the complaint of dysphagia always obese?
How many feet away from that portable chest XRAY machine do you have to be to keep from being zapped?
Why aren't there air fresheners everywhere on the GI floor?
How come surgical scrubs come in only two sizes, way too big and way too small?
Where do all those tube things disappear to in the hospitals tube system?
Why do patients always turn their head toward you to puke instead of the other way?
What is it about foley bags and elevators?
Just exactly how long does it take to do a stat set of lytes?
How do you get charcoal out of your shoes?
How come you can never find the patient and their chart at the same time?
How do you get that D**** IV pump to stop beeping?
Why is it that you always need a pen and can never find one?
Just who exactly is that person who is always walking around with a clipboard but doesn't seem to do anything?
Why are foleys and ng tubes kept in that room you have to have a code to get in?
Who keeps drinking the last cup of coffee and doesn't make anymore? (Coffee keeps the ER running!)
Why is the patient's ID bracelet over the only good site for his arterial line?
How does anesthesia know to put tape or a monitor lead exactly over the place you need to make your incision?
Who is "some dude" and why does he keep shooting people?
Why is it that the patients level of complaints is often inversely proportional to the degree of injury?


I will keep trying to submit these studies to the NIH, who knows perhaps there might be a grant out there.

T/T ratio

I have to admit that I am a big fan of competition and a fair market when it comes to most things. It hurts me to think that we may need some king of national healthcare. The reason I am so concerned is this. If we can deregulate the insurance industry similarly to deregulating the airline industry, we might lose a few insurance companies, but in the end we might get lower fares and better benefits for our ER frequent fliers. The problem though is that no matter what we do, some of those who come to the ER won't get insurance if it was the cost of a pack of smokes or even free. (I really do think we need to deregulate the insurance industry, but i digress.)

These patient's who would never get insurance are the one's who tend to come it when the bar closes after they have wrecked their car and taken all the meth they can. They can usually be rapidly identified by their T/t ratio > 1.0. Where T=tattoos, t=teeth. As luck would have it, a T/t ratio > 1.o seems to confer temporary immortality for all but the most horrendous major traumas. Other factors that seem to help identify this group and that confer temporary immortality are the following: postitive for over 3 illicit drugs on their tox screen, facial tattoos*, blood alcohol of 0.3 or greater, being readily recognized by the ER staff, transferred from jail*, allergic to all pain medications except OXYCODONE, had last bath 2 weeks ago*, colostomy from prior gunshot wound, homemade tattoo especially if it is spelled wrong, and lastly if they are pushed out of a car that leaves the Er at high speed. (*original composer of this trauma scale unknown, immortalized by Rip Pfeiffer M.D.)

Interestingly, the same patients with a high T/t ratio also are the ones who seem to know "a good lawyer" and threaten to sue. Anyway, they are not the ones that are going to take the time to fill out forms for health insurnace even if it was free.

SWIT PDQ Sign

When I first finished my residency, I thought that my training had given me all the tools that I needed to practice in my speciality, then reality set in. After residency I learned that when you are called to the ER, the first thing to do is see how the ER staff are acting. They see scary things all the time, if they are acting Freaked out, you should be. A great example of this is what happened last night. Unless they are coming by ambulance, the first person to see what is going on is the receptionist/triage person at the front desk. They are used to seeing hundreds of patients a night, so when they page you STAT before the patient is even in the ER you know it is not good. This is the dreaded SWIT PDQ call. (Something wrong in there and its happening pretty damm quick!) In this case a knife sticking out of someone's head.

Other signs that should worry you. If the ER pages you and you call back and they say "DR. So and so wants to talk to you", you know its not bad. If they say "Dr. can't talk now and needs you STAT", this is real bad. In the middle is when the Dr. is right there waiting for your call. This can be worse than bad, because not only is something bad happening but he/she aren't sure how to help it.

Above all, if the ER staff is nervous and you aren't, you are missing something important!!!!

Pones and Risins

Things have been a little crazy lately. It is the end of the year and people have either met their deductables and are seeking help with things that they have waited on for all year, or they figure there is no chance that they will meet it and had better get in. No matter what though, their surgery has to be before the first of the year.

This leads to the difficult situation of addressing the large pone that has grown on the side of someone's head. I am learning that a "pone' is a rounded swelling, while a 'Risen" has a head to it, or maybe it is the other way around. Either way, I don't think that "pones" and '"Risens" are things to ignore, but if you don't have insurance or you have $5000 deductable, there is a significant inventive to hope that it goes away with time.

I wonder if we should change the term "holiday season" to "surgery season". Our hospital OR is 33% busier during November and December with the influx of so many elective cases and cases that really are not elective but have been delayed for insurance reasons.

Code "Brown"

Of all the codes called in the hospital, this call "Code Brown" turns even the most hardened healthcare provider into a squirming ball of goo. In a "Code Blue" everyone seems to show up to try to help or see what is going on. There is one person who grabs the crash cart, another who grabs the oxygen and yet another who starts CPR. Others show up from anesthesia, xray and the lab. There is even a person whose whole job is to document the whole thing for medicolegal records. Call a "Code Brown" and suddenly everyone is deaf or just has to run to the other side of the hospital for some stat thing.

After you call a "Code Brown" the real heros eventually arrive. The orderlies, nurses and patient care assisstants. They delicately ensure privacy and daintily move all the invasive lines and take care of the "Code" with true decorum and care. The frequency of "Code Browns" in the ICU is often not noticed by the patients or even their families and I am sure that they don't even say thanks to the true "Code Brown Heros" of the hospital.

ACD

Acute caffeine deficiency. Trying to cut back on caffeine is hard but it is helping the insomnia!

Some days it seems that you just can't win. I usually try to encourage patients to stop smoking and have heard all the excuses but I have had such good luck with Chantix. We had several people who work with us in the office stop smoking with it and it sure has helped many of our patients. Today I saw a heavy smoker with a large neck mass and after the biopsy and the thankful news that it did not appear malignant, I suggested that he stop smoking and explained how the medication works and the success that we are seeing. He said no way and that he saw a report on "Good Morning America" about how the medication caused someone to committ suicide. I then suggested that there are other medications and support programs to help stop smoking and he looked right at me and said "no way, that causes suicide". I so hard wanted to say, "if you continue to smoke, you will be committing suicide", but didn't. I haven't seen the "Good Morning America" report, but I am pretty sure that they did not elude that stoping smoking causes people to committ suicide but I am pretty sure that they didn't do anything to help people stop.

Dumpling Toxicity

Somedays it's hard not to say what you think. It seems more and more people I see are disabled for one reason or another. When I ask them why they are disabled, I am often puzzled. You can't work, but you can drive and do other things but the government is paying for it? Usually, the diagnosis is fibromyalgia or low back pain but the ones that really get me are those that are disabled because of obesity. They will not say "I am disabed because I'm obese", rather they say that it is because of their knees, hips, back pain etc. They then get stickers that lets them park closer to the restraunts.

Then I see patients who are dying of cancer or on chemo who can't get disability. It just doesn't make sense.

Hanging Crepe'

Why can't the pathologists be the ones who have to tell people that they have cancer? I mean they could come in and tell them and then leave. After all, you really don't know that they have cancer until the pathologist tells you.

I think having to deliver bad news is the hardest part of the job. No matter how hard you hope and pray for better news, sometimes you have to tell people that they are going to die. Then it gets worse. You do everything that you can do to help ease their suffering and comfort their family as you watch them slowly die. As they die, a piece of you dies as well.

Today, I had to give someone bad news. The very next patient was irate because I took so long with the previous patient and that I would not sign disability papers for their non-existant injury. I smile and apologize for their wait and explain that I dont due disability forms but will be glad to help them with their medical problems.

Pupillated eyes

Medical terms always seem to be a bit hard to explain and worse to remember. Not to mention that so many things are named after someone. (Throckmortons sign for example) Sometimes in the ER, patients will try to explain what surgeries they have had or medical problems and I just cant figure it out. Its not their fault, its ours with our big fancy doctor words.

Then, there is my daughter. She went to the eye doctor and when I asked her how it went, she looked at me and said it was ok, but she didn't like it when he pupillated her eyes! Pupillating, what a great term! It conveys exactly what he did! I think she in on to something, new medical terms that everyone can use and understand!

On a side note, it got me to looking for other medical terms that could be changed to make them easier to understand. I also found out that there are some terms that there are no medical glossary equivalents. So far I have not found the actual medical term for boogers. I then asked an opthalmologist friend of mine what the medical term is for the eye gunk that you get in the mornings and he stated that those are called "eye boogers". A gynecologist suggested that we rename "Hysterectomy" to "womb outofme". As you can imagine, the discussions that followed became enough for a new medical dictionary or at least a small phamphlet.

CNS QNS (abbreviation)

(Central nervous system/quantity not sufficient) Recently, I have had several patients come in an ask about certain "studies" that they heard on the news and the conslusions that the news reporters have made from them. Generally they are about a certain vitamin or dietary substance and cancer rates. The problems with these studies are that they look at numerous variables and are designed to see if any of the variables group together. They do not say that one variable caused the other.

Unfortuantely, the results of these studies are presented in such a way as to make people think that the vaiables are causal, usually to sell a product or sway a jury. A classic study noted that the incidence of nasopharyngeal carcinoma was higher in patients who ate a lot of fish. Was eating fish the reason? No, the population who ate the fish was of central asian ancestry who had a higher incidence of the carcinoma due to other reasons.

Like most things, studies are all about the spin. Hopefully, we can increase our CNS quantity about statistics and scientific method to avoid the spin.

Humble Pie

On my way home after going to the OR in the middle of the night, I was given a great big piece of humble pie. It was after three in the morning and driving home to get some sleep before the next days clinic I saw lots of red and blue lights on the interstate ahead of me. I slowed down and got in the farthest lane to avoid the accident. Out of the corner of my eye I saw an EMT laying on his belly trying to intubate a victim lying decorticate in the middle of the onramp. It was a horrible accident.

I pulled over and ran over to help. It was bad accident with the victim thrown from the vechicle and an obvious head injury. I identified myself as a physician to the police offer and felt for a pulse. There was none. The EMT was trying to suction lots of blood while another paramedic was holding in line traction. Lying on his belly in a pool of blood and mud in the middle of the night he was able to get a good tube, I listened for breath sounds and it was in. No pulse, we pumped chest, loaded him on a board, he was in the ambulance in minutes. The police moved in unison to clear the way and the ambulance sped off with victim to the trauma center with epi and atropine going down the et tube.

The speed, effiency and professionalism I saw was awe inspiring. This was the paramedics first accident out of training and he perfomed like it was another day in the park. The police and fireman work like a well experienced offensive line.

Somedays in the ER and OR with all the equipment and help we get to feel like heros because we saved a life. The life was saved well before we see them, by EMTs, paramedics, police and fireman, lying on their belly, covered in blood and muck in the middle of the night.

Arnold's Nerve

(This is the nerve in the external ear canal that causes you to cough when it is stimulated with a Q-tip, car key or other foreign body) I am in the ER waiting to take a case up to the or for an active bleed desperately wondering what I can use to scratch the itch in my ear.

The ER is such an interesting place in the middle of the night. I often thought that anyone who the judge gives community service to should be forced to serve it in the ERs third shift. You get to see such a diverse picture of the community and see what is really going on in the world. There is the beligerant drunk with the facial lacerations spitting on the nurses in the first room, the 90 y/o lady with shortness of breath asking to go out to smoke, the drug addict in acute opiate withdrawl, several fractures, a stab wound to the chest and the r/o MI's. In the peds hall there are the acute asthma exacerbations in children who parents smell of pot who demand that their children get scripts for codeine, the newborns with FUOs lined up for their spinal taps. Outside, the EMTs and Police are resting waiting for another call and catching a cup of coffee. There is the smell of old vomit, rubbing alcohol and blood that has made it through the gi tract wafting though the halls when the ambulance bay doors open. Occaisionally the radio alert will go off and report that another ambulance is enroute nonemergent with a patient with uncontrolled fever of 98 degrees or someother taxpayer wasting adventure while the ALS Unit is flying in with a patient in asystole.

The or calls and is ready, the blood is coming from the blood bank, off we go through the double doors to the elevator. Suddenly its quiet except for the sounds of respiratory bagging the patient. Doors open right into the OR corridor and straight into the room. My ear still itches.

Hooters' Sign

We had a bad cancer case that took for hours and my neck and back was aching. I went to reach for my Bextra which had really worked well and all I had was some old Vioxx samples. Of course my brain went ito a rant about lawsuits. I hear all the time about the Vioxx lawsuits and can't help but remember Dow and breast implant cases. It sure seems that there is a race on for attorneys to sue Merck before the science debunks the case. In the case of the breast implants, how come if a jury finds a person criminally guilty but later science (say DNA) shows that he is innocent, he is freed, but in a tort case if science shows the jurys screwed up the plaintiffs dont have to repay the defendent? I mean after it is all said and done, silicone implants are back and the only major complaint about them that has been proven is that many patients wanted them replaced because they were to small.

Blue Screen of Death Sign

This is what happens to your hospitals electronic medical records while the hospital is getting ready for a Joint Commission inspection. I always wondered if the morbidity and mortality of a hospitals census goes up before a JACHO inspection? It seems that just before the inspection everyone is running around trying to make sure yet another form is filled out and filed correctly that has nothing to due with patient care except to make sure that there is no nurse left to take care of the patients.

The latest is the form that shows that we have approved all of the patients home medications on admission whether we are having them take them or not and then the form that has us approve all their home medications on discharge whether we have prescribed them or not. I have decided to scribble N/A on all of them. I will let you know how it works out.

Munchausen by Proxy Syndrome

Finally made it back. Boy have I been terrified lately, it seems that every new patient that I have seen has had cancer. Luckily, we can help most of them. But I digress. I have often thought that the best way to fix our tort system was for the attorneys to start to feed on themselves and last week I got my change to help it along.

A local attorney has helped a group of people bring suit against their employer for disability due to noise induced hearing loss. When the plaintiffs had their hearing test, they all showed evidence of malingering. Apparently, their attorney did not know that an audiogram is very good at picking up fakers and in fact can often prove it. He had advised his clients to feint greater hearing loss for greater value in court. When the plaintiffs were confronted with the evidence that they had tried to rig the test, they uniformly reported that their attorney had advised them to do so.

Presently the issue is now before the judge, the defending attorney has moved to have the case dismissed, and the prior plaintiffs have retained an attorney to sue the original plaintiffs attorney for malpractice. It is all quite interesting.

EMR sign

Stat consult called. Rush in to see patient. On the floor I can't find any of the nurses by the patients room. Instead they are all at the nurses station trying to enter things into the EMR. I ask for the patients vitals and find out that they are in the computer. The computer doesn't let anyone log on. (passwords have to be changed every so often and now it has locked up the system, good old HIPPA), I ask the nurse what she thinks the vitals might be but she explains that they are taken by the nursing assistant and then entered into the computer. I try to find the assistant and luckily she has them written on the back of a napkin but she is not sure whose is whose.

Finally we get the computer up and running which lets me access the patients history and progress notes. The patients history is : "waiting to be transcribed". Interestingly, all the JACHO forms are there. I did find the vitals.

I am so glad that we have EMRs to help save lives, just whatever we do, make sure there are lots of napkins!

Green gas

The other night on call we were discussing the current issue of carbon emissions and global warming. My friend was conversing while drinking a diet coke. As he opened the can, out went a fiss of carbon dioxide. I though, well there goes some carbon into the atmosphere. Then I thought, how was that carbon dioxide put into the can? Well, energy was used to run the compressor to get the carbon dioxide from the air and then to put it back into the car. So, next I wondered just how much carbon dioxide in the atmosphere is from the carbonated beverages? About the time that I was doing this I burped, which had some more carbon as a by product of my own metabolism breaking sugars into CO2. It was about this time that the OR was ready and I had more important things on my mind.

Quicke's Edema

Intense swelling of the uvula (caused by ranting!) . Slowly my week of call is ending. I often am puzzled by the meaning of emergency. This is a result of having to answer emergency calls in the middle of the night. My favorite is the call that comes in at 2:00 am from the patient who can not sleep. I try my best not to say "I know the feeling".

Even when it is not that busy at night I find that I am always tired. It is the anticipation that any minute that I might have to rush in. I can't imagine what it must be like to be a fireman, police officer or EMT. How do they ever sleep on those long shifts? Well, off to sleep hoping that it will be quiet. Long live EMTALA!

Black line finger

This is the black impression that occurs on the middle finger due to constant pressure from a pen.

CMS has now required that anesthesia document in their records when the pre-operative antibiotics were given. The main problem, anesthesia is not who are giving the antibiotics! They are given in the holding room. So again we have anesthesia having to run around to find that information and document it rather than taking care of the patient.

Often when going to the floor to see a patient in the hospital, I am amazed as I can't find any of the nurses. When I ask where they are, the answer is usually in the back doing charting. I understand now why there is a nurse shortage, there is not enough of them to do all the paperwork. When I asked JACHO and CMS representatives about the amount of paperwork, the answer was "to improve patient care".

I would rather have the nurse take care of my patients than their chart.

A Detroit city employee has filed suit against the city because of her co-workers perfume (http://www.foxnews.com/story/0,2933,288130,00.html). She is using the Americans with Disabilities Act as the basis for her suit. Already, her co-worker has had to stop using an air freshener which makes me wonder if the real victim of the case is the co-worker who has had to deal with the plaintiff's B.O.

I digress. What constitutes a disability? I hate people chewing with their mouth open and cracking gum, in fact it makes me sick to my stomache. Does this mean I can sue any business that I enter if they do not make people chew politely? Or, can I just have disability benefits?
Detroit already has enough problems with all the lawsuits against the city busses and their inability for fire problem drivers due to union lawsuits.

How do we fix the slippery slope that has become the American with Disabilies Act? The Sweeds have a solution. They focus on not what you can't due but rather on what you can. If you can't do your job because of perfume, go find a job you can.

MMOB

MMOB (Minding my own business) seems to be the factor most often implicated in major trauma presenting to the emergency department. Overlawyered.com had a recent post describing how the British are removing "Accident" from the legal lexicon of automobile crashes. Their comment was that this action was part of the continued need to always find someone to blame for everything. For our trauma cases, the person MMOB is always the victim to SD (some Dude).

I am hoping to find the reformer of this current attitude and write MYODF (my own D**** fault)!

Gomer sign

Recently there has been considerable outrage in the media of "patient dumping" by hospitals in Los Angeles. This is indeed an unfortunate thing and needs a solution. First, lets look at the problem. A homeless person is either sent to the hospital or comes in with a medical condition. The hospital then renders care for that condition and is ready to discharge the patient. What do you do when the patient does not have a home and what is the hospitals responsibility?

I am temped to say that the problem can be solved by having the patient walk into an attorney's office and stay there until the attorney can solve all the patient's possible legal problems, but will not go there. As it stands now, we have a hard time with homeless patients coming into the er claiming chest pain as they know that this will be several days of meals and shelter at the cost of the facility. Often, the missions are unable to take the patients or refuse. This is ontop of all the social workers trying just to get the patients medicines to take. I do not think that another legal, un-funded mandate is the answer. My solution, if these patients are not to be returned from whence they can, then fund and establish shelters for them.

Starburst sign

A woman in Romeo, Michigan has filed suit with the Mars Company claiming that she now has TMJ disorder after chewing on a Starburst candy. She states that now she has problems sleeping and chewing as a result. (I am always amazed that patients who have complaints of dysphagia and jaw pain are overweight). I am sure that poor dentition, gum chewing and bruxism in no way contributed to her problem.

I know that it is human nuture to blame others for all our own problems, but how did this get to be the basis for our tort system? If I choke on a cough drop is it the cough drop companies fault? How can we change this, or better yet, how can we make it not profitable to file these suits.