Sunday, November 18, 2007

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.


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!!!!

Sunday, November 4, 2007

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.