SNL Video Goldmine

This site is chock full of some of the best commercials and short video clips from SNL. Enjoy.

OOPS I CRAPPED MY PANTS

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Hedley & Wyche

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SNL: Schmitt's Gay

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Full Speed

By the time I hurriedly finished suturing the jagged facial laceration of my young trauma patient, sweat was pouring off of me. It was a complicated repair, certainly, and it was somewhat difficult for me to find a position of comfort. But the room wasn't hot and I wasn't really concerned about the patient in front of me or the quality of my work. I was thinking of the patient I had sent to the CT scanner some 20 minutes prior, and the full waiting room was weighing heavily on me as well.

The fact that I hadn't been called out of the room by a panicked nurse was reassuring, I hoped, but I honestly wasn't sure that my patient would be alive by the time I returned. And yet, without the scan, I had no more interventions to attempt and nobody to call for help. Sometimes it isn't even clear which organ system is causing a patient such horrible distress. I'd already done three EKGs, afraid it might be his heart. They were mildly suspicious, but not diagnostic of anything. I tried to perform an ultrasound, but the patient's rapid breathing, severe pain, and large girth made the study almost worthless, so I aborted the procedure because I honestly thought the patient was either going to die right in front of me or pretty darn quick if I didn't get some answers fast. So with some hesitation and dread, I sent him off to the CT scanner ("where patients go to die").

But I'd already anesthetized the disfigured face of my young trauma patient prior to the arrival of this trainwreck, and I needed to complete the repair before the sensation returned. Having a few minutes to spare, I charged in and did my best despite the rush of adrenaline that made my hands tremble a bit.

As I sprinted back to the shock room, I was pleasantly surprised to see that my other patient had stabilized, and the CT scan ultimately gave me the answers I needed. It appeared that he was going to be OK, at least for the time being.

To the patient with the stubbed toe, all I can say is this: when you see an agitated ER doc running around the department barking orders, soaked with sweat and fully charged with adrenaline, it might not be the best time to express your displeasure regarding your waiting time. Can you not see that I'm doing the best that I can?

But I am truly sorry for yelling at you. Please come back and see us.

Panda Bear MD on Single Payer

He writes so well, it almost makes me want to quit blogging.
But I won't. I'll just bow to his excellence.

The truth hurts socialist liberals more than a junkyard dog biting their scrotum.

Bravo.

The Good Rush

I wish we could use placebos in the ER, if only for our own amusement.

I'll never forget the last time I saw one given. The guy was a "chronic pancreatitis" patient who we saw fairly often, without clear evidence of disease. Because he was polite and I'm a softie for that approach, I agreed to order him some Demerol and Phenergan, and I happened to be in the room as the nurse was preparing to give the injection.

As the nurse slowly pushed the syringe full of fluid into his IV, our patient was watching her as intently as a cat stalking his prey. He then laid his head back, sucked in a breath through his remaining teeth, and let out a satisfied "Ahhhhhhh."

"That was just the flush," said the nurse.

Night Shift Ramblings

Scene: Weekend night in the ER; we are swamped as usual. It's 3 AM, and the waiting room is still full. I've already been up to triage twice to personally bring back patients with real emergencies. Lesser emergencies will have to wait.

I'm at the desk, charting after a code.

TECH: "Say, doc. Can a drunk patient sign out AMA? She doesn't want to wait any longer."

ME: "I dunno. What's she here for?"

TECH: "Being drunk."

ME: "Is there anyone else with her to take her home?"

TECH: "Yeah, but they're all drunk too. Well, one of them is not as drunk as the rest."

ME: "Bingo."

The weirdest part of the shift was that I kept getting calls from the radiologist about critical CT scans of patients that were still in the waiting room. You know it's a bad night when the radiologist is doing your triage for you.

So I go out to the front and look for Mrs. Jones with an intracranial hemorrhage. It's a disaster out there; I don't know how the nurses deal with it. All eyes are on me as I scan the room and yell "Mrs. Jones!"

The other patients seemed to glare at us as I pushed the stretcher down the hall toward the treatment rooms. The fact that she and I were both white while most of them were not made me acutely uncomfortable. Perhaps they thought she was getting special VIP treatment. Perhaps they wished they could trade places with her. If they only knew.

Lesson to patients: yeah, it sucks to have to wait for hours to be seen, but you really don't want to have the sort of problem that requires immediate attention. Trust me.

Liar of the Week

DUDE: "I've been throwing up and having diarrhea for a week. I can't keep anything down."

ME: Weird. You don't even look dehydrated, and you appear healthy and comfortable. "When is the last time you threw up?"

DUDE: "This morning."

ME: "Have you been able to eat or drink anything?"

DUDE: "Well, I had some pizza before I came here."

ME: So you've been spewing from both ends for a whole week, but now you are able to eat pizza and you feel fine. "So why did you come in tonight?"

DUDE: "My work made me come."

His abdomen was a little tender, so I ordered some IV fluids and blood tests. The nurse returned shortly and said "He's refusing the IV, and he wants to talk to you."

DUDE: "Can I just get a work excuse?"

I Think.....

Thanks to Dr. Wes and Mother Jones RN for kindly awarding me the Thinking Blog Award. I'm honored that these wonderful bloggers who I hold in the highest regard decided to include me in their lists of those who inspire thought. Believe me, the feeling is mutual.

However, like Dr. Dork, I too am wary of these memes and am generally uncomfortable with tagging others for these chains. I don't forward chain letters either. And I find the requirement to post a link to the meme originator (whose site I wouldn't recommend to anyone anyway) a bit tacky.

So please forgive me for not participating fully, but know that I do greatly appreciate the thought.

Ask Me - by Dr. Edwin Leap

"‘Ask me’. It’s a question being posed by a little badge now worn by nurses around the country. It seems harmless enough. At our little hospital, it means ‘Ask me if I’ve washed my hands’. Seems like a reasonable and harmless question. Some places, it probably means ‘Ask me if I have done my time-out,’ or some other little administrative caution. It’s one more little reminder to ‘do the right thing.’ We get a lot of those these days (...)

I was thinking. Maybe, as we do our time-outs and scrub our hands red, as we smile and get cups of ice and endure abuse with a smile, we could create our own ‘Ask Me’ buttons. But let’s ask some questions with a twist. How about some buttons that ask the things clinicians want to ask everyone else?"
Read the rest...

- Dr. Edwin Leap

(via 911 doc)

Life Saving Initiative of the Month

We have been notified of a new policy which was obviously developed by the pencil-
pushing meddlers up on the twenty-eighth floor of a shiny new building far far away from the hustle and bustle of the emergency department. We are now required to order a rate on our IV fluid boluses. If I wanted a rate, I'd have ordered a rate. There are only two rates of fluid administration I ever really need to order in the ED.....wide open or none.

Anything else is just jerking off.

I want my patient to have a liter of normal saline intravenously. If the patient is stable, I really don't care if it goes in over 10 minutes, 30 minutes, or an hour. Just give them the dang liter and re-assess them for me please. I might order another one later. If the patient is unstable, your fancy machine won't pump fluids fast enough for me. I want two liters infused yesterday.

When all is said and done, nobody gives a damn what rate the fluids went in. The only thing that matters is did the patient live, and if so, the accepting team might ask "how much fluid did he get in the ER?"

Not "how fast did it go in?"

Cue Jeopardy Music...

So this guy comes in with a chief complaint of chest pain. He's spitting in a cup, unable to swallow after eating some steak earlier. My diagnosis: esophageal food impaction (I'd never heard the term "Steakhouse Syndrome" before, but I like it).

Him: "I don't think so. I only nibbled at my food. It just feels like a big bubble in my stomach."

Me: "Well let's see. Here, have a drink of water."

He takes a sip, and there is a pregnant pause where we stare at each other for a few seconds: "What are you staring at?"

Me: "I'm just waiting. If I'm right, you're gonna puke any second now."

Him: "Oh, really? RAAAAAAALPH! (vomits violently)"

One sublingual nitroglycerine fixed him.

The Thank You Note

It's rare that I actually get one of these, but when I do, I cherish it more than gold. Out of 3000+ patients a year, I figure I might get a half dozen thank you notes, mostly from the elderly. Their rarity makes them more precious, I suppose. If everybody wrote them, they would probably be taken for granted.

When you're feeling a bit down, nothing warms your heart more than reading a thank you note from a patient. This one is particularly special to me because this little girl went to so much trouble to make it; pasting two different colors of paper together and drawing a picture of her stitches.

What a little angel.

Med Glossary - Part 4

This is fun! How about,

"I haven't had a bowel movement in two weeks."

Honestly, we get people who come in saying that. What they really mean is:

1) I haven't had a fulfilling bowel movement in two weeks, and I really haven't been regular ever since Bush stole the election.
(My advice: just relax and think of Hillary. Works for me!)

2) I've had some little turds, but I still feel bloated. My stomach doesn't normally look like this. (Picture 250# person lifting their pannus)

3) I've given myself a dozen enemas and I'm still so uncomfortable. Do y'all give enemas here?

4) Dang, this vicodin really binds a fella up, don't it?

5) There is a parasite in my intestinal tract that is consuming all of my nutrients, and as he grows, my stomach swells more and more. I got it from eating goat cheese in Lithuania. I've been to sixteen different parasitologists at the Mayo Clinic, and they all tell me my condition is incurable. I have a PhD in epidemiology, and I'm now in law school. I'm sick of getting the runaround from everyone; I want you to get to the bottom of this problem tonight. Do you have a parasitologist on call?

6) Can I get a work note?

Med Glossary - Part 3

"I can't walk"

To me, when a patient says "I can't walk," he means that he cannot physically ambulate. Not necessarily. He might mean, in increasing order of likelihood:

1) I'm too weak to walk, and I really cannot even get out of bed. (10%)

2) My _______ (back, knee, hip, stomach, head) hurts so much that I don't want to walk. If I can just get a pain shot and some vicodin ES, I'll walk right out of here. (15%)

3) I just walked three miles from the bus stop to get a refill on my vicodin for my neuropathy. Now that it's after midnight and the buses aren't running, I need a cab voucher. And some crackers. (20%)

4) I'm so weak/dizzy that I don't really want to walk, but I can in fact ambulate with encouragement. (25%)

5) I'm too depressed to get out of bed. I have a long litany of woe and lots of non-physiological somatic complaints I'd like to tell you about. Where should I start, doctor? (30%)

6) I want a work excuse. (100%)

Med Glossary - Part 2

In this second part of the series, the chief complaint is:

"I spit up some blood"

This is a meaningless complaint; I never know what patients mean by this, so more questions are always necessary. Typically, it will be one of the following:

1) I coughed up some sputum with a little streak of blood on it, like a red thread lying on top of the phlegm.

2) I coughed up a mouthful of frank blood.

3) I vomited 10 times, and the last time there was a little streak of blood on top.

4) I vomited a bucketful of bright red blood . I'm feeling a little dizzy too.......

5) I vomited some brown liquid that might be blood. My "boo boo" has been dark this week too.

6) I had a nosebleed today, and I spit out some blood afterwards.

7) I have rotten teeth. When I spit, I noticed some blood in my saliva.

8) I want a work excuse.

Med Glossary - Part 1

I've decided to start a running series on what people really mean when they say something. Different phrases mean different things to different people.

For example, "I can't keep anything down."

To me, that means they are vomiting within a few minutes after they try to eat or drink anything. But to some people, it means:

1) After my second bottle of tequila, I started vomiting. I haven't tried food or water.

2) I can drink water, but after I ate burritos and salsa with pico de gallo, spanish rice, and refried beans my stomach hurt, and I vomited. How much did you vomit? "Too much."

3) I vomited a couple of times last night, but not today.

4) When I eat or drink, I have diarrhea, but I haven't vomited at all. It just "goes right through me." Patients often think that if they have diarrhea right after eating or drinking that the same substance they ingested is coming out in the toilet immediately. Not so.

5) I want a work note.

Hong Kong Phooey

DISCLAIMER: Due to recent concerns by some hypersensitive douches, I want everyone to be clear that my posting of this video is not intended to denigrate individuals of East Asian persuasian, martial artists, cartoon dogs, or shirtless drug addicted rockers for that matter. I just dig Sublime, and this is a badass video.



Oh, yeah....Don't Push is my favorite song of all time, and this video of Date Rape has a cameo appearance by Ron Jeremy in it. Ouch, LOL.

The Worst Spinal Tap

The lumbar puncture is one of my favorite procedures. Over the past 15 years, I reckon I've done hundreds, and I'm rarely unsuccessful. I've performed the procedure on tiny babies, thrashing demented octogenarians, comatose patients on mechanical ventilators, and plenty of healthy young folks. When things go smoothly, the patient hardly even knows it's happening.

My favorite part of the procedure is the feel of the needle as it pierces the dura mater, the tough membrane surrounding the spinal canal. The needle, if passed slowly and delicately through the successive layers of skin, fat, and connective tissue, will tell you exactly where you are if you listen to it. There is a little quiet space without resistance right before you reach the dura, called the epidural space. As the needle touches the relatively thick dura and is slowly advanced, it stretches the membrane inward ever so slightly before it passes through with a delicate "pop." Ah, there it is.

One of my more memorable taps was surprisingly uncomplicated. Truthfully, I doubted that I was going to get what I needed that time; I even called our radiologist to check his availability to do the procedure under flouroscopy in case I failed. My patient had taken a drastic turn for the worse and could barely follow commands, and her generous girth made me fear that the 3 1/2" spinal needle would be insufficient to the task at hand. Proper positioning of the patient and identification of the anatomical landmarks are the keys to a successful lumbar puncture, and both aspects of this case were relatively daunting. But once I felt the pop, I knew I was homefree, and I still had a half inch to spare.

As I withdrew the stylet, a nasty turbid yellow fluid spurted out of the end of the needle. Normally, the crystal clear spinal fluid should barely drip out of the end like a leaky faucet. Maybe it was my imagination, but this foul brew actually seemed to make a noise as it initially spewed forth, and I probably jumped back a little bit reflexively. After hooking up the pressure manometer, I turned off the stopcock as the fluid rapidly passed the 45cm mark, afraid that it would overflow out the top of the device. I actually felt a bit sickened as I filled the tubes with this foul omen of death. This liquid would have looked more natural in a bedpan than in these clear plastic laboratory tubes.

For the medicos, the final CSF tally:
WBC 14,000 (normal 0-5)
RBC 140 (normal 0-5)
protein 290 (normal 15-45)
glucose 0 (normal 50-80)
segs 100%
rapid antigen panel positive for pneumococcus

High Profile Poisonings

There have been several interesting and deadly poisonings recently. Recall the disfiguring dioxin poisoning of Ukranian politician Viktor Yushchenko a couple of years ago?

Then there was the fatal poisoning last year of former Russian agent Alexander Litvinenko by the rare radioactive isotope polonium-210, one gram of which could kill 50 million people.

Now we have two Soviet-born Americans who have been diagnosed with thallium poisoning while visiting Russia. How they may have ingested the poison — a colorless, tasteless substance that can be fatal in doses of as little as one gram — was not clear.

Also this week, an expert in Russian intelligence, Paul Joyal, was critically injured when he was shot by two men in his driveway only days after he accused the Russian government of involvement in the poisoning of former KGB agent Alexander Litvinenko. In an interview broadcast on "Dateline NBC," Joyal had also accused the Russian government of trying to silence its critics: "A message has been communicated to anyone who wants to speak out against the Kremlin: If you do, no matter who you are, where you are, we will find you, and we will silence you — in the most horrible way possible," Joyal said.

Haunting words indeed: his assassins shot him in the groin.

Lead poisoning can be horrible too.

90 Lashes

Islamic Law sucks.

A 19-year-old Saudi woman who was kidnapped, beaten and gang raped by seven men who then took photos of their victim and threatened to kill her, was sentenced under the country's Islamic-based law to 90 lashes for the "crime" of being alone with a man not related to her.

The woman is appealing to Saudi King Abdullah to intervene in the controversial case.

"I ask the king to consider me as one of his own daughters and have mercy on me and set me free from the 90 lashes," the woman said in an emotional interview published Monday in the Saudi Gazette.

"I was shocked at the verdict. I couldn't believe my ears. Ninety lashes! Ninety lashes!" the woman, identified only as "G," told the English-language newspaper.

Five months after the harsh judgment, her sentence has yet to be carried out, "G" said she waits in fear every day for the phone call telling her to submit to authorities to carry out her punishment.

Lashes are usually spread over several days. About 50 lashes are given at a time.

Does that make it better or worse?

Steroid Shots for Back Pain

Are essentially worthless. So don't bother.

When it comes to treating chronic back pain with sciatica, epidural steroid injections may only bring small, short-term relief, according to a group of neurology professionals.

Sciatica is pain running down the back of the leg, where the sciatic nerve is located. It often accompanies back pain.

In reaching its conclusion, the American Academy of Neurology's Therapeutics and Technology Assessment Subcommittee reviewed four studies on epidural steroid injections for back pain with sciatica.

Based on the findings, epidural steroid shots are not recommended for long-term back pain relief, improving back function, or preventing back surgery, write neurology professor and subcommittee member Carmel Armon, MD, MHS, and colleagues.

Taken together, the four studies show that patients who got epidural steroid shots had a slight drop in pain two to six weeks after the injection, compared with patients who got epidural shots containing no medicine (placebo injections).

However, the epidural steroids didn't relieve back pain more than the placebo at 24 hours, three months, or six months after administration, the review shows.

The epidural steroid shots also didn't appear to improve the patients' average back function or help patients avoid back surgery.

"While some pain relief is a positive result in and of itself, the extent of leg and back pain relief from epidural steroid injections, on the average, fell short of the values typically viewed as clinically meaningful," Armon says in an American Academy of Neurology news release.

Armon's team didn't have enough data to evaluate the use of epidural steroid shots for neck pain.

With few high-quality studies to review, the researchers call for further studies on epidural steroid injections for neck and back pain.

MedBlogs Grand Rounds 3:24

Grand Rounds is up over at GruntDoc.

Bright and early, too.

More on Agitated Delirium

Once again, a report in the mainstream media describes "excited delirium" as a "rare and controversial condition." It isn't rare or controversial to the emergency physicians quoted in the article, however:

The term "excited delirium" began showing up in coroners' reports and in the charts of emergency room doctors in the 1980s, on the coattails of the cocaine epidemic. Dr. Corey Slovis, a professor of emergency medicine and chairman of medicine at Vanderbilt University Medical Center, said patients become "wild and bizarre" and "are often found running down streets, screaming, and sweating until dehydration."

Slovis and others are convinced excited delirium is a "real clinical disorder." But the fact that the disorder seems to manifest most often when people are in police custody, and is often diagnosed only after the victims die, gives civil libertarians cause for concern.

Eric Balaban, a lawyer for the American Civil Liberties Union National Prison Project, says the cause for these arrestees' deaths is police brutality, not excited delirium.

"There remain many questions. Excited delirium still doesn't exist as a recognized diagnosis. It can't be found in any medical textbooks, and the AMA still doesn't recognize it as a diagnosis. Medical examiners only picked up the term to explain and whitewash excessive use of force by the police," he said.

But physicians who have seen people in the throes of excited delirium insist it can't be mistaken for anything else.

Dr. Gary Vilke, an emergency room physician at the University of California at San Diego, said excited delirium causes police intervention, not the other way around. "These are people running around naked, breaking the windows of cars and getting the attention of police. … They are excited and delirious, hence the term. … Cops have to intervene, and a struggle is inevitable."

What's really killing these people isn't police brutality but an overdose of adrenaline, said Dr. Assaad Sayah, chief of emergency medicine at Cambridge Health Alliance. According to Sayah, when people are abused by cops, the trauma is obvious. Excited delirium deaths, he said, are "not related to an actual trauma to the patient."

Contrary to the article, the condition is in fact recognized in the medical literature. A simple medline search reveals several articles and studies describing the condition.

As I mentioned previously,

"Patients with agitated delirium in the setting of a simulant-induced psychosis commonly die while they are being subdued and restrained, whether they have been tazed or not. Yet every time I read about such an occurrence in the media, it is presented as an unusual event. Maybe it was the taser....maybe it was the chokehold.....

Maybe it was the drugs. Ya think?"

Eclipsed

Don't miss it!

The first of two total lunar eclipses in 2007 is unique in that it is partly visible from every continent around the world. The entire event will be visible from Europe, Africa and western Asia. In eastern Asia, moonset occurs during various stages of the eclipse. For example, the Moon sets while in total eclipse from central China and southeast Asia. Western Australia catches part of the initial partial phases but the Moon sets before totality. Observers in eastern North and South America will find the Moon already partially or totality eclipsed at moonrise. From western North America, only the final penumbral phases are visible.

UPDATE: Grrrr. It's too cloudy in the eastern sky here to see the moon.

Learning to Fly

Our facility just rolled out a shiny new electronic medical record and computerized order entry system this week. Emergency physicians are now encouraged (well, forced) to order all laboratory tests, X-rays, and medications electronically, via drop-down menus on computer screens. And of course all patient charts are created with a keyboard and touchscreens too. The paper system which had served us well for so many years is now officially extinct.

Although we were trained how to use the new system, it's difficult to learn the intricacies of something like that until you are actually in the hot seat. I initially found it very difficult to concentrate on patient care while I became accustomed to the new system. When you have to spend an extra 10 minutes trying to figure out how to order a suture kit, for example, that's 10 minutes you aren't spending thinking about your patients.

I liken it to trying to fly a plane with which one is unfamiliar: a pilot trained to fly piston-powered airplanes transitioning to light jets for example. You can train on a fllght simulator for weeks but still not be able to open the door to the jet when you try to board the real thing. And while you know how to fly a plane, you might not know how to lower the landing gear on THIS particular plane. So the possibility of a crash is increased.

Little quirks in the system were both frustrating and amusing. A urine pregnancy test was inadvertently added to the urinalysis of an elderly gentleman (thankfully, it was negative). A patient was accidentally discharged from the system, and it took us 15 minutes before we could figure out how to find and replace the electronic record so that we could resume charting and writing orders.

A simple x-ray cannot be ordered without answering multiple drop-down questions:

1) is the patient allergic to iodine? (no, but I'm not giving any iodinated contrast; it's a foot X-ray)
2) does the patient have a working IV? (no, but he doesn't need one; it's only a foot X-ray, dammit!!)
3) did the patient drink contrast? (no, does any patient EVER drink contrast for an X-ray of a stubbed toe? AAARRRGH!!!)

We also get lots of WARNING ALERTS like this:

1) The pain level for this patient (1/10) is severely above normal!!!!!
2) The systolic blood pressure for this patient (139) is severely above normal!!!!!
3) Severe drug interaction!!!!!!! (if we give a dose of Toradol in the ED and then discharge the patient on Motrin, for example)

How did we let this happen? Shock the monkey!