Chronic Painer Revenge Fantasy

Courtesy of Sean Conlon, a chronic pain sufferer in New York who used to be anonymously known as Redhawk but who now blogs under the pseudonym Payne Hertz. I won't link him, but with a little internet sleuthery you can find his whiny blog yourself, if you are so inclined. He thought I was on the wrong track with my pain scales, so he came up with this:

"This has led me to create my own pain scale, one which uses very objective criteria and which has the advantage of firmly establishing an objective, empirical baseline in the doctor's mind from which he can better understand and rate his patient's pain as well as measure its impact on the patient's life. Unfortunately, this scale only works with male doctors.

To use my scale, first grasp the doctor firmly by the lapels. Now, while simultaneously releasing a loud "Ki-Ai!" Karate shout, bring your knee vigorously into your doctor's testicles. While the doctor is on the ground writhing in agony and trying to catch his breath, explain to him "That's what level 10 feels like." After giving him a minute or so to regain his composure, kick him in the shins, telling him "that's what level 7 feels like." Now spin him around and give him a firm boot in the ass, and say "that's level five." Follow this up with a couple of slaps in the mouth, which will rate a "3." When you are done establishing these objective pain-rating baselines, bend over and give him a gentle pat on the back and say "that's level one."

Sean, I would love for you to try that out sometime. But my question for you is, if you are already at a "level 10" from your chronic mystery pain and someone were to hypothetically spray you in the eyes with pepper spray, stab you in the neck with a pencil, or break your elbow by vigorously hyperextending it, would that not bother you at all because you're already maxed out, or would your pain level go up to a 15 or so? Just wondering.

And I would also like to mention this excellent observation from girlvet, who recently posted:

"I have seen a couple of people get out of control when they didn't get their narcs. I read an article in emergency medicine magazine that takes about a doctors role in treated chronic pain in the emergency setting. What's fascinating about it is that the author says that 50% of chronic pain sufferers have personality disorders or affective disorders. I can vouch for that. They wear you out, the people who come in for chronic pain because they are people who are neurotic and difficult to work with. Antidepressants have been found to be very helpful in these people, along with psychological help. They seldom get it."

Indeed.

And if anyone reading this happens to work in an Emergency Department in New York and is unfortunate enough to come across this gentleman....you might want to guard your nuts.

The Waiter

So a well-known frequent-flying sickle cell princess is finally brought back into a room after a 3 hour wait in triage. I actually have a soft spot for these patients somewhere deep inside my crusty facade, because unlike many other chronic conditions that cause mystery pain, this disease actually harms those who are afflicted with it. You never see an old sickler, and it's rare to see even a middle-aged one. So I consider these patients to have terminal illnesses, and I have no problem giving them as much pain medication as they want or need.

And I hate to see them wait so long before they get treated too, but as usual, we were doing the best we could that day. Sicklers typically suffer alone; their families must have learned long ago that there are better places to spend half a day than sitting by the bedside of an alternately moaning, complaining, and snoring chronic pain patient, even if it happens to be someone they love. So the families usually just drop them off in triage, and hopefully they are available to pick them up if the patient improves enough to go home.

But not this guy.

She had literally been in the room all of 2 minutes, just long enough for me to check when she was last discharged from the hospital (one week prior) and look over the meds she had received during her last ER visit (about a pound of morphine), when her boyfriend was already at the nurses' station, asking when she was going to see the doctor.

So I went to see her and then came directly out to enter the medication orders in the computer. I'm just starting to type my note, when he's back at the desk, asking when she is going to get her shot. It'll be just a couple of minutes, I tell him. It's already ordered. As it is ordered, so shall it be done.

Two minutes after the shot, as the nurse is charting, he comes out again to ask for a cup of water for her. Five minutes later, it's a warm blanket. Then a sandwich. One of the other nurses tossed some slippers on the counter, just in case.

"Dude, she's got you running all over the place," I told him. "We'll get her whatever she wants, but maybe you could ask her to make a list or something so we can take care of it all at once."

Maybe we need a menu.

Happy Halloween

Global Warming/California Fires Connection

It's no surprise to hear that some politicians are blaming the recent California wildfires on global warming. But I haven't heard anyone consider just how much excess global warming is going to be CAUSED by these fires. How many thoughtful hybrid purchasers and considerate carbon offset dupes had their efforts negated by this single week of tragic infernos?

I wonder.

In 2002, CO2 emissions due to wildfires in Colorado equaled an entire year’s worth of the state’s transportation emissions, according to the National Center for Atmospheric Research.

Once again, I humbly suggest that Earth > man.

Scalpel's Helpful New Pain Scale

Here's how it works:
A nurse or doctor or associate walks into the patient's room.
A simple question is asked, "So, how are you feeling?"

I don't want to hear any freaking numbers, just answer the question. I'll assign the number.

0 - Asleep. Doesn't answer.
1 - Shake to arouse, repeat question. It doesn't matter what answer the patient gives, they're a 1.
1 - "I'm OK"
2 - "Pretty good"
3 - "Not too bad"
4 - "It hurts a little"
5 - "It hurts"
6 - It really hurts"
7 - "It hurts really bad"
8 - "AHHHH!! IT REALLY F__KING HURTS!"
9 - "AHHHH! AHHHH! AHHHH! AHHHH!" (heard from nurses' station, no questioning necessary)
Nobody's a 10.

Here is how I might use the information to guide my treatment.
We really only need four categories:

For 3 or less: no more pain meds need to be given in the ER, but they might get a prescription to take at home.

For 4 or 5: an oral medication is probably sufficient. The patient is probably ready for discharge.

For 6 or 7: they will probably be offered an injection of something or other, and they will be re-evaluated before disposition.

For 8 or 9: they will likely need IV medications until they move down on the scale.

Some painful conditions are going to get IV meds anyway: MI, appendicitis, cholecystitis, hip fractures, or nonspecific abdominal pain with vomiting, for example. Some traumatic injuries or musculoskeletal pains will probably get an IM injection even if at the higher levels, unless we need an IV for other reasons. Some treatment of mystery pains without objective evidence of disease or in the setting of multiple repeat visits might depend on how busy we are. If a nerve block is appropriate, it is the treatment of choice for many painful conditions.

Any descriptions of pain which demonstrate any form of complex thought will be defaulted to the 6-7 level. Any mention of baseball bats, knives, sledgehammers, or dismemberment would fall into this category (unless the patient really was hit in the head with a baseball bat, of course).

Any mention of the number 10 will cause me to default to the Objective Pain Scale.

Pain Scale Absurdity

Two patients came into the ER by ambulance complaining of pain.

One was a young woman with another migraine, who "usually gets" Dilaudid 4-6 mg IV in addition to IV Reglan and Ativan. She was allergic to many other medications, but she had a full bottle of dilaudid 8 mg pills and some Actiq lollipops in her purse from two different pain specialists. Her usual medications also included Ambien 20 mg at bedtime and Xanax 2 mg every 6 hours. Although she complained of vomiting constantly for 3 days, her vital signs, physical exam, bloodwork, urinalysis, and imaging tests were all negative, and she never vomited in the ER. She spoke calmly and was in no apparent distress.

The other patient was an elderly lady who had fallen at home, fracturing her hip. She was taking a blood thinner, so her grotesquely angulated and deformed thigh was also markedly swollen. The fact that she had crawled down the stairs after her injury in order to call the ambulance probably contributed to the swelling and deformity somewhat. She trembled a bit as she asked for something to relieve her pain.

Guess whose pain was a 5/10 and whose was a 10/10?

JCAHO, your pain scale sucks about a 12 on a scale of 1 to 10.

Thanks to KevinMD for the link!

Life as a Cruise Ship Doctor

Sounds like fun.

"The clang of a gangway or thrust of engines usually wakes me up. The cabin is efficiently spacious; a double bed, computer, TV, desk, enough floor space to do some yoga (which I conveniently postpone). Best of all, is the two portholes that look out onto the ocean, and the lack of cabin mates that most crew are afflicted with. Three S’s later, epaulettes strapped to shoulders, it’s a gentle stroll to the breakfast buffet. Breakfast is rather continental, nothing to rave about.

8am is the first clinic- a combination of general practice with the odd curve ball. The wonderful nurses do a great job of filtering the trivial from that which is worth consultation, so in a way, the clinics can be quite interesting. There is also the continuity of crew care. Its great working with different ethnic groups, each seem to have a particular fascination (gross generalization to follow); For the Indian continent it is “lack of power”, Eastern Europeans have “terrible pain”, Asians cough with sore throats. Probably more to do with their jobs on the ship than anything else.

11am and it’s self improvement time until lunch. This involves an interactive computer programme where I learn how to say “the ball is on top of my aunty” in Spanish, or how to type without looking at the keyboard… I wasted years. It’s back to the buffet for lunch. The salad bar is great, the main area has about five hot dishes, usually tasty but again not overly, and slightly unhealthy. I take a leisurely three course meal culminating in dessert- cake and fruit. Conversation is fun; there are enough social extroverts to keep it at gutter level, an area I know a fair amount about.

While others head back to work, the casual Doctor gets to go to the guest gym- A buffet of machines that flex and extend every part of the physique. Believe it or not, in three months I have lost weight, grown four more abdominal muscles (a four pack with two to go) and developed an addiction to the elliptical machines. I now walk by pulling myself around with my arms. There is the option of basketball, a swim, a sunbathe, more food, however finding an opponent can be hard as everyone else has to work.

The sand man usual takes hold of me for a mid afternoon snooze. The afternoon clinic passes and evening draws near. Dinner is similar to lunch. Afterwards it more self improvement or its self degradation at the crew bar- Always good for a laugh and a few tales of ship life.

Of course there is the weight of the communication station you carry as you are on call. However they get put in their little electric beds every second day when you are off and can do what you like in an European city. Due to sea days, this seems to come up about every three days, and can be complicated by problem patients.

Internet access is 24/7, phoning home is easy, and people are friendly, but life in a metal box is not all desserts and running machines, well, actually it is."

Read more....

The Yellow Dog Vote

She may not have the charisma of Edwards, and she certainly doesn't inspire like Obama. But she's a woman, sort of, and that means a lot to some folks. Her campaign treasure chest is overflowing with ill-gotten yen, and her advisory panel includes a convicted criminal to whom her ersatz husband owes a favor. She is too hawkish for many pacifist liberals, and her fake cackling laugh annoys even her supporters.

But yet her nepotistic journey to the Democrat presidential nomination seems inevitable, and so it's almost nose-holding time for many on the left. Their thirst for power allows, no forces, them to vote for even the most corrupt, least experienced candidates as long as they answer to "Blue." Because some things are much more important than integrity.

Woof!

UPDATE: Woof Woof!!! (Hillary photo goldmine)

Me, Friendly?

I was recently asked to write a post on another blog as a guest blogger, something I'd never done before. When I saw that Dr. A had preceded me as a guest blogger on the site, I was honored to be in such fine company. I knew immediately what I was going to write about too...tips to make an ER visit go more smoothly. Then Dominic e-mailed me to say that Kim had already guest-blogged on that topic. Obviously Kim is a blogstress of the highest order, so she'd already nailed it. But since I have the delicacy and maneuverability of a freight train, I proceeded to add some of my ideas to her topic.

The big question was, could I be friendly enough for the MedFriendly site? I had to bite my lip a few times (and delete a few lines), but I think it turned out well. Thanks to Dominic Carone, Ph.D for hosting me, and go check out his site. It's a very patient-friendly site that seems to have been around for quite a while, and it is certainly worth a look.

Global Warming Indoctrination

One of the world's foremost meteorologists has called the theory that helped Al Gore share the Nobel Peace Prize "ridiculous" and the product of "people who don't understand how the atmosphere works".

Dr. William Gray, a pioneer in the science of seasonal hurricane forecasts, told a packed lecture hall at the University of North Carolina that humans were not responsible for the warming of the earth.

"We're brainwashing our children," said Dr Gray, 78, a long-time professor at Colorado State University. "They're going to the Gore movie [An Inconvenient Truth] and being fed all this. It's ridiculous."

click here for the story

It's happening right now in public schools all over the country, I can assure you.

My daughter arrived home from school just last week, skipping down the sidewalk after getting off the bus. The first thing she asked me when she came in the door was "Daddy, do you believe in global warming?"

Fortunately, I had long been expecting such a question, so I had already prepared my answer.

"That depends," I said.

Before I said another word, I could already see the distrust and disappointment in her eyes. I'm sure she had hoped that I would simply reinforce the lessons she had learned in class that day and we would soon be off on a door-to-door crusade spreading the word to our neighbors about the dangers of this impending tragedy, saving the world one house at a time. Alas, it was not to be. The job of a parent is to help the child interpret what they have learned in school, and perhaps to see things from a broader perspective. And I enjoy being a parent.

"Do I believe that global warming exists? Definitely. The earth does in fact get warmer at times, but it also gets colder at other times. Do I believe that the current trend means that the earth will only get hotter and hotter until we are all crispy critters rotting in the street? Definitely not."

"But we are causing global warming, aren't we Daddy?"

"We might be causing some changes, but the Earth is much more powerful than humans will ever be. And despite our best intentions, no human being has ever been able to change the weather. We can't prevent an earthquake, we can't deflect hurricanes, and tornadoes pretty much pwn us like noobs whenever they occur. Our only hope is to run and hide if they come around. So even if we were in fact causing the Earth to get warmer (which has never been proven, by the way), why would anyone think that we could possibly change the weather to make it cooler? We can't even stop a tiny little rain shower. Besides, I like my car."

"But what about the floods? My teacher told us that the icecaps were melting and that the water was going to rise up and flood all of our houses."

Now this made me a little upset. Spreading your misinformed political agenda is one thing, but lying to little kids and scaring them unnecessarily is quite another.

"Even if your teacher was right about the concept of global warming (which she is not), water levels wouldn't rise up that much for hundreds of years. You and I will both be long dead by then, and our great great grandchildren will be rich from their new oceanfront property. Aren't they lucky?"

"But I want to do something about global warming. What can we do?"

"Here's the deal. Al Gore flies around in a ridiculously expensive private jet, spewing so much carbon dioxide into the atmosphere that our relatively insignificant efforts to reduce our own waste would make as much difference as taking a spoonful of water out of the swimming pool. But I did notice that you left the light on in your bathroom this morning. When Al Gore gets rid of his private jet and when you turn off all of your lights and the TV, I might think about trading in my obnoxiously loud, gas-guzzling sportscar for a Prius like your uncle Shadowfax.

Oh wait, that was uncle GruntDoc with the Prius. The heat must be getting to me.


UPDATE: List of crackpots for the moonbats to reflexively dismiss.

Healthcare Costs Are Actually Declining

This is not a new article, but the perspective raised by the author is worth revisiting. Enjoy.

Insights by Peter Huber:

"The cost of health care in the U.S. has been declining steadily for the last 50 years. It will decline faster still in the next 50. All of the doleful commentary about mushrooming costs and budget-busting programs ignores the principal economic costs of illness, which are falling fast, and the science of pharmacology, which is transforming the economics of health care.

By far the largest economic cost of illness is lowered labor productivity. Sick people can't work, and when adults die in their prime, they take all their intelligence, skills and initiative with them. Until recently, the cost of illness among children and the elderly was also shouldered mainly by the healthy adults who devoted countless hours to their care. Such costs aren't reflected in revenues to doctors or hospitals, still less in federal insurance programs. They are felt in lost corporate profits, lower wages and, for many women, tireless but entirely off-budget toil in the home.

Several developments radically changed this economic calculus in the second half of the 20th century. Vaccines all but eradicated many of the most common childhood diseases and substantially curbed infectious disease among adults as well. However much it cost to develop the whooping cough vaccine or to distribute it free to families who couldn't afford it, the cost must surely have been dwarfed by the economic gains that came from freeing up mothers to engage in other pursuits. Antibiotics had a comparable impact. Tuberculosis was a fantastically expensive disease a century ago--think of the balconies in the mountains of Davos or New York's Saranac Lake. Polio meant braces and iron lungs. Those costs have all but disappeared.

But while the costs of incapacity, home care and the sanitarium declined, spending on hospitals and physicians rose sharply. Families began outsourcing their health care, particularly for the elderly. This pushed the costs out into the open, where they could be covered by insurance programs and decried by budget experts. The real cost of health care--avoiding disease or recovering from it--certainly continued to drop fast, but now the costs were incurred not in time but in dollars--often government dollars--and that of course changed the debate.

Most of those dollars, however, are still spent buying time--the very expensive time of doctors, nurses, geriatric attendants and countless others who have replaced mom in the business of soothing the fevered brow and changing the bedclothes."

Read the rest...

Peter Huber, a Manhattan Institute senior fellow, is the author of Hard Green: Saving the Environment From the Environmentalists and the Digital Power Report.

Scientist Creates Artificial Life Form

This is an exciting and somewhat frightening step in our advancement of knowledge. Quantum scientific breakthroughs can be used for the good of humanity, or they can create inconceivable horrors. And like nuclear fission, this technology will probably do both. But once the box has been opened, you can't close it back.



"Craig Venter, the controversial DNA researcher involved in the race to decipher the human genetic code, has built a synthetic chromosome out of laboratory chemicals and is poised to announce the creation of the first new artificial life form on Earth.

The DNA sequence is based on the bacterium Mycoplasma genitalium which the team pared down to the bare essentials needed to support life, removing a fifth of its genetic make-up. The wholly synthetically reconstructed chromosome, which the team have christened Mycoplasma laboratorium, has been watermarked with inks for easy recognition.

It is then transplanted into a living bacterial cell and in the final stage of the process it is expected to take control of the cell and in effect become a new life form. The team of scientists has already successfully transplanted the genome of one type of bacterium into the cell of another, effectively changing the cell's species. Mr Venter said he was "100% confident" the same technique would work for the artificially created chromosome.

Mr Venter believes designer genomes have enormous positive potential if properly regulated."

Read the rest.

An "Oh, Sh_t!" Moment

And a cool X-ray to go with it.

From Rugbygirl.

Spicy Beef with Noodles

I haven't posted a recipe in a while, and since this one turned out pretty good, I thought I'd save it for posterity. More onion and pepper would have been better, but I used what I had.

Ingredients:

4 oz egg noodles
1 pound precut beef strips for stir fry
red onion, sliced
bell pepper, sliced
one can sliced water chestnuts
ground cayenne pepper to taste
(sliced fresh jalepeno pepper would have been a good substitute)
1-2 tbsp olive oil

I marinated the precut beef strips in a mixture of Teriyaki and Worchestershire sauce with minced garlic and ground black pepper for 2 days, stirring occasionally. I like to start the marinade as soon as I bring home the groceries, then I can cook later in the week when it's convenient.

• Boil the noodles as per package instructions, drain, set aside.

• Add the olive oil to a large skillet, and heat to high.

• Dump the beef and marinade into the oiled skillet, stirring constantly for a couple of minutes until well-browned.

• Add the vegetables, turn down heat to medium, stir occasionally for 10 minutes.

• Add the noodles, stir well, turn off the heat, and cover the pot for a few minutes. Stir again before serving.

Makes 4 servings for about 6 dollars.