Reaching for the Light

The matriarch of the family had reportedly lived a rich and fulfilling life, but the last few months had been hard on her. Since suffering a surgical complication and a rough postoperative course, she had lived in the hospital more often than not. So when she was found unresponsive in bed only a few days after her latest hospital discharge, it looked like the end was near.

Unfortunately, but not surprisingly, her doctors had not discussed end-of-life issues or overall prognosis with the family, and she did not have an advanced directive. So the difficult conversation was once again left to me. Perhaps it was the massive stroke it appeared she had suffered, the deep coma she remained in, or the cumulative strain of the last few admissions. Perhaps it was simply her age, which was certainly advanced. Or maybe it was something else. But for whatever reason, this was one of the easier "let her go" discussions that I have encountered. The family was unanimously comfortable with the idea that maybe she shouldn't be intubated or placed on life support.

We then stepped outside the patient's room so that a chest X-ray could be taken, and I swear to God this is true. As the radiology tech aimed his targeting light on her chest to center the beam on the X-ray plate, this woman who hadn't moved a finger despite our yelling her name, inserting an IV, or giving her a sternal rub... gradually raised her hand up towards the light.

That was freaky.

The Gods Must Be Crazy

That was a great movie.

"The bushmen of Xi's group are living well off the land. They are happy because the "gods" have provided plenty of everything, so no one in the tribe has unfilled wants. One day, the pilot of a passing airplane drops a glass Coke bottle. Initially, this strange artifact seems to be a boon from the gods — Xi's people find many uses for it. But unlike anything that they have had before, there is only one bottle to share among all members of the group. This exposes the tribe to a hitherto unknown phenomenon, property, and they soon find themselves experiencing things they never had before: jealousy, envy, anger, hatred, even violence.

Xi assumes leadership and decides that the bottle, renamed "the evil thing", must be thrown off of the edge of the world, and he volunteers for the task."

And so he set out to heal the souls of his tribesmen.

The Sad Truth About Flying

If you suffer a cardiac arrest during a long-distance airline flight, oxygen isn't going to save you. Airlines don't always have medical personnel aboard, unless a Good Samaritan physician happens to be on the flight and agrees to come forward and help (hopefully it's not a Dermatologist or Pathologist). A defibrillator might buy some time, but not in every case. Even if the AED happens to restore a functional heart rhythm, it still cannot treat the underlying disorder, which is often fatal despite the most appropriate land-based treatment in our modern emergency departments.

Airlines do not carry a full complement of ACLS drugs or, to Nurse K's chagrin, cath labs. The 30,000 feet-to-balloon time is completely unacceptable. They can't check an ECG or monitor the cardiac rhythm, and they don't even stock thrombolytics.

I'm sure a lawsuit will be brought against American Airlines in this case, but the sad truth is that if you have a cardiac arrest when you're 30,000 feet over the ocean, then you are likely going to die whether the oxygen tanks are working or not.

Another sad truth.

Cat of the Day

Meet Oatmeal, my daughter's new kitten from the ASPCA.
She sort of reminds me of Eclyse.

Hey, at least I'm not talking about politics.

The Princess hates her, btw.

Brain-Eating Amoeba

Scary.

Since Murrieta Fire Capt. Matt Moore fell ill in November, he has been in and out of four hospitals, all the while growing sicker from a mysterious illness that doctors were at a loss to identify. Now he is on life-support in a critical-care unit in San Diego.

Late last month, his family and friends finally got some answers. But the news was not good. Moore, 43, who is married and has three teenage children, is suffering from a rare and usually fatal parasitic meningoencephalitis caused by a brain-eating amoeba found in soil.

continued...

Best wishes to Capt. Moore and his family.

My Brain Scan

Frighteningly accurate.



h/t Medblog Addict, whose scan looks considerably different than mine.

Orthostatic Vital Signs

This discussion at Girlvet's reminded me of how I used to explain the interpretation of orthostatic vital signs to my medical students and residents.

Why do we obtain orthostatic vital signs? In a dizzy patient, we want to see if their current hemodynamic status accounts for their dizziness. In elderly patients or other patients we suspect of having neurogenic orthostasis, the evaluation of orthostatic vital signs allows us to measure their hemodynamic response to standing. In dehydrated patients, we want to see if they have been adequately rehydrated. Of course, many medications may blunt the orthostatic changes in vital signs, but important information can still be gathered by their measurement.

Classically, we were taught that a drop in systolic BP by more than 20 points and/or an increase in pulse rate of more than 20 beats per minute after a change from supine to standing suggested an abnormal hemodynamic status. If there is only a pulse increase but no drop in blood pressure, the test is less significant. If there is a drop in blood pressure without an increase in pulse, one should consider whether medications might be contributing to this pattern.

In the elderly patient, abnormal orthostatic VS in the absence of dehydration may not be affected much by the administration of fluids due to underlying disturbances in blood pressure regulation, and alternate therapies may be more appropriate if the patient is symptomatic.

In the dehydrated patient, the presence of orthostasis, particularly when symptomatic, suggests inadequate rehydration. Orthostasis can also be an important early sign of occult GI bleeding.

If an abnormality in orthostatic vital signs is discovered, the significance must be placed into context. The greater the change in orthostatic vital signs, the more likely there is a problem that needs to be addressed.

Despite modern medicine's overreliance upon blood tests or radiographic imaging studies for the diagnosis of various maladies, the measurement of orthostatic vital signs is quick, cheap, easy, and still valuable after all these years.

Fear of Poisoning

It's been a weird week.

One guy I'd never met before who works as a tech in another department upstairs came to the nurses' station and started talking to me as if we were good friends. He then asked me if I could run a blood sample on him to check for heavy metals, because he was afraid his wife was trying to poison him. He didn't want to be evaluated, he just wanted me to draw his blood and somehow order a heavy metal screen, off the record.

As if.

Then tonight we get toothbrush dude. He'd just bought a new toothbrush, and after using it his gums felt tingly, so he suspected that someone had clandestinely laced it with some sort of toxic chemical substance. He brought the toothbrush with him in a Ziplock bag so that we could have it analyzed.

(photo credit)

Another Drug Bust

My latest narcotic-seeking patient had a dozen or so ER visits in the last 6 months, all but one of which culminated in both Vicodin ES and SOMA prescriptions. Only one doc stood his ground; most chose the easy way out.

There was no objective evidence of injury, of course. There was a reported fall in a grocery store somewhere along the line, and a reportedly abnormal MRI which was reportedly done elsewhere. There were 4 ER visits to our facility in the past month, and the patient's Orthopedist who practiced at another hospital was reportedly out of town until next week. Of course the patient was out of pain medications. Again.

Yawn. Are you starting to see a pattern here?

The patient really didn't want to elaborate on his medical history because he was in "too much pain." Well, that's one of the reasons to see only one physician for your chronic pain problem, I suggested helpfully. That way you don't need to go through the entire history over and over.

Nor did the patient really want to be examined. Too much pain, once again. Well, that's one of the reasons to see only one physician for your chronic pain problem. That way the examination can be more focused.

"Are you going to give me my medications or not?" he finally asked.

I'd like to talk to your Orthopedist to make sure we treat your condition appropriately. I'm concerned about the number of ER visits you have had, and I'd like to see if we can come up with a better solution for you.

"I told you already....he's out of town until next week."

Well, I can probably get in touch with one of his partners to expedite an earlier appointment at least. I'll be back in a couple of minutes.

Of course, the Orthopedist did not exist. There was no physician with that name or with any similar names. And when I returned to the patient's room to make sure I got the doctor's name correct, he was gone.

Of course, the patient will still receive a bill for my services, even though the disposition was incomplete. But I don't really care if he actually pays the bill. That was the most emotionally fulfilling 15 minutes I spent all day.

Queen - Another One Bites The Dust

What is Torture?

There's a very interesting but somewhat one-sided discussion about the subject over at Sid's place, so I thought I'd bring it over here for my readers to have a go at the topic.

Here are my thoughts:

Torture is basically putting someone in an uncomfortable situation to try to influence their behavior. The difficulty is drawing the line to decide what is allowed treatment of prisoners and what is not.

Is harsh questioning torture? Is a cold room? How cold? What about making someone stand up for a long time in one place? Or listen to music they don't like? Or depriving them of sleep? Heck, so far that sounds like my third year surgery rotation.

Our special forces go through much more hostile training than that, although I understand the difference that since it is on a voluntary basis and that they can quit at any time, it's not really the same thing at all. But the differences are mostly psychological. Torture, like pain, is based on individual perception. To some, sitting through an entire baseball game might be torture; to others, that's a nice way to spend an afternoon.

Is denying prisoners such comfort items as cigarettes considered torture? The Geneva Convention specifically states that POWs should have access to cigarettes and a commissary, among other benefits (articles 26-28). Of course there is some controversy about whether terrorist groups qualify under that document.

How about verbally misleading a prisoner? You could show him a finger from a corpse and tell him it is from one of his family members; every day he doesn't cooperate, you will bring him another one. Too gruesome and cruel? But yet since nobody is physically harmed with that technique, is it really "torture?"

What about verbal threats? Threatening them with a dog? With a gun? With a mock execution? That particular mock execution produced very important information which may have saved several of our soldiers' lives, if I recall correctly.

What about loud noises, either sudden and unexpected or constant and blaring? What about visual or auditory propaganda? Bright lights? Solitary confinement?

Are these things really torture? We aren't talking about using power drills or car batteries here. Or is any "mistreatment" of prisoners so abhorrent that we should always provide them with comfy feather beds, morning coffee, afternoon tea, Marlboros, and internet access? Is any attempt to extract information from prisoners always wrong?

Let's hear it.

(picture via The Smoking Gun)

Buffing the Chart

Buffing the chart is like waxing your car after you wash it. Both will get you where you need to go even if you don't make them all nice and shiny, but a properly buffed chart and a meticulously waxed car are not only things of beauty, they add a bit of protection against the elements too.

Are those vital signs a bit out of the norm? Let's repeat them before we let the patient go. That kid whose mom says "can't keep anything down?" If we see him having a sippy cup/Cheetos midnight snack in the waiting room, you better bet we're going to chart it. The "happy, playful" notation is a personal favorite too. The back painer who "can't walk?" I guess he meant that he couldn't walk unless he needed a cigarette. Or unless he was refused his narcotic of choice. Busted!

Of course, if a patient doesn't agree to any of the CYA tests or advice that we suggest, then we've got to record our discussion in the chart. If a patient would rather accept the 1/10,000 chance that he might die from undiagnosed meningitis than undergo a spinal tap, then who am I to impose my will (and my 3.5 inch needle) upon him? But I have to write a paragraph about it for the attorneys in case his family hits the jackpot.

I would never suggest that anyone write anything in the medical record that wasn't accurate. I can't recall a single instance where I have done so. But we can be a bit selective about what information we choose to include in the record. If the axiom that "if it isn't written in the chart, then it didn't happen" can be used against us, then we can use that principle to our advantage in selected situations as well.

If Dr. Molasses still hasn't gotten around to seeing the patient in bed 8, charting "patient upset about the wait, still awaiting MD evaluation" doesn't help anyone. Charting something like "the ER is very busy with critical patients, patient informed about the delay, offered warm blanket and fluffy pillow" is maybe more useful.

One of my personal irritations is when a triage nurse writes a paragraph for the chief complaint. It's called "chief" complaint for a reason; we don't have to include every little twinge of discomfort the patient has suffered since the Carter administration. "Flu-like symptoms" or "chest pain" are sufficient, thank you. Elaboration in the nurses' notes is always welcome, but let's keep the chief complaint area clean and polished, please.

I Met a Saint

It seemed like a typical overdose. Another teenage girl who took too many pills, more in a cry for help than any real desire to harm herself. So I ordered the mega laboratory panel and gave her some charcoal. Nothing too exciting or dramatic, she drank it without putting up a fight. She had a friend who had driven her to the ER and remained at the bedside the whole time. Three hours, maybe more, I can't remember. Her friend seemed very compassionate and was obviously concerned about her. It seemed like they were close friends, maybe even sisters.

Eventually, I learned that her friend wasn't even an acquaintance. She was a stranger who had noticed the patient crying in a parking lot and asked her what was wrong. The patient then admitted that she took a bunch of pills, so this remarkable young woman drove her to the ER and stayed with her until she was safe.

The patient really didn't have any friends, and her family lived hours away. After she declined admission and promised not to harm herself, the saint even drove her home.

Chief Complaint of the Weekend

"UNCONTROLIBLE BOWL FEVER"

I think they meant bowel, but their exquisite timing makes up for their poor spelling.

On an unrelated note, Scalpel or Sword? just got its 200,000th visitor. Thanks for stopping by, everyone!

Take It Out!

An anxious young woman with painful genital herpes and lower abdominal pain presents to an ER for evaluation. She agrees to have a pelvic examination performed, so you proceed, with your favorite chaperone assisting. You are very suspicious of PID, and since the patient is a nulligravida, you really want to obtain the appropriate STD sample.

She tolerates the insertion of the speculum with difficulty, because of the painful herpetic lesions. As you open the speculum to view the cervix, the patient yells "TAKE IT OUT!!!"

Your chaperone is standing right next to you, ready to hand you the Q-tip for the STD panel (which will take about 2 seconds for you to obtain). Do you:

1) Take out the speculum immediately, skip the STD sample, and order a CT scan instead?
2) Take out the speculum immediately and swab it with the Q-tip, hoping that will be sufficient?
3) Tell the patient, "just a second more," while hurriedly obtaining the cervical swab and then quickly removing the speculum when you are finished?

Just wondering.

Or for nurses, how about this? You are asked by one of your colleagues to try to obtain an IV on a alert and oriented but moderately whiny fibromyalgia patient with diffuse abdominal pain. The patient yells "TAKE IT OUT!!!" just as you get a tiny flash of blood, but you still need to to advance the needle another half a millimeter. Do you:

1) Try to advance the needle and catheter anyway since you are almost finished?
2) Tell the patient to hold on for just a second more while continuing to stab her with a needle?
3) Immediately remove the whole apparatus and notify the physician?

Is there a difference between the two scenarios?