My Daughter, the Artist

...created this from scratch with Microsoft Paint for a wolf-drawing contest.

Does anyone know of any better art software programs so she can advance her career and support me when I retire?

Quote of the Night

I'll set the scene first:

The Zoll pads are in place, the sedative has already been drawn up in a syringe, the Type A Texan with new-onset atrial fibrillation is in a hurry to get his cardioversion over with so he can go eat dinner (hell no, he doesn't want to be admitted), I'm at the computer finishing up another chart before I start the procedure. The nurse at the bedside, ready to go, asks the patient...

"Do you want to push the button?"

On Tailoring the Explanation to the Patient

I recently treated an unfortunate young lady who suffered from the dual diagnoses of pulmonary emboli and cocaine addiction. Her last PE had almost killed her, but her social situation and drug addiction made compliance with a complicated medical plan difficult, so she seemed like a good candidate for a Greenfield Filter.

When describing the apparatus itself, I used my favorite instrument - the analogy:

"It works like the steel wool in a crack pipe," I said.
"It keeps the lumps from getting to your lungs."

What's My Name?

This is the f**kin' shit I be talkin' about
Half rappin' ass mothaf**kers
You think it's a game? You think it's a f**kin' GAME?

- "What's My Name?" by DMX

Rapper DMX was arrested at a Phoenix mall Saturday on suspicion that he gave a gave a false name and Social Security number to a hospital to get out of paying for medical expenses.

Maricopa County Sheriff Joe Arpaio said that when DMX, whose real name is Earl Simmons, went to Scottsdale's Mayo Clinic in April, he used the name "Troy Jones" and failed to pay a $7,500 bill.

The CRAP Score

(Canadian Relativity Adjusted Pain Score)

via allnurses.com

CRAP=(OPS+AF)(SC)(EC)

OPS=Old Pain Score
AF=Adjustment Factor
SC=Story Credibility
EC=Exam Credibility

The key value here is the Adjustment Factor. For "LPT" patients (Low Pain Threshold) this will be calculated as follows:

• For every point over 10 which the patient reports, subtract one. If they say their pain is a "12" then subtract 2 points and start with an 8.
  

• For every visit the patient has had to your ER in the past 12 months for a painful condition that was either chronic or went undiagnosed, subtract 1 point.

• If you push on a non-painful or uninjured area of the patient's body, the shin for example, and they say "Ouch", subtract 1 point.

• For every allergy to a non-narcotic medication that could be effective for their condition, subtract 1 point.

• If they are wearing sunglasses, subtract 1 point.

• If they still have tape or EKG lead residue on their body from a prior hospital visit, subtract 2 points.
  

For "HPT" patients (High Pain Threshold) you will be adding numbers to their pain score:

• If a spouse or family member forced them to come in, add 1 point.
  

• If you check their records, and every time they've come to your ER for a painful condition something was torn, broken, ischemic, or perforated, add 2 points.

• If they have no allergies add 1 point.
  

• If they are tachycardic or hypertensive add 1 point.

Here is an example: a young man presents to your ER for his 7th visit this year for a migraine headache and reports his pain as "12" on a 10 point scale. He is allergic to Reglan, Imitrex, Toradol, Prednisone and Tylenol. He also has been to the ER 5 other times in the past year for back pain or abdominal pain, all times sent home with normal studies.

When you enter the room he is yelling at someone on his cell phone and eating Cheetos, but tells you, "This is a bad one doc." On exam his VS are normal and his abdomen and back are both tender. "I didn't even notice they were hurting," he says. His CRAP score would be (10-6-2-5-5-1)(0.5)(1) which would be negative 4.5, but since his number is negative, you decide to leave out the credibility conversion for a score of negative 9.

You tell him that pain medications are not indicated for his headache because his CRAP score in negative 9 and he can go home whenever he is ready.

Thanks to the anonymous commenter for the great find.

Funny Picture of the Day

Supposedly it's not a fake, unlike the honorable mention (see background story here).

UPDATE: Witty comment - "Remember the scene in “Blazing Saddles” where Cleavon Little got some whites led by Slim Pickens to show them how to “sing black” with their version of “Camptown Races”? In this case, the cartoonist is Slim Pickens, showing us what it’s like to “think conservative”, but as in the movie, the joke’s on him."

Great analogy, but the actor in question was Burton Gilliam, not Slim Pickens. Anyway, I smell Hillary.

Chronic Pain vs. Childbirth

I've written quite a bit about pain on this blog, and I always enjoy the comments and personal anecdotes of my contributors, but I have noticed an occasional comparison that strikes me as a bit of a stretch.

When a chronic pain patient really wants to impress me with her supernatural pain tolerance, she will occasionally state that her natural childbirth (for some reason these women always have their babies naturally) was nothing in comparison to the pain of her ______ (insert chronic pain syndrome of choice here).

And furthermore, the baby always seems to be of above-average weight - no 5 pound preemies for these stalwarts. I imagine that the labor was exceptionally long as well, and that the only analgesia required was a moist towel across the forehead and some soothing words from the hubby.

Now I'm certain that I've witnessed far fewer childbirths than some of my readers, but the ones I've seen looked pretty uncomfortable, especially the primigravidas. I guess it's a good thing that these exceptionally painful syndromes tend to strike people with such hardy pain tolerances, because if the pain is that much worse than childbirth, then a normal person probably couldn't handle it.

Just saying.

Fireworks Fun

An oldie but a goodie. Ouch!

Happy Independence Day

The US Declaration of Independence

The Delta P

Treating our patients' pain is a priority in the ER, but it isn't our highest priority. And of course all pain isn't created equal. When the waiting room is full and everyone has 10/10 pain, we have to distinguish them somehow. One consideration is the mechanism of pain: an obvious injury like a broken wrist is more convincing than some of the "mystery pain" syndromes like migraine or fibromyalgia. But of course some conditions cause excruciating pain without an immediately apparent source, and all pain deserves to be treated. But in what order?

One philosophy is to consider the change in pain from baseline, a function that I will name the delta P (or ΔP). If a fibromyalgieur or a chronic back-paineur lives at a constant 6/10 pain level and they present with 10/10 pain, then their ΔP=4. Similarly, if a previously healthy and pain-free little girl falls off her bike and scrapes her knee, presenting with 5/10 pain, her ΔP might be 5.

So there you have it, the delta P: a mathematical representation of why acute pain is treated before chronic pain.

ΔP = Pa (acute pain level) - Pb (baseline pain level)

Scalpel's Theory of Relativity

I try to see really old patients and those with terminal diseases as quickly as possible, because when someone doesn't have long to live, every minute counts. A 10 minute wait to them is like hours for us.

I also try to see screaming babies as quickly as possible, because I don't like listening to screaming babies. I prefer that they scream at home, where hopefully their parents love them enough to tolerate their screaming. A screaming baby does not necessarily represent an emergency. To me, however, it does.