WhiteCoat

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Reader Poll

Friday, February 22nd, 2013

So I had a problem with a patient and family recently and I’m looking for solutions from everyone who reads this blog.

An elderly patient who lives at home with his wife, his son, and his son’s family was brought by the ambulance to the emergency department for “not feeling well.”
As I attempted to get more of a history about the patient’s symptoms, the discussions angered the family.
“When you say that you don’t feel well, what do you mean?”
“I’m sick! That’s why I came here so you could tell me what’s wrong.”
“But I don’t understand what you mean when you say that you’re ‘sick.’ Do you mean that you’re nauseous or you’re having pain or you’re feeling weak?”
“No, none of that.”
The daughter in law then stood up next to the bed and firmly said that he “just doesn’t look right.”
That didn’t help me much, so I said “I’ve never seen him before, so I don’t know where to begin in finding out what is wrong. What about him doesn’t look right to you?”
She threw her arms up in the air and rolled her eyes. “What do you want me to say? He doesn’t look right.”
No, I didn’t grab his head, turn it to the right and say “There … problem solved.” I just stopped asking about his symptoms.
“OK, well how long has he not been looking right for?”
“Oh, it’s been a while now ….”

After about 15 minutes, I was able to determine that the patient was sleeping more than usual for anywhere between 3 days and a week, depending on who was answering my questions.

After I left the room, the nurse told me that the whole family was upset with me because I was being “difficult.”

So the questions I have for you all are the following:

1. If you’re in the medical field, and a patient/family provide you with a vague history, do you try to find out more information? If so, what approach do you use?
2. If you’re not in the medical field, how would you suggest that a health care provider respond to you if the information that you are giving them isn’t helping them figure out what may be wrong with you?

I think that these are questions that a lot of people would like to know, so please chime in below.

Thanks

Dear Diary

Wednesday, February 20th, 2013

I hate the movie Pitch Perfect. Actually I like the movie itself, but my kids won’t stop singing the frigging songs. I have heard the songs from that movie in my sleep for months now. The latest thing that my kids have taken to doing is re-enacting the “cup” scene where Anna Kendrick sings You’re Gonna Miss Me When I’m Gone using a cup. Before school in the morning, “you’re gonna miss me when I’m gone.” At night after dinner, it’s a chorus of “you’re gonna miss me when I’m gone.” Without a doubt I am NOT going to miss that damn song when it’s gone. I can’t take it any more. Ditto for Don’t You Forget About Me. My head hurts just thinking about the words.

When I try to go to sleep, then it’s the dogs’ turn. About half of the nights of the week our boxer snores … loudly. Most of the time Mrs. WhiteCoat will call her name and wake her up to stop the snoring. Sometimes, Mrs. WhiteCoat has to throw a slipper at her to wake her up. When that doesn’t work, she’s actually had to tip over the bed a couple of times to get the dog to wake up. Even that didn’t work last night. After being dumped out of bed, the dog woke up, climbed back into bed, and promptly started snoring again. By that time, I was awake and I was tired. So I sat up in bed and yelled like a dog … I barked at the top of my lungs for about five seconds. I think it roughly translated into “wake up and be quiet or I’m going to tie your ears in knots.” Our older dog sat bolt upright in his bed and was looking at me with his head cocked to the side. The boxer was doing a John Belushi imitation (forward to 0:30) spinning back and forth trying to see where the attack was coming from. One of the girls let out a scream from down the hall. I laid back down and then I couldn’t sleep because I was giggling to myself. But the snoring stopped.

Once Mrs. WhiteCoat went to sleep, she had bizarre dreams. In one dream she was trying to get into our oldest daughter’s room, but she couldn’t get the door open. So she broke the door in. It was freezing in the room. Our daughter was sitting on the bed and she could see her breath. “Come on, let’s go,” Mrs. WhiteCoat said. “I can’t move,” our daughter replied. So Mrs. WhiteCoat ran into the room and grabbed her, then headed for the door. The door closed and she opened it. While doing so, she bumped something behind her. She turned around. It was her carrying a laundry basket. Her mirror image dropped the laundry basket, pointed at our daughter, and said … “check her potassium level.” Then she woke up. And no, we didn’t check her potassium level. What are we going to put for the reason … vision in a whacked out dream told me to?

Almost back to normal after surgery. There’s still a bulge there and yes, it is the hernia. Just some postoperative swelling. Have to wait another week before I get back into normal activity. It’s strange not feeling the area pressing up against my pant leg like it used to. And after about six days I no longer feel like I have a weight tied to one of my “boys” … if you know what I mean. Still a little sore walking around, but I’ll get over it soon enough.

I was going to try some walking this week and slowly get back to running on the treadmill, but I can’t do that because Junior WhiteCoat and his friends had to watch some dumb YouTube clips where people were trying to launch themselves off of treadmills. Then they had to try it for themselves and busted the damn treadmill. They bent a roller and they bent the platform and the manufacturer doesn’t make either any longer. Fortunately, I anticipated someone in the house being a victim of dumbassery (Junior was the odds-on favorite) which is why I bought a cheap used treadmill instead of a fancy expensive new one. So said treadmill goes out to the curb this week and I have to look for another used model. Doubt I’ll be able to beat the $150 I paid for the last one, but we’ll see.

So back to the wall thing. I was trying to videotape what I was seeing as I pushed through the insulation. So I had a camera in one hand and a MagLite in the other hand. I used the MagLite to push away the insulation and something flittered in front of the light. I jumped back thinking “Holy second cousin, Batman.” But how could bats be in a wall? Don’t they like to hang? I pushed through the insulation again and a loose piece of insulation pulled off the edge. I found a crawl space behind our closet that I never knew existed. Like 6 or so feet deep, 4-5 feet tall and about 20 feet wide. Damn. It was like a varmint party room in there. On the floor between two rafters were a bunch of chewed up sunflower seeds. Then I stuck my camera in the area and recorded to see if anything was around. Nothing when I reviewed the movie. I put on some protective eyewear and stuck my head inside to look around. Up in the corner of one wall, something had chewed its way through the wall leading to the outside. I stuck a straightened coat hanger in there and went outside to see where the end came out. Couldn’t find it. Then I realized that our house has a brick exterior. More secret passages inside to be discovered.
We called the exterminator, but apparently no one deals with varmints. Only bugs and mice. That’s when hernia surgery stopped me from climbing around further.
The good news is that since I stuck the hanger in the hole, the scratching hasn’t been back, either. So either whatever it is either became pregnant and is hatching spawn to create a habitrail through the walls of our house or it got scared and moved on to another house. I’ve already decided that I’m going to open up the wall and put flypaper and mouse traps all over the place. So I don’t think that the mysterious scratch is of a flying variety. My guess is on a squirrel. We’ll find out next week, I suppose. Maybe I’ll even post a couple of pictures.

Mending

Thursday, February 14th, 2013

Surgery went uneventfully, I think. Don’t remember much of it because of the dang Versed.

While walking back to the outpatient surgery room, I never thought what big business surgeries are for hospitals. The outpatient surgery floor had a long curving hallway of identical rooms, one after another, all with freshly-made beds, blankets folded neatly on top of the beds, and patient belonging bags draped over the blankets. Walking by the rooms, it was almost like having the same picture flashed in front of my face over and over again.

After I got settled in the room and started watching the news on the flat screen TV in the room, a rapid-fire succession of people came in and out of the room … nurse, nurse anesthetist, anesthesiologist, OR nurse, then surgeon. I could hear them going from room to room and could hear them repeating similar information with other patients. Most common question was whether my pain was being controlled. Thanks, Press Ganey.

I didn’t even have time to flip through the news stations before I was being wheeled off to the operating room. Traveling down the hall I could see little vignettes of other patients waiting for surgery through the doorways to the patient rooms. An older lady with a priest standing at the head of the bed talking to family. Little girl watching TV with her parents. An older businessman with reading glasses flipping through pages of the Wall Street Journal.

I felt a tug on my IV line. The nurse anesthetist was walking beside the bed and had a syringe that she was twisting onto my IV line.
“I’m just going to give you a little Versed.”
Great.
I felt the rush of cold IV fluid running up the veins in my arm, but was still wide awake as we waited in line for the doors of the OR to swing open.
I thought to myself “I wonder how cold the OR will be this time.”

Then I heard my youngest daughter’s voice.
“Wait a minute,” I thought, “she’s supposed to be in school.”
Someone was rubbing my hand.
I opened my eyes and my beautiful wife was sitting next to me with a smirk on her face. Apparently I was being an unconscious smart ass and don’t remember a bit of it.
Damn Versed.
I asked her several times what the surgeon said. She told me several times but I didn’t remember. I do remember her telling me that she was going to text it to me so she’d stop having to tell me.
The surgeon apparently told my wife that the hernia was fairly large and I apparently kept remarking that wasn’t the hernia.
The nurse asked me if I would rather have some water or some juice after surgery and I asked for a double shot of tequila.
I’m sure my wife couldn’t wait to get me out of there.

So I’m back home and relaxing. Groin is sore. Kids are feeding me their unwanted Valentine’s candy. Hope to be up jogging tomorrow.

Thanks to my excellent surgeon for his expertise and to the hospital staff for their prompt and courteous care … and for putting up with all of the other wisecracks that my wife probably didn’t tell me about.

Dear Diary

Thursday, February 7th, 2013

Well, I thought we escaped it, but we didn’t. The past week has been full of emesis, diarrhea, and disinfectant spray. Just when we think that things are on the mend, someone else in the family starts having a stomach ache. The vomiting is the worst. When it starts out, it sounds like a loud belch … until you hear the progression of the sounds. Yeah. Too much information. But on a good note, I have seen that my kids are immune to boredom. They were able to watch the same episodes of Disney sit-coms a half dozen times and still got mad when I turned off the television.

I’ve cut back on my work hours a little which gives me some extra time to hang out with Mrs. WhiteCoat and the kids. Kind of fun taking a morning to walk through the mall or going to lunch and catching a matinee before the kids get home from school. In fact, I took about a 30% pay cut from previous years, but we’re happier than we were before, I get to see a lot of the kids’ events that I used to miss, and we pay a lot less in taxes.

Last weekend at one of my son’s wrestling matches, I had some mom from another team call me an asshole. Probably won’t be the last time. And I wasn’t even the one instigating.
Wrestling matches last 1:30 each round. There are three rounds per match. It was a team meet and my son’s team was just barely beating another team — whose parents were sitting in the bleachers right next to us. During one of the matches, their wrestler was getting beat and, while on the mat, he signaled the referee that he was hurt. The referee stops the match and the wrestler jumps off the mat and goes to get some water.
Several of our parents started yelling. Wrestlers aren’t allowed to take water breaks in the middle of matches. The opposing team’s parents started yelling at us. I kept my mouth shut.
Mom from their team: “You all can just shut up!”
Mom from our team: “You BETTER not be talking like that to my family.”
One of our team dads yells “Your kids get water breaks? Our kids don’t get water breaks. Is that in the rules somewhere?”
A loudmouth mom from the other team yells “Hey SHUT UP. He has ASTHMA.”
Then I just let out a spontaneous laugh. I wasn’t laughing at the kid’s medical problem. I just thought to myself that I’ve been doing it wrong all these years. I should just be giving patients drinks of water instead of steroids and albuterol for their asthma attacks.  What a dunce I am.
Loudmouth mom looks at me and yells “What are you laughing at, ASS-HOLE?”
Them’s fighting words, of course. But I kept my mouth shut. I just smirked at her, held my water bottle high in the air, and took a long swig. Mmmmm. Breathing better already.
The water didn’t help as their wrestler got pinned shortly after his water break ended. I had about a half dozen snarky comments that I wanted to blurt out at the mom, but I didn’t want to start a brawl in the stands. So I opted to have another long swig of water. Mmmmmm.

Next week I’m having another surgery … on Valentine’s Day no less. Hopefully not a big deal. Just getting a hernia repaired. I’ve been dealing with it for a while, but now it has gotten big enough that it hurts, so sometimes I have to put my hand in my pocket to push it back into place to stop it from aching. I gave a lecture last week and noticed that a couple of people were watching my hand in my pocket while I was talking. When people in the front row think I’m playing with myself, it’s time to get the problem fixed.
The surgeon agreed to do the procedure under local anesthesia, so hopefully I’ll be out in a few hours. Just have to remember to get Valentine’s gifts before the 14th this year.

(more…)

Open Mic Weekend

Saturday, February 2nd, 2013

theatre curtainJust in case anyone was wondering what happened to Open Mic Weekends …

If you’re bored with the Super Bowl, you can post any medically-related comments, questions, or observations in the comments section. I’ll try to answer any questions on Monday or Tuesday.

As usual, the only rules for comments are that there are no personal attacks and that the comments/questions have to be medically-related.

Ancient Shaman Ritual

Thursday, January 17th, 2013

String on SignOn the way into my shift, I walked by a room and noticed that there was iodoform gauze packing hanging on the sign outside the room.

Why was it there?

Someone found it on the floor and put it there so no one would trip?
Ancient Shaman ritual to ward off evil spirits?
Secret code showing the surgeon where his patient had been waiting for the past 6 hours?

Nope.

Turns out that the patient had a gangrenous foot that strongly smelled like rotting flesh. The iodine from the gauze almost acted as a barrier to the smell spreading. When the patient first arrived, the odor reportedly wafted through the entire ED. By the time I arrived for my shift I only noticed the faint odor of iodine.

Of course curiosity got the best of me and I had to open the door to see how well the iodine gauze was working.
Gauze … great idea.
Opening the door … not so much.

Sappy Dog Pictures

Sunday, January 13th, 2013

Just a couple recent pictures of our dogs that made me smile (post title from the late great William the Coroner – he’s been gone for more than a year now)

Smoking a Cigar-bone Petting me.

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Picture my vocal cords

Saturday, January 5th, 2013

Dammit Shadowfax. Epiglottis picture You had to re-tweet the whole “taking pictures of your larynx with an iPhone” meme, didn’t you? Started with tweet by @traumagasdoc. Then @Shadowfax retweeted it. Then @maggiemay419 got involved.
I don’t have an iPhone. I upgraded to a Samsung Galaxy which is larger, so it’s a little more of a chore to jam the thing in the back of your mouth. The first time I tried it, my 6-year-old daughter looked at me and yelled “Mom! Dad’s eating his phooone!”

After a few dozen tries and several episodes of making myself retch, the best that I could do was a picture of my epiglottis. I angled the phone. I extended my neck. I pulled on my tongue, I used a spoon to push my tongue out of the way. No luck. Best picture is to the right. Tongue is at the bottom of the picture, epiglottis is in middle, trachea is dark area just out of view, back of my throat is at top of picture.

@traumagasdoc had a perfect picture. I’m convinced he is a Muppet.

Potential idea for an entrepreneur – create a detachable periscope-like mechanism that hooks onto the iPhone camera lens and can re-direct the iPhone’s LED light to use for video laryngoscopy using a smart phone. How cool would that be?

The WhiteCoat Year in Review

Thursday, January 3rd, 2013

I was going to post this yesterday but I got all fired up over the whole Press Ganey thing. Sorry about that.

What has happened in the past year?

My humble little blog has quite a few visitors over the past year. Depending on the source, last year I had between 700,000 and 780,000 unique visits and nearly 1.4 million page views. I just shake my head and say “dang.” That’s a lot of eyeballs. Hopefully that means we’ve been doing something right.

The most popular posts over the past year paralleled the top search terms leading people to this blog.
Ten times as many people linked directly to the home page of my blog than who linked to any specific article. Below are the next most popular posts in order of popularity.
Antibiotics More Harm Than Good For Strep Throat?
FDA: Zofran May Be DEADLY
**MEDICAL BLOG LINKS**
Ectoparasitosis
Doctor’s Work Notes and Medical Ethics
Treating Asthma on the Cheap
Amanda Trujillo
Narcotic “Allergies”
A Death Knell for Press Ganey?
Birdstrike also had several posts in the top 20. Not bad for a noob. ;-). Thanks for the contributions, brother.

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Dear Diary

Saturday, December 29th, 2012

The holidays have been eventful so far.

In the “I wish I had my camera ready” department: Driving down the main drag in town where all the stores are located. A man in Clifford the Big Red Dog outfit is walking up and down the street with a sign saying that puppies in the pet store on the corner are $100 off up until Christmas. At the stop light someone sticks his head out the passenger window and starts yelling at Clifford. Clifford keeps walking. Rolled down the window to hear what the guy in the car was saying and heard him yell “don’t buy there – they sell puppies from puppy mills!” Clifford drops the sign, spins around, and gives the motorist two front middle toes.

Went to a holiday party and was discussing the economy with a friend. Said that he was having problems with home life. His parents moved out of their house and are living with him in their spare bedroom. His adult son and his son’s fiancée are living in his basement. Another adult son dropped out of school and is living in his attic with a girlfriend. His quote was “I don’t have a home any more … I have a commune.”

One of our family members went to the big goldfish bowl in the sky on Christmas Day. The kids won a bunch of goldfish at an amusement park 5 years ago and the goldfish have been part of our family ever since. Flash started swimming upside down a few days before he died. The causes of upside down swimming are apparently related to a swimbladder problem in fish. We treated him with antibiotics for possible infection and gave him peas to combat possible “bloat” since peas are a laxative for fish. Despite antibiotics and peas, Flash died. He had a good life, though.

There are sooooo many people showing up in the emergency department over the holidays. Our hospital is packed. Of 26 beds in the emergency department, 19 were being used to board inpatients at one point during my last shift. Makes seeing patients a little more difficult when there’s nowhere to put them. Everyone in the waiting room is wearing masks because most patients are suffering from influenza-like illness. My informal survey of patients is that <10% of patients I treat for influenza symptoms have been immunized for influenza. Both the immunized patients on my last shift were elderly and had mild symptoms compared with their non-immunized counterparts.

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