Archive for the ‘Random Thoughts’ Category
Wednesday, October 10th, 2012
Did you ever have one of those months where you had about a hundred things to write about, but you had no time to write about them? Yeah, that’s been me lately.
So where do I begin?
Just got back from the ACEP Scientific Assembly in Denver. Have another post about that later. So I’ll begin with the kids.
Lots of birthdays in the house this time of year. My middle daughter happened to be born on the same day as I was. By far my best birthday gift ever. One of the things that was at the top of her birthday wish list was an Orbeez Soothing Spa. The web site says that Orbeez are “wet and wacky, soft and squishy, fun and funky, bouncy and beautiful.” In reality, it’s more like some marketing genius has convinced 10-12 year old little girls that they need to come home and relax in a spa-like foot bath after a hard day at school. Us? We walked uphill both ways to school in bare feet over shards of broken glass and nobody batted an eye. Now, every kid who watches afternoon cartoons needs a foot bath. So, despite my better judgment, we got her Orbeez for her birthday. To activate these things, they must be soaked in water first. Then they go from a little pebble the size of a BB to a large squishy ball the size of a marble. once activated, then kids can put their feet into a foot spa so that they can have soothing relief or from a hard day at school. The problem is first of all that once the kids find out that these things can be squished, then you find squished Orbeez all over the house. Stepping in one unexpectedly in one’s bare feet is not pleasant. Apparently, the dogs don’t think that they taste very pleasant, either. After a few days, an odor began to waft through the house. Did Mrs. WhiteCoat just express the dogs’ anal glands? No. Did someone pour anchovy juice on a used sweatsock? Nope. It was the Orbeez foot bath. These superabsorbent polymers apparently absorb more than water.
Next year, I’m putting a loofah sponge and some moisturizer in an Orbeez box for her birthday present.
Mrs. WhiteCoat also had a birthday at the end of last month. I was going to get her more perfume, but I was scared off by all of these women in lab coats chasing me through the store. Then I noticed … the stores already have Christmas decorations. That’s just un-American. I am not buying anything from a store that has Christmas decorations up before November 1. It’s just the principle of the matter.
And if I see one Santa Claus looking all smiley at my kids before Thanksgiving, I am going to knee him in his jingle bells.
Tuesday, September 25th, 2012
This has happened twice to me, but I’m learning …
The first patient was several years ago. She came in with headaches. Her blood pressure was 220/110. The headache wasn’t an issue. The patient hadn’t taken her blood pressure medications that day and had a history of headaches. There was no change from prior headaches. We gave her pain medications, gave her the dose of clonidine she was supposed to be taking, and she felt better. Her repeat blood pressure was 176/96. I told her that she really needed to take her medications every day and that she could follow up with her family doc later that week for a blood pressure recheck. Then I discharged her.
Forty five minutes later, she was still sitting in the room talking with the nursing supervisor.
Then the nursing supervisor asked me if I felt comfortable discharging the patient.
Yes, yes I did.
Wasn’t I concerned about her blood pressure and her headache?
No. Her blood pressure was improved to the point that she could be discharged and her headache had resolved. She was stable for discharge.
Afterwards, I saw the nursing supervisor make a phone call, then go back in the room, then leave.
I went back in and asked the patient if there was a problem.
“No, no problem. We’re leaving.”
Then the family member in the room said “We’re going to another hospital like the nurse said. Her blood pressure is much too high for her to be discharged.”
I asked them to wait a moment while I tracked down the nurse and the supervisor.
The nurse had finished her shift and left the building, and by the time I found the nursing supervisor, the patient had left.
Lots of meetings after that incident.
Then it’s deja vu all over again.
A patient comes in with the worst headache of his life. Those are the words he says to me as soon as I walk in the room. Never had headaches before, bent over to pick up garbage and headache began. Hasn’t let up in over 8 hours. Radiates into his neck.
I already know where this visit is heading.
He got three rounds of IV pain meds and his pain was still in the “severe” range.
We ordered an “unnecessary” CT scan. After all, it came back normal.
Then I go to explain the necessity of a lumbar puncture.
Fortunately for the patient, his mother in law was a nurse educator at the nursing school in town. He ran the case by her and she said that a lumbar puncture wasn’t appropriate since it wouldn’t tell us anything that we don’t already know.
I told him about pseudotumor cerebri and meningitis and the subarachnoid bleeding that CT scans sometimes don’t pick up.
The patient’s nurse then said that MRI will see the things that CT scan doesn’t … including bleeding.
So I go to one of the textbooks and copy one of the pages showing that CT scan is much better than MRI at picking up subarachnoid hemorrhage. I give a copy to the patient and to the nurse. Her response was that I was being “vindictive.”
At that point, I threw up my hands. I told the patient that if he didn’t want the test, I’d be forced to admit him to the hospital for monitoring. If he didn’t want that, he’d need to leave AMA. I told him my concerns with him doing so and asked him to come and get me if there were any other questions.
Twenty minutes later, the patient told me that he decided to go against the advice of his nurse educator and his nurse and he reluctantly agreed to the lumbar puncture.
His pressures were on the high side, but normal.
Cell counts … one WBC. Three RBCs.
“See,” the nurse said, “no blood.”
However, the CSF protein was twice normal.
“So what do you think of the protein, then?”
“You’re the doctor. That’s why you get paid the big bucks.”
Now the differential diagnosis of elevated CSF protein is large and includes infections, tumors, abscesses, multiple sclerosis and bleeding. The problem was that acute severe pain isn’t a typical finding in tumors, abscesses, or MS and that it didn’t look like an infection based upon the CSF results.
I called the neurologist to discuss the case. She thought the patient had a small bleed and that the blood had broken down, causing the elevated protein levels. She recommended that the patient get an MRI/MRA.
So we were able to get the patient in for the test a couple of hours later and the patient ended up having a small dural tear. Oh yeah, he forgot to mention that he was in a car accident a couple of days earlier. Wasn’t having any pain from it, so didn’t’ think it mattered.
And the patient’s nurse reminded me that if I had just listened to her, I could have saved the patient a lot of time in the emergency department and he wouldn’t have had to go through cost and risk of a lumbar puncture.
It was then that I realized that the nurses are always right.
This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on WhiteCoat’s Call Room, please e-mail me.
Saturday, September 15th, 2012
It’s been about a month since the last open-mic weekend.
What’s on your mind?
All weekend everyone is welcome to post any medically-related comments, questions, observations in the comments section. Will try to answer any questions through the weekend.
Only rules are that there are no personal attacks and that the comments/questions are medically-related.
Have a safe and enjoyable weekend.
Wednesday, September 12th, 2012
Can you or an emergency physician that you work with win Nurse K’s coveted “Dr. No BS” award?
Check her blog to get rules and post your scores in the comments section or on her twitter account.
She includes science behind some of the scoring, as well.
Interesting in that some people in the comments section are already uncomfortable with some of the scoring. Have fun with it, don’t overanalyze it.
And if the contest makes you think about how you manage some patients in the ED, that’s probably a good thing.
Monday, September 10th, 2012
I’m not going to tag anyone else for this meme, but I liked the idea that Ramona Bates (Sutured for a Living and @rlbates) put out on her Twitter feed from Wing of Zock. Play along if you want and drop a comment in the comments section if you do. I’d like to read them.
Describe the three patients that had the greatest impact upon you and how they shaped your career as a physician.
Not exactly sure I can say how each of these patients shaped my career, but below are three of the patients who have had a large impact on me.
The first patient I ever saw in an emergency department as a student was probably what turned me on to emergency medicine. Before my emergency medicine rotation, I was pretty much set on going into orthopedic surgery.
It was kind of a crazy situation. Inner city emergency department. Patients stacked up in the hallways. People pushing me out of the way. Me getting lost. Where is the attending around this place? Then one patient on a bed in the corner caught my attention. She was yelling at another patient down the hall. He’d yell at her. She’d yell back at him.
Wednesday, September 5th, 2012
Not to interrupt the interesting discussion going about BirdStrike’s post regarding what a life is worth, but …
Kids are all back to school. It was funny watching three of them enter new schools this year. The video of Junior WhiteCoat trying five times to open his locker then getting mad when dad did it on the first try was priceless. The video of Mrs. WhiteCoat crying when youngest daughter got on the school bus for the first time and waved to us through the window was also priceless.
Speaking about crying … we went to see the movie “The Odd Life of Timothy Green“. Every one of the kids was bawling at the end. Apparently my kids weren’t the only ones. Critics seemed not to like the movie very much. I thought it was entertaining.
Speaking about movies … all the WhiteCoat kids are getting little movie roles lately, but they all seem to be horror flicks. Junior is going to audition for another one today. Funny that middle daughter is starring in a horror movie but if she tries to watch one, she freaks out and can’t sleep for the next week. Even talking about the plot of a horror movie makes her sick.
Speaking about getting sick … both dogs have some type of virus that the vet says is going around town. Vomit and diarrhea everywhere. Carpet cleaners must love it when this stuff happens.
By the way, if a dog vomits on the floor, licks it up, runs away when you call her name, vomits on the floor again, then licks up a little bit of it before being scooped up and carried outside in mid-heave, then vomits the same material again in the grass, does that count as one episode or three episodes of vomiting?
Mrs. WhiteCoat was upset because she thought I was letting the dogs eat their vomit. Initially, she was right. Why waste food, right? Then, after the second vomit, I realized that they would just walk around the house vomiting up the same food over and over again, leaving spots all over the carpet. That prompted a more urgent and concerted effort to get the dogs outside.
Then how pitiful is it when the dogs stare at you with those sad eyes when you’re eating dinner and they get a small serving of chicken and mashed potatoes on their plate because their stomachs are upset? Not even any gravy?
Here’s a sappy dog pic from before initiation of the exorcism. I’m just glad that whatever they have doesn’t get passed to humans.
Speaking about Mrs. WhiteCoat getting upset … we took our four kids and a few of their friends to a water park for the end of summer. Half-price. Can’t beat it. So afterwards, we go out to eat at a family restaurant before making the trip home. A gentleman in suspenders staggered in the restaurant, and while passing our table on the way to the bathroom, stopped and in his garbled speech says to Mrs. WhiteCoat “Hey, you don’t look too bad for being an OctoMom!” I had to look away. She says “there are SEVEN children at the table and THREE of them do not belong to us.” Mr. Suspenders says “Well you still don’t look too bad” and he staggered off to the bathroom.
My reminders that he was paying her a compliment and that “QuadraMom” just didn’t have the same ring were met with repeated evil stares.
In between my trips to the emergency department to rule out sepsis every time I go running or hit the gym (abnormal vital signs under Jim Dwyer sepsis criteria, you know), I’ve been kind of bogged down with work at my other job. Have lots of posts lined up, but just not enough time to get them out of my head and onto the computer screen.
But I’ve been labeled as an idiot overtester by a nursing school professor who consulted on a family member in the emergency department, and comments on this blog have been cited as an example of how all medical professionals are “fat haters”.
Should be back to blogging about these and other subjects after attending a conference tomorrow.
Friday, August 31st, 2012
If you’re an EMT, don’t start lecturing me in front of the patient you just brought in about how she was involved in a “motor vehicle collision” and not a “motor vehicle accident.” I was half joking when I asked you if you meant that she was in a motor vehicle “accident” when she rolled her car in a ditch. Your dissertation about the difference between accidents and collisions afterwards … you aren’t going to win that one.
Unless your patient was in a demolition derby or intentionally ran into another vehicle (which I haven’t seen in 15 years), the wreck was an “accident.” We’ve been using the same terminology for decades. It serves us well. We don’t need to change it.
Yes, in most cases, patients are brought to the emergency department because two vehicles “collide.” So technically, most MVAs are also “collisions.” But what about the rollover that your patient was involved in? What did her vehicle “collide” with? And if a vehicle runs into a ditch before coming to a stop on the other side of the ditch, did it really “collide” with the ditch? Collisions are usually considered a contact between two moving bodies.
I’m also aware of the old argument by “traumatologists” that motor vehicle accidents should be called motor vehicle “crashes” because most fatal crashes are caused by speeding, intoxicated, or distracted drivers, so they shouldn’t be considered “accidents.”
If you want to go all brainiac on me and use the scientific definition of “collision,” then perhaps cars do “collide” with ditches. They also collide with gravel when they’re rolling down a gravel road and I suppose that their tires even collide with the asphalt when they’re driving down the street. So if we’re going to use the scientific definition of “collision,” we probably should use it consistently.
Somehow, the following inbound report, although scientifically proper, just doesn’t work: “the car was colliding on the street asphalt when it collided less frequently with the street at a stop sign and subsequently another vehicle that wasn’t able to collide with the street at the same rate of deceleration accidentally collided with the vehicle in the rear, causing the patient’s shoulder to collide with the seat belt and the patient’s face and upper torso to collide with the air bag.”
Can’t we just agree that the report should be something like “a restrained driver was rear-ended in an MVA with air bag deployment”?
And if you give me an inbound report saying that you’re “en route to your emergency room with a patient who is A and O times four who was involved in a motor vehicle collision and has a low grade fever of 99.1″ … well … let’s just not go there.
Oh, and you left the engine running in your patient transport vehicle.
Why do we call it an “ambulance”, anyway?
Tuesday, August 14th, 2012
I’ve got a question for all you pharmacists and other experts out there.
Is there some scientific basis why we laBEL mEDIcatION BoTtLeS liKE We’RE COMPuter HACKers?
The practice appears to me to be more commonplace, so I tried to find some scientific studies demonstrating its effectiveness.
While several articles show “tall man” lettering may improve drug name recognition, I was only able to find a reference to one “technical report” from Grasha et al. from 2000 that purportedly demonstrated an actual decrease in medication errors by capitalizing dissimilar parts of similar medication names. I wasn’t able to find any clinical studies demonstrating that the hacker labeling actually decreased medication errors.
If people who administer medications don’t know that 1000 phenytoin equivalents of “CereBYX” solution are given for seizures, that 20 mg CelEXA tablets are used for treating depression, and that 100 mg “CeleBREX” pills help alleviate arthritis pain, then they shouldn’t be administering medications. Similar concept to the MS04 and MgSo4 argument from years ago.
Is there other research showing improved safety of “tall man lettering” in clinical practice? If so, it should be widely disseminated.
If not, why are we basing the national standard for medication labels on a single “technical report”?
How do we know that writing names in this manner doesn’t cause more medication errors without performing double blind studies?
At some point, I think that “alarm fatigue” is going to set in and that “tall man” lettering is going to be used so much that medical providers will be conditioned to ignore the lettering completely.
Saturday, August 4th, 2012
Sent from a reader …
Because stool obviously transmogrifies as it exits the rectum.
Stool contained on the end of one’s finger after performing a rectal exam and then transferred to a hemoccult card causes hemoccult cards to give wrong readings and therefore the results “may not be accurate.”
However, stool that is plopped in the toilet, mixed with water, possibly urine, and whatever else is growing in the toilet bowl … no problemo. Definitely accurate.
This “results may not be accurate” disclaimer is reportedly added to every stool sample the hospital reports because the hemoccult card manufacturer said that the cards are only to be used for “formed stool”. Not sure how the lab tests to determine whether the sample is “formed” or is “diarrhea,” but I’m not a lab technician. Perhaps they test the moisture content of the sample prior to actually applying the requisite number of drops of hemoccult developer.
The hospital also reportedly had an entire committee meeting where multiple educated professionals and administrators thought it was appropriate to include the “results may not be accurate” disclaimer given the manufacturer’s guidelines.
That then begs the question that if the stool results “may not be accurate,” then why is the hospital reporting on the results at all?
I’m sure that a fear of liability for not following the manufacturer guidelines in using the product had nothing to do with the committee decision, either.
Sunday, July 29th, 2012
There has been a lot of “spinning” of the tragic shooting that occurred in Colorado last week.
More guns. Less guns. Democratic policy issues. Republican policy issues.
I’m going to try not to add my spin to the mix, but I do want to raise one issue for everyone to consider.
As this event unfolded, there were many stories about how there were delays in EMS response and how police were “pleading” for ambulances to get to the scene. You can read about the issues involved at the link.
The point I want everyone to think about is the importance of emergency medical services.
I regularly post about hospitals closing their emergency departments. US cities have lost 30% of their emergency departments in the past 20 years. Earlier this week I posted an article about some “expert” in England who believed care would be improved by closing emergency departments and consolidating care.
There are many issues that influence the availability of emergency medical care which I am not going to list at this point to avoid trying to “spin” the issue. You all can debate them in the comments section if you’d like.
Just consider that when a mass casualty event occurs in the future … whether it is a natural disaster, a fire, large motor vehicle accident, a shooting, or an act of war … do we really want to make emergency medical care harder to access?
Few people appreciate the importance of emergency medical services until they are the ones having an emergency.