Grandma got run over by a reindeer

One of my least favorite things about the holiday season is the grandma phenomenon. The grandkids live far away and only see her on Christmas and Easter. So it's been awhile. Did I mention she's 80 years old and in a nursing home? So the family gets together for Christmas and the grandkids realize that grandma's old! "Grandma doesn't look so hot, does she?" " Grandma, you look so much older than last time I saw you (8 months ago)! We had better get you to the hospital!"

I have no problems seeing Grandma and even running what are likely unnecessary tests to make everyone happy. Chances are, grandma is a little bit dehydrated. Aren't we all? But if grandma has no complaints, I don't want to keep her in the hospital. And the family usually wants me to. "Can't you find a reason to admit her?" I try to explain the risks of hospital-acquired infections and deconditioning on someone who really isn't sick, but it is rarely successful. The families usually refuse to take grandma home, so what can I do? They feel better because they swooped in to rescue this poor old lady and now they can relax and enjoy the rest of Christmas without the shadow of the woman they once knew sitting quietly in the corner.

Holiday cheer!

I told my husband that I am responsible for baking a treat for our annual holiday party, held during the shift on Christmas Eve day (12/24). Because it's an Emergency Department, there is no time that everyone can be off, and there always needs to be a crew working the holidays. He reminded me of the first time he visited for an on-shift party. It was my birthday, I was working, and the nurses had a surprise party for me in our back room. They called my husband and invited him to come. There were sandwiches, salads, chips, cookies and a cake. They had decorated the room as much as they could. It was so sweet. We were all chowing down when my husband came in. Now, he loves to eat, but had a hard time. We don't have a bunch of extra tables in the ED, so we set everything up on gurneys. With tablecloths of course! It doesn't bother me at all to eat food from a stretcher where someone may have had a boil lanced, a pelvic exam or CPR, but apparently, some people are squeamish!

There but for fortune

Despite my usual ranting about my patients' ridiculousness, I usually just feel bad for them. Some of them lead lives I can't even imagine. And when I see their children, I get this feeling that they will be stuck in the same rut. I was so privileged growing up middle class with educated parents who expected a lot from me. So many of these kids have parents who are just kids themselves!

In any case, last week I had a "there but for fortune" patient. The medics brought in a forty year old woman as a "code" (meaning dead, basically). She had a history of drug use and depression and her boyfriend found her unresponsive in the house. Instead of calling 911, he decided she was just drunk and threw her in the shower. When that didn't work, he called the medics, who found her in asystole (flatline). They decided to try to resuscitate her anyway, which never works from asystole. Anyway, they brought her in and one of the EMTs remarked, "We pulled a dead body from the basement of the same house last year around this time!" My god. It made me think about how lucky I am that I never got into alcohol or drugs and that I am married to a man who wouldn't assume that my blue, unresponsive, not breathing body was just intoxicated!! We were unsuccessful in reviving her. The boyfriend never showed up at the hospital and we couldn't get in touch with her mother. Like many of my patients, her emergency contact had a phone number listed, but it was out of service. We asked the police to look for the mom, but as of 7 hours later, when I left for the day, no one had come. Can you imagine dying in your own house and no one showing up? Horrific.

Sleepless

It's 5am and I've been awake for two hours obsessing about my patients. And that's one of the downsides of being an Emergency Physician- they're really not MY patients. Except for the few patients who routinely visit the ED, either because of lack of a family doctor or surplus of chronic diseases, most of the patients I see are unfamiliar to me. I don't have a file with each person's medical history, medications and allergies, and the patients often don't know their own information. We don't do the same kinds of testing from the ED that one can do from a primary care office. Most tests and procedures need to be scheduled ahead of time, but patients walk in with the expectation that anything they need done can be done right away. After all, it's a hospital. I saw one woman the other day who asked me if she could get a hysterectomy (which she pronounced hystamectomy) that day, since she was already there.

But back to why I can't sleep. I saw a patient the other day who had chronic nausea and had a fairly substantial workup for it. She was scheduled for a special test as an outpatient the next day, but called her doctor that morning and said she was still nauseaus. He told her to come to the ED to be admitted. I can't admit someone for nausea. To top it off, it was her third visit to the ED in 48 hours for the same thing. I never order this particular test that she was scheduled for. It's just not something that we order, since it is not an emergency test. But I called radiology and they were able to fit her in that morning. I was so proud of myself and felt like I was doing a real service for this woman. The test was read as normal. I called her doctor who asked about a specific portion of it. When I spoke to the radiologist, he told me that I had to order that other part specifically or they didn't do it, and that now it was too late. Now the patient and her specialist are furious at me. What can I do? She'll get it again as an outpatient like she should have the first time. But I hate when people are mad at me.

I've become less obsessive over the years of my practice, but I have many nights awake thinking about what I could have or should have done, despite the fact that it usually doesn't make any difference in patient outcome. I guess that the day I stop worrying, I should quit medicine, because I will have stopped caring.

Why are you here?

I'm sure I'm a pleasure to be with, but it still doesn't explain why some people choose to visit the Emergency Department. I find myself listening to patients' chief complaints and asking questions, eventually asking the biggie: But why are you here? Case in point- a man with end-stage AIDS came in to the ED by ambulance at 4am. Fever? No. Weakness? No. Vomiting? No. He couldn't sleep. He took a sleeping pill, but still couldn't sleep. And I found myself asking the question that I try to avoid, "But why are you here?" And when I say "here", I mean the Emergency Department. What is it that you want me to do? This is not an emergency. Most nights, I don't sleep. An inconvenience, yes. An annoyance, again yes. But an emergency? Most definitely not. I offered to hit him on the head with a frying pan.

Another patient came to the ED recently with two years of abdominal pain. TWO YEARS! She'd seen multiple specialists, had invasive procedures and surgery and still had pain. Nothing had changed. So why are you here???? She told me she "couldn't take it any more". Again, what did she want me to do? Amputate her...abdomen? Not something I'm credentialled for. But I offered any way.

There is no life-fixer-upper magic pill or injection in the emergency department, folks.

Anxiety attack

No one would argue with the statement that life is stressful. Money, relationships, health issues, all conspire together to make living a daily challenge. And I can understand feeling overwhelmed and anxious. I often feel that way! Insomnia, weight gain, snapping at my family- they are all manifestations of anxiety. But it would never occur to me to go to the hospital for it! Last week at work, a 21 year old man was practically carried in by his mother because he was having an anxiety attack, complete with hyperventilation, carpopedal spasm and crying. Carpopedal spasm is spasm of the hands and feel that occurs when you hyperventilate. Breathing too fast upsets the balance of calcium in the muscle and the dominant muscle forces of the extremities clench. In any case, this 21 year old was sobbing. His chief complaint, according to his mother, was that "he gives his heart away too easily". He laid in the stretcher, covered in tears, with mucous pouring out of his nose. He couldn't get it together to use a kleenex, so his mommy sat by his bed and wiped his face. Now, I've had my heart broken, but it never occured to me that the hospital might fix it! What did they want that the emergency department could provide? Drugs? Couples counselling? I couldn't put him in the waiting room, because he was such a mess. So people who were actually sick, not just sad, waited for a bed, while he cried. As a naturally sympathetic person, I tried my best to make him feel better, but it was hard even for me. I did my best, but my instict was to shake him by the shoulders, look him in the eye, and tell him that life doesn't get any easier. We need to learn to deal with life's disappointments if we don't want our hands to be permanently stuck in spasm.

Anatomy lessons

I don't know how anatomy is taught in other countries, but in America it isn't taught at all outside of health profession schools. The average citizen doesn't know what a gallbladder does, much less where it lives. And this lack of fundamental knowledge of our own bodies makes us completely paranoid whenever we don't feel well. "Help! My lip is tingling! I think I'm having a stroke!" "Oh my god, I have back pain! I think my kidneys are failing!" That is actually one of my favorites. Everyone with back pain thinks it is kidney related. They also think that their kidneys reside just above the waist (which they don't). Ask them what their kidneys do and get a blank stare.

In any case, I picked up a chart to see a new patient and the chief complaint was "fatigue". In a 25 year old male without any medical history. I hate fatigue in young people. Guess what? I'm tired, too. And some days all I do is yawn and without coffee, I'm a danger on the road. But do I think it's a serious medical condition? No. I went to interview the patient, who was sitting up on the gurney talking animatedly to his girlfriend. When he spotted me, he flopped against the stretcher and moaned, "I don't feel good." Please. I tried to ask him some questions about his symptoms, but he would only give me one word answers. At that point, the girlfriend chimed in, "I want him tested for everything." "Everything?" I asked. "That's a lot. Can we narrow it down?" She rattled off the usual diabetes, high blood pressure, appendicitis (??) and then threw the big one at me. "I want him tested for cervical cancer." "Cervical cancer? I can't test him for that." "Why not?" she asked, angrily. "Because he doesn't have a cervix," I replied, trying to be polite. "How do you know he doesn't have one? You ain't even examined him yet!" She had me there.

Twisted

I feel pretty lame. One week into this blog and I've already skipped three days! Of course, I've been at the hospital, which, indirectly, is working on the blog.

I guess that's twisted logic, but it's one of the skills I've picked up from my patients. Often, I try to convince them that their bad habits are economically unsound, since the threats of lung cancer or cirrhosis of the liver don't seem to be deterrents. "Two packs a day? That's an expensive habit! Think of the money you could save by quitting! Ten bucks a day is $70 a week." I even do the math FOR them. But they one-up me and proudly show their financial wizardry. "It's ok, I save money by going out of state. It's not expensive at all!"

Then there was the young woman (26 years old, as I recall) who came in complaining of abdominal pain. When I told her that her pregnancy test was positive, she just groaned and said, "Again?!?" When asked how many times she had been pregnant, she said "at least twenty". I guess you start to lose track. She went on to say that she had two children and had aborted the rest, except for the "couple" of ectopics she'd had. I should have known better than to ask if she used any kind of birth control, but I asked. "No one will give me a tubal. I asked my doctor and he just won't do it." I just looked at her. "Have you tried not having sex?" The blank stare I received was answer enough.

Everyone's an expert

The patient in room 6 was a middle-aged male, a heavy smoker, who was complaining of chest pain and shortness of breath. We tend to take chest pain pretty seriously in the emergency department, as there is a zero tolerance policy for missing MIs (myocardial infarctions or heart attacks). Still, about 3% of people with an MI will be sent home from the ED. His EKG was ok, but his story was convincing. I had him on oxygen at 2L/min, but his oxygen saturation was still low. I turned it up to 4L/min. He looked at the regulator and told me that he was receiving too much oxygen. I explained that 4L was not an unusual amount of oxygen and that he needed it. He guffawed (really) and laid his hand on my arm, "No offense, ma'am, but I deliver medical equipment and I think I know how much oxygen is too much." How could I argue with those credentials?

TV star

Another humiliating experience last week. A patient's sister referred to me as Doogie Howser every time I entered the room. I just laughed at first, then toned it down to a smile, and finally told her that I was 40 years old, not 15 (in fact, I am neither 40 nor 15). "Well, you look like a little girl! Are you really a doctor?" It took all my strength not to say that I was a doctor who was prone to intubating and chemically paralyzing people who tease me.

As a resident, many years ago, I was suturing up a large laceration on the arm of a patient who was in police custody. He had sustained the injury when he attempted to climb a barbed-wire fence to avoid arrest. (Note to self- only climb smooth fences when running from the cops.) The patient's other arm was handcuffed to the stretcher, so the officer felt comfortable walking in and out of the room. He kept peering at my work and finally said, "Do you know what you're doing?" I assured him that I did. He walked out for a few minutes, came back in and said, "Are you sure you're doing that right?" Again, I answered yes. Ten minutes later, "Does that look right to you?" I laid down my suture materials and calmly said, "Everyone in this room who has graduated from medical school, raise your hand. It looks like I'm the only one, so we'll continue to do it my way." He didn't bother me again and the patient/prisoner couldn't stop grinning.

Let me call you sweetheart...

My experiences as a female physician are completely different from those of my male colleagues. This blog won't be completely about what it's like to be a girl doc, but the first few postings will. I am repeatedly called "baby", "sweetie", and "honey" by male patients. I can easily forgive these slights from older patients. After all, they were raised in an era when that was acceptable. But people my own age!?! I try to let it slide, but one 30 year old patient called me "sweetheart" one too many times. I asked him not to keep calling me that, but that only encouraged him. As I pulled on my glove to do a rectal exam, he said, "I don't really need that, do I sweetheart?" I just smiled, saying, "Lower your pants, and that's DOCTOR sweetheart to you."

Hey nurse!

While sitting at the nursing station in my emergency department one morning, I heard the patient in room 10 bellow out, "Hey nurse!" Not being a nurse, I continued what I was doing and waited for the nurse to see the patient. No one was answering him despite several rounds of "Hey nurse!" I looked over at room 10 and saw a giant man in nothing but a hospital gown. Said gown was dangling precariously and drenched in urine. He looked at me and repeated, "Hey nurse!" "I'm not your nurse, sir, I'm your doctor. What do you need?" I asked. He looked at me, shrugged his shoulders, and started again, "Hey lady doctor!" I've been "lady doctor" to those nurses ever since.

My medical school in upstate New York graduated its first female physician in the mid-1950's. Since then, the number of women in medicine has exploded. In fact, many major medical school graduating classes are now more than 50% women. Despite this, the public's perception is that women are nurses and men are doctors. It is not unusual for one of my Emergency Department patients to tell the nurse who is discharging them that they are angry that they have not seen a doctor during the visit. This despite the fact that I introduce myself as a physician and wear scrubs, a lab coat and an ID that all say "MD".