that's DOCTOR sweetheart to you

Statuesque

2007-06-30T22:47:00.000-05:00

The patient's mother brought her in to "rule out seizures". The patient was a 5 year old girl, singing, smiling, interactive. When asked why she was worried the girl was seizing, mom said, "She keeps telling me she feels like a statue." "Is she shaking? Staring into space?" "No," mom replied. "She says she feels like a statue." I asked her if the child was still talking and moving when she was feeling like a statue. Indeed, she was. "Do you feel like a statue right now?" I asked. She answered in the affirmative with a nod of the head and a big smile. After a full neurological exam, which included watching her walk and skip around the Emergency Department, I told mom that I didn't think she was having seizures. "Then why does she say she feels like a statue?!" asked mom. "I think she's just being 5. She has an active imagination." Silence from mom. She clearly didn't believe me. I explained that a seizure workup is beyond the purview of the ED and offered to give her the name of a pediatric neurologist. She took the neurologist's name and when she gets to that office, I'm sure he'll wonder what kind of idiot ER doctor sent her.

If it ain't broke...

2007-05-14T13:21:00.000-05:00

OK, so this lady came into the department with a cough and shortness of breath. According to her, she just needed antibiotics and a sleeping pill. According to me, she was wheezing. She had no history of asthma, so I decided to give her some nebulizer treatments and get a chest x-ray. When the nurse went to get her for an x-ray, the patient told the nurse that she didn't need one, because she knew her chest wasn't broken. Honest and true.

Ranting

2007-05-14T13:01:00.000-05:00

There was a story in the Palm Beach Post the other day about senior citizens buying a quick-access card for emergency medical care as part of their condo dues. http://www.palmbeachpost.com/localnews/content/local_news/epaper/2007/05/12/s1a_ER_CONDOS_0512.html

The article states that by showing the card on arrival to the emergency department, a patient will have his or her care expedited. This is the kind of idea that makes Emergency Physicians cringe. In the Emergency Department, no one is supposed to get special treatment. As patients come in, they are seen by a triage nurse and assigned a severity score. The sickest people go first. As they should. People who aren't having an emergency should go to their doctors' offices. But they don't. I have been chewed out by someone with an ankle sprain for a delay in care that was due to another patient's life-threatening condition. I asked him if he would want his grandmother to wait if she were dying and he said, "She should, if I was here first!" Poor grandma.

The underlying problem seems to be the misuse of the Emergency Department for problems other than emergencies. Here are a few advertising slogans I have come up with for the ED:

The VIP Lounge- Are you too important to make an appointment? Come down to the hospital and throw your considerable weight around.

The My-Doctor-Won't-Refill-My-Percocet-Room- Is your doctor blaming YOU for your addiction to narcotics? Go to a doctor who doesn't know you! Then threaten a lawsuit!

Chez Chronic Condition- Are you sick of your chronic abdominal pain? Is a life of bad decisions catching up with you? Come to the ED and kvetch!

The Sick-to-death Room- Have you seen every specialist there is for your numb toe and everyone says you're fine? Do you KNOW you need an MRI but no one will order it? Come to the Emergency Department and use the secret passwords: "I just can't take it any more".

All's well that ends well...

2007-05-04T13:37:00.000-05:00

When people hear that I'm an emergency physician, they inevitably ask, "What's the grossest thing you've seen in the ER?" It's a fair question, but what grosses out the average person doesn't bother me at all. I love to open abscesses because of the feeling of satisfaction that comes with each milliliter of pus that pours out. The awful smell just enhances my joy. But now, I have the greatest gross story ever!

Last week, the local police did a raid on a known drug house. Three of the inhabitants thereof surrendered immediately, but the fourth, who later became my patient, barricaded himself into a bedroom. The SWAT team was called in (a little overkill if you ask me) and they broke down the door. Upon entering the room, the police observed future-patient swallowing several packets of cocaine. They brought him to me for "medical clearance" for incarceration.

Let me clarify "medical clearance". A few years ago a local police district had a man die in custody. It was discovered that he had been highly intoxicated and likely choked to death on his own vomit without anyone noticing. Since then, all suspects who are apprehended are brought to the ED for medical clearance. This supposedly takes any responsibility for the patient's welfare off of the police and shifts it squarely on to my shoulders. I even have to see people with no complaints! What am I clearing? I haven't the foggiest.

However, this was a legitimate clearance issue. If the cocaine packets burst inside future-patient-now-current-patient's intestines, he would die very quickly. The patient was also completely crazed on cocaine. He was brought in with his hands cuffed behind his back, screaming obscenities, fighting with everyone, wearing a layer of cocaine powder around his lips (think Dave Chapelle's drug addict sketch). He freely admitted to using "crack, percocet, xanax, and cough syrup with codeine". When I asked about heroin, he got very defensive and told me, "Hell no! I'm a man of god!" We all have our criteria. In any case, it was obvious to me that this man was not going to cooperate with the flushing out of the cocaine packets and wasn't in a mental state to make coherent decisions. His heart rate was 160 and his blood pressure was through the roof. His veins bulged out of his forehead. We gave him some powerful sedatives and he soon conked out. A tube was inserted through his nose into his stomach. We administed what is called "go-lytely", which is an agent that cleans out your intestines really fast. People take it the night before a colonoscopy to give the doctor a squeaky-clean view.

Two hours later, he still hadn't pooped. I listened to his abdomen, which sounded like a volcano getting ready to erupt. The nurse kept checking to see if he had gone. About an hour later, the nurse checked the patient's bottom and saw something sticking out of his rectum. This brave nurse pulled out the object and found himself holding a little baggie with a bunch of money rolled up in it. What a good place to hide your cash! I have always used a wallet but am reconsidering. The nurse had little time to celebrate, though, because he had taken the proverbial finger out of the dyke, and poop flew everywhere! It was all over everything and everyone. And THAT is the grossest thing I've ever seen.

Physician, heal thyself

2007-05-03T07:41:00.000-05:00

It's been a while, I'm aware. Sometimes, doctors are patients, which is what happened to me. And being a patient really sucks. I've always known that I prefer to be wearing the white coat rather than the blue gown, but until I spent a few years in the gown, I didn't really know how it felt.
Delivering bad news is something I do nearly every day. Hearing bad news is relatively new to me, but I've become an expert. And what I've learned is that it isn't really what you say, it's how you say it. The tone of voice is so important. I wanted to know that my doctors were really sorry things weren't turning out well. They seemed as surprised and as sad as I was. And while that didn't give me the outcome I was seeking, it made me feel so much better.
I'm an emotions-on-my-sleeve kind of gal, but have often felt like I have to hold it in when interacting with patients and their families. Now, I don't hold back as much. I let them know how sad I am for them. And even though I can't change the situation, they feel just a little bit better.

Some weird stories

2007-01-22T20:19:00.000-05:00

First of all, I was hit by a patient on my last shift. I'd never been hit before. Spit on- yes. Groped- yes. Cursed at- daily. But no patient has ever intentionally raised a hand to me. This woman was bipolar and out of control. We try our best not to sedate or restrain patients in the Emergency Department if we can redirect them verbally. This woman tried to escape, but did not have the capacity to make decisions for herself. I stopped her and put a hand on her shoulder to try to guide her back to her stretcher. She raised her hand a smacked me. It was only on the arm and it only stung for a few minutes, but I was shaken. For her safety and the safety of the staff (me included!), we gave her some powerful sedative medication. I went to check on her later and she looked at me and said, "I'm sorry." I don't think she knew what she was apologizing for, but she did know that she had done something inappropriate. The mind does amazing things.

Next, the goofiest statement of the week. From a woman who had complaints from her head to her toes. When I asked which thing specifically brought her to the Emergency Department, she of course replied, "all of them". In any case, I was asking my usual list of questions, which includes an allergy history. "Well, I used to be allergic to ketchup, but since they took out my fibroids, I can eat it." What?!?! Is this one of those scientology things?

Last is my "I can't believe the lives that people lead" moment of the week. I attended to a young man, about 25 years old, who was brought by the police to be examined before going to jail. He was in handcuffs and had some dried blood in his mouth. He said that the police had beaten his head against the ground nine times and that he had lost consciousness. He seemed a little out of it, so I decided that he needed a CT scan of his head. During my questioning, he revealed that although he is on a powerful heroin-antagonist, he still used IV heroin, his last use being that morning. "Doc, while I'm here, can you look at my arms? I think I have some infections." He sure did. "Do you skin pop?" I asked. "No, I just have bad aim." He asked for a drink of water and I told him that I didn't want him to drink anything until he had his head scan. He was furious. "You could have blood in your brain, which could kill you," I said. He looked at me and said, "Maam, I use heroin every day. I could die at any minute. A little bit of blood in my head doesn't scare me. If I die, I die." There was no answer to that. Before I could get him some water, he agreed to have the scan. It looked fine.

It's not a tumor

2007-01-12T19:51:00.000-05:00

Unfortunately, it was. Today I had to tell two patients and their families that they had brain tumors. It is so uncommon to even have one patient with a brain tumor that two kind of overwhelmed me. Both patients were stoic, but their spouses started to cry. It's not necessarily a death sentence, but there is just no good way to tell someone that he/she has cancer in the brain. One patient presented with 2 weeks of worsening memory loss and difficulty word-finding. The other had a change in her mental status. We thought she was on drugs. She wasn't. She had two tumors in her head that were pushing against the other side of her brain. It had been going on for a few weeks and her family doctor told her she had a "complicated migraine". I don't have the benefit of knowing these people. This is the first time I'm meeting them and I have to give them life-changing news. I used to cry with them, but have developed some coping skills in order to keep my sanity. But coping skills aren't enough for these two patients.

0 for 6

2007-01-07T18:40:00.000-05:00

It was one of those weeks- I couldn't figure out what was wrong with anybody, it seemed! In one shift, I had four different patients with abdominal pain and none of them had any objective signs of disease. Normal blood tests, CT scans, urinalysis. Even their exams and stories were inconsistent. One of the things I like most about medicine is the search for the right answer. The clues are often hidden, poorly expressed or both. I get such a sense of satisfaction when I figure something out. But not figuring it out is so annoying. One young man had right lower quadrant pain, which made me suspicious for appendicitis. His pain had been there for four days. He had told the triage nurse that his pain was in his left upper quadrant, diagonal from where he told me it was. I treated his pain and ordered some tests. They were all normal and his pain kept coming back. I sent him home. I still don't know what was wrong with him. A teenaged girl came in with right sided chest pain that brought her to tears. Her mother insisted that her right neck was swollen. Her exam was essentially normal. She had no risk factors for a pulmonary embolus (blood clot in the lungs), but I did a CT scan of her neck and chest to make sure. Needless to say, they were negative. When I went back to tell her, the pain had completely resolved and her breathing was unlabored. What was it? I have no idea.

Grandma got run over by a reindeer

2006-12-29T09:09:00.000-05:00

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!

2006-12-17T14:41:00.000-05:00

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

2006-12-17T14:33:00.000-05:00

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

2006-12-10T05:06:00.000-05:00

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?

2006-12-05T10:42:00.000-05:00

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

2006-12-03T17:47:00.000-05:00

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

2006-11-28T16:37:00.000-05:00

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

2006-11-23T12:59:00.000-05:00

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

2006-11-19T16:39:00.000-05:00

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

2006-11-19T16:30:00.000-05:00

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...

2006-11-17T14:41:00.000-05:00

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!

2006-11-17T14:23:00.000-05:00

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".