Tuesday, August 24, 2010

Liar, Liar

We have been seeing a young man with escalating frequency for several years for breakthrough migraines; he is always brought in by his father, who is aggressive and impatient. He berates the staff if his darling boy has to wait his turn or is not seen ahead of chest paineurs, individuals with difficulty breathing or other mundane complaints such as diabetic emergencies. The kid is polite but suffers from the father's bad behavior; Daddy is a doorway-leaner and hallway stalker, frequently interrupting us by demanding to see the doctor and telling us how much pain the kid is having. Therefore,we keep them in the waiting room, bringing them to a treatment room at the last minute when we are sure the doctor is ready to see them, and not one minute before. The father has only himnself to blame.

I noticed that his visits in the last year were actually down; only 6 or 7 compared to the 22 visits the previous year. I realized that the kid had been away at college and his ER visits coincided with Winter, Spring and Summer breaks. Interesting, yes?

Demerol was the kids usual poison until we stopped stocking it. Now he gets one shot of morphine and is immediately sent home. Every case is different, of course, but this is how most of the frequent migraineurs are treated; they are told up front that we give them one shot, then it is out the door. It is their responsibility to follow up with their provider for definitive long-term management of their chronic problem. We have learned not to sit on these because it always turns into a tug of war. Give a shot of narcotic, wait 30 minutes (usually while they sleep), wake them up for vital signs, "pain still 20/10", start an IV, give them a liter of saline and more narcotics, etc, etc,. Generally after a couple of hours the docs will get tired of it, give them just one more med and send them home to sleep it off. An argument always ensues because their pain is not completely gone. This just sucks the life out us, drains our energy, and often our last remaing reserves of compassion. It is best for the patient and for us to be clear on what the patient can expect, disabusing them of the notion that what they want is not necessarily what they will get; this is especially important when the expectation is enough narcotics to easily tranquilize a bull moose.

On this particular day we were working with the Talker. He is a great doc; he loves to spend lots of quality time teaching. His sincerity and genuine caring is apparent; he does not automatically give the patient what they want and/or thinks they need, and is very patient with the Web MD self-diagnosticians. He does not automatically xray every boo boo that walks through the door, even though the patient expects it. He does a careful exam, and if the mechanism of injury does not warrant, he will not expose the patient to radiation needlessly just because they think they should have it. He spends lots of time talking about ibuprofen, ice, elevation, etc. He spends lots of time with his patients in general, and many ask if he has a private practice because he listens. I love to work with him because I always learn something new. Also, because his goal is always good medical care and not necessarily good customer service it makes me think a little before I just order patient tests before the patient is seen by the doc. Thinking, "What would the Talker do?" frequently guides my decisions; also common sense.

The young man with the migraine came in alone for this visit, which was really unusual. He was seen and examined promptly because 1) it wasn't busy and 2) his annoying father was not present. After the Talker spent about 15 minutes, the patient received morphine. He assured us that his father was in the car waiting, which was proven to be a lie since he was observed getting into the drivers side and driving off.

But he had left his wallet behind; a call to the boys home was answered by the father, who said the kid was at work. We told him that the Talker would like a word with his son when he had the chance.

Monday, August 23, 2010

Two Men Enter, One Man Leaves

Um, yeah. This was WAY too much drama me.

Man and woman, let's call them Dick and Jane, were brought in with relatively minor injuries from a car crash. They had been out drinking. Jane was driving. Jane was sufficiently toasted, wailing, "Where is my boyfriend Dick? Is Dick Ok? Why can't I see him? I'll kill myself if anything happens to him!"

Another man, let's call him Bob, came in looking for his wife; he had come across the wreckage of his wife's car, and was told by police that the driver had been taken to our ER. That would be Jane.

Of course, it was news to Bob that Jane had been out on a date instead of at the movies with girlfriends; needless to say the existence of Jane's boyfriend came as a complete surprise. Hearing Jane yelling drunkenly for her boyfriend was the tip off. Ooops. I was glad the police where there, even though we didn't need them.

I will say that Bob handled himself with aplomb; he never once raised his voice. He was dignified even though he must have been hurting terribly. I felt badly for him, but what can you say. He advised Jane that she was not welcome at home, and that he would contact her when she could pick up her things. Jane's response was to feign unconsciousness, if that is possible if you lack a conscience to begin with.

In my opinion he is well rid of her.

Friday, August 20, 2010

No Scabs Here

I had a phone message from some nursing agency calling for "nurses in all specialties" to work at a northwestern Mass. hospital for, get this, STRIKE coverage.

The offer included guaranteed 36 hours of pay, per diem, housing, travel, meal allowance, heck, probably even manicures and pedicures. My response?


Other than starvation (which,regretfully, wouldn't be happenin' anytime soon for me) there is not a single reason in the world that would entice me to cross a picket line. Not even for a million bucks.

Monday, August 9, 2010

Well, What DID you think was gonna happen?

Jay Leno had a rather amusing segment called "What Did You Think Was Going to Happen?". There was a video clip with a young man straddled between the front bumpers of two facing cars, with his, er, um...junk.... stationed directly over a lit bottle rocket. Predictably, the bottle rocket lodges in his jeans at Ground Zero; hilarious hijinks ensue. What Did You Think Was Going to Happen indeed.

I silently ask the same question of many of our ER patients. There is a great dearth of common sense out there. A vast wasteland devoid of both common sense and, frankly, any sense at all. Of course, the patient's own agenda frequently defies any kind of sense or even native intelligence. Many simply have no brains at all.

It never ceases to amaze me how frequently ignorance is eclipsed by galactic stupidity.

There is no cure for the common cold. Only bonedheads and the uninsured/free care/I'm never gonna pay my bill crowd anyway show up at the ER for antibiotics to cure said cold. Two nights in a row. One guy was seen twice in 24 hours because his pneumonia wasn't better after 1 dose of antibiotics; he wasn't worse, just not miraculously better. Dumbass.

As you know from previous posts, many days I feel like the Narcotics Elf who works with Dr. Santa Claus. We see the same people over and over and over. Sometimes they hit the right doc, sometimes they leave with nothing but their pud in their hands. These are the "Pitch 'til You Win" repeat offenders. One of our more routinely presenting frequent drug-seeking flyers has apparently pushed even Dr. Santa Claus over the edge.

She had been seen by Gil earlier in the day for her really bad (yawn) migraine. He went off the board and gave her Fioricet, which is an OK drug for migraines but which does absolutely nothing at all for someone who just wants their vicodin or percocet. "Vikes or perky Percs" as my colleague Kerry calls them.

Anyway, she sent in one of her frequent flier co-dependents to scout out which doc was working and was busted by Sheila, the secretary. "Oh", she said, "I just wanted to see if Dr. Santa Claus was here tonight; I thought I would just say hi". Sheila kicked her out and told her that she was trespassing unless she wanted to see the doctor. Riiiiight. Way to go Sheila, booting her out, quite rightly. Well, what did you think was going to happen?

Play along with me now as we delve into the world of
"What Did You THINK Was Gonna Happen?"

You may vote for the most stellar example.

1. For three months in a row, the same idiot has come to the ER requesting refills of his extensive list of psychiatric medicines. For three months in a row, we have refused. He couldn't seem to understand why the result was not different for month four.

2. One woman has refused to take her antihypertensives or antidiabetic meds in six months. She is five foot nothing and weighs over 300 pounds. She smokes about 2 packs of cigarettes a day; everytime she comes in she has grande mocha Frappucino and a charming new tatoo to show us. Is anybody shocked and appalled that her BP is Patent Pending/130? I certainly am not. She routinely refuses admission (and yes, we have had a psych eval done) and claims that with all of her other expenses she can't afford her meds. Maybe holding off on the tatoos and Frappucino's would help, but I doubt it.

3. One young man came in with back pain; I often look up the previous visits when the story doesn't quite match the way the patient behaves in triage. For example, they might whine about how tight the blood pressure cuff is when they are texting with 10/10 pain. Or, not realizing that we have a camera in several areas of the building, we often watch patients exit their vehicle and walk normally across the parking lot, only to turn on the drama once they hit the door. I never say anything though I often will comment to the doc that I had observed a normal gait before entering the department. Hence the "look up".

This particular young man has not been seen in about 10 months; prior to that he had been seen at least 8 times in two months with various pain related complaints. On the final visit, he was give a script for 15 Percocet by Dr. Santa Claus. The pharmacist called, concerned that the "1" had been changed to a "4", so it looked like Santa Claus had written him for 45 Percocet; it's just not done. Nor do we give out narcitic 'scripts with refills. With a different colored pen. The phamacist was instructed to tear the 'script up and advise the patient that tampering with prescriptions was against the law. Dr. Santa Claus was kind enough to document this fact in the patient's chart for future reference. He is lucky he was not arrested. You can imagine that the kid was pretty pissed that he did not get any narcotics this visit.

4. Here's one from the lazy EMS from my own town, who called on the land line to say that they were bringing a 23 year old who had taken an overdose of Zyprexa (used to treat schizophrenia and bipolar disorders). He had stable vital signs and seemed "OK". That was the report. Are you fucking kidding?

Um, no, you won't. For one thing, any overdose is presumed to be a suicidal attempt until proven otherwise, regardless if it was accidental, ESPECIALLY with a history of psychiatric issues. That means that the patient must be watched continuously to assure his safety until he is determinied to be safe. Or shipped off to inpatient treatment. That means a security watch, which we emphatically do not have. We also do not have any social workers available at our facility to do an evaluation. The physician instructed them to take the patient to the Mother Ship. Lazy, like I said, to presume to do otherwise.

5. We actually had a teenager come in with testicular pain, brought in by his father. This occurred after the teen had some physical contact with his girlfriend; apparently not enough. He was diagnosed with blue balls; Dr. Cripes said he had to give a little birds and bees lecture to the mortified teen. I thought the father should be the one who was mortified. Cripes was at a loss as to how to come up with a medical diagnosis for blue balls; Google to the rescue. It is called vasocongestion. Don't try this at home.

Saturday, August 7, 2010

Alaska Tails

Sherry is safely back from her annual back-country paddling trip in Alaska. You may recall that last year, she had a real problem being stalked by grizzlies. Her husband subsequently failed to keep his word by purchasing, and learning to use, the necessary weapon that would ensure their safety.

Fortunately it was a remarkably griz-free adventure this year; except for the last day.

Sherry and her husband are dropped off by a bush plane, paddle to a certain point and then rendezvous with the pilot at a pre-determined time and place. This year, because her husband was doing some type of observation for the Park Service they were given a satellite phone (and a Jr. Ranger badge). This would serve to be a fortunate happenstance.

At the end of their trip, Sherry and her husband Dick were awaiting pickup on the appointed day by a small float plane; a little pond was to be the landing area. Sherry told her story:

"The wind was blowing a gale, and there was quite a bit of chop on this pond; it was relentless. These float planes have to land precisely, otherwise they would tip over and crash. The pilot made three or four passes, and I knew he wasn't going to be able to land. Sure enough, he called us on the sat phone and said there was no way. He has to come from two hours away, so he said he would come back the following day, and for us to call him at 6:30 AM to let him know about the wind conditions".

"I didn't sleep all night. The wind kept howling, and I was concerned that we would be stuck another day. It was so bad we had the tent tied to the gear bags so it wouldn't blow away. Finally, just about 6:00 AM the wind died down. Dick called the pilot who said he would arrive about 9:00. I was relieved and settled back in to get a couple of hours nap at least".

"At about 8:30 I got up, and Dick and I packed up the tent. We were pretty much out of food, but had a couple of granola bars so we pulled them out to eat while we sat on the gear bags and deflated canoe to wait for our ride. That's when we saw it: a giant grizzly. It was down at the end of the pond eating a caribou. Dick and I kept our eyes on the bear, but he seemed pretty engrossed in his breakfast and didn't seem to notice us".

"About this time, the wind picked up again with a vengeance. Now I was nervous, as if I wasn't when I spotted the bear. Maybe 10 minutes later we spotted the plane. I was thinking we were in some pretty serious trouble if he couldn't land, because the wind was gusting."

"The pilot had to come in low, right over the bear in order to land, so I know he realized we had a serious situation. The bear was pretty pissed off about it, too, roaring and waving a paw at the plane. The pilot tried to land, twice, a third time, then a fourth; each time the bear was roaring. I really didn't think we were going to get out of there; I had no idea how much fuel was available to burn on failed landing attempts, so I was feeling pretty desperate by this time. All I could imagine was spending another night with this really angry bear in our back yard".

"Finally, there was a lull in the wind; I had a feeling that this was going to be the last attempt. The plane came in so low I thought it was going to hit the bear, who was definitely not happy. At this point,the bear did something really odd; it THREW the caribou at the plane! I have never seen this before, nor had the pilot.

"The plane landed safely, loaded us in and we were on our way. The bear retrieved the caribou and continued with his meal, paying no attention to us at all. It was a great trip, but boy, was I glad to get out of there".

We are all happy to have Sherry home safely, but the phrase "when caribou fly" has become our new favorite saying.

We saw 24 patients last night. This, in a 6 bed ER with two nurses and one doc. Plus, the doc was Gil. Lord love the guy, but he is a cautious soul and we had some sick patients. Plus at least 6 dental paineurs, of which two left because the wait was at least 90 minutes. Can you imagine?

The campers from the several overnight camps kept coming. I don't know, perhaps it is the first time in a year many of these kids have been outdoors; they have fractured fingers, been stung by bees/mosquitoes/ spiders and one camp hamster (a campster?). As my son used to say, "ham comes from a hamster".

One day a week we offer a free walk-in blood pressure clinic. Not too many people use it, maybe a dozen or so. But for some of these crusty Yankee old-timers, it is perhaps a day out; and free to boot. One of the cranky old ladies never remembers to bring in her little booklet, so she gets a new one every week. We give these out gratis; I envision her house with about 3,000 little booklets, each with one or two blood pressures written in it. I seriously doubt that her PCP ever sees these readings. Or anybody. She is a little ritualistic, needing to sit for at least 5 minutes to "settle", then another 5 minutes to rummage around for the booklet she does not have. Several minutes are expended in divesting "only the left arm!!" from about 4 sweaters. Finally, she will squint up at me suspiciously and ask me who I am, and if I am new. We go through this every week. After taking her blood pressure and writing it in the new booklet I have provided, and she clucks and mumbles and frets her way back into her clothing, she is out the door, pushing a walker sporting 4 tennis balls in the legs.

Having your triage area tied up for 20 minutes on a free service: priceless.

One woman came in who just wants me to check her O2 saturation. Why? "I just had an asthma attack and if the reading is normal I don't want to be seen".

OOOOOOOOOOkay. We offer a 15% discount on ER co-pays that are paid right away; we take major credit cards even. But, you can't collect on this type of time-wasting activity which included informing the patient to return if she stopped breathing. Or whatever.

New Cathy emerged from an extended visit with one patient. "Well, she wanted to know if I had found Jesus, and I couldn't get out of the room; any suggestions for next time?".

"As the token atheist at a Catholic hospital, I am perhaps the last one to ask; I could give you some talking points from my perspective, but I doubt it would go over well", I said drily.

Gil says, "That happened to me once; the patient was jumpig up and down, waving his arms and yelling, "Praise Jesus! Praise Jesus!", so I just started jumping up and down yelling "Praise Jesus!" too. Then security took over".

"My son suggested that this might be an effective way to deal with telemarketers; I can just imagine. 'Hello, I am calling from XX Loan Corporation, are you interested in refinancing your home?'. 'Why no, but have you found Jesus?'. Could work pretty well", I said.

The hits just kept on coming. One little guy, I don't know how he managed this, fell off his bike and cut the soft palate in his mouth pretty badly. The rubber grip on the handle bar was mostly worn away, exposing much of the hollow metal edge, which wound up piercing the roof of his mouth. He was so scared, but did OK. It could have been so much worse.

The Last Patient of the night (whom we finally saw about midnight) was actually having an anxiety episode. She insisted that it was "overactive kidneys". I was too tired to pursue that she perhaps meant "overactive adrenal gland" that is located ON the kidney. The adrenal gland produces cortisol, a hormone that is important for several body functions, such as blood pressure regulation and release of insulin; it is also released in increased amounts in response to stress. Also, it is responsible for anxiety reactions, which is pretty much a "flight or flight response" gone haywire. That is tonight's science lesson, class.

Ativan helped, and she left with happy adrenal glands.

Wednesday, August 4, 2010

Summer Stuff

It has been a hot month. Even here in the arctic tundra it has been over 100 degrees some days. It is so hot the face of the Old Man of the Mountain would have slid off by now, if it had not already done so.

I hate the heat, there is nothing about it I like unless I am floating in water with a frosty drink in my hand. Can't eat, can't sleep, have no energy to do anything. Plus I stick to my leather sofa.

Mary, my kayaking buddy won't even go paddling if the temperature is any higher than about 93 since she doesn't do well in the heat either. Now she is being treated for Lyme disease since she discovered that pesky bulls-eye rash after a couple of days of fever.

If you have pets, and they tend to be outdoors a lot, ticks are a part of life. If I have fallen behind with the tick treatment for Tina, I can pick 7 or 8 of them off at a sitting. Tina loves it when I check her for ticks...she gets the most marvelous massages.

So I really don't get why people come to the ER to get a tick removed...and we get a lot of them, sometimes 3 or 4 per night. And these are ticks that I could basically pull out on my own in triage...but I won't, now, will I? Everyone pretty much gets treated for Lyme anyway, just to make the visit worthwhile.

One young man was brought in by an aunt; I suspect he had some sort of developmental delay. He was spending the summer working in the area.

Auntie had just returned with her nephew from her PCP; he had diagnosed his rash as heat rash. While not a classic bulls eye rash, the aunt was unsatisfied, and insisted we test him for Lyme.

Sure, no problem; and based on some of his other symptoms, Lyme was not completely out in left field. We treated him for Lyme anyway, something the PCP had not done. Several days later, the test came back positive. The kid was already being treated and everyone was happy.

We also get a lot of 'spider bites', 'allergic reaction to bee stings', and bug bites in general.

One mother brought in a 2 year old with "hives"; turns out there were about 30 mosquito bites, the poor kid looked miserable. Discharge instructions included "keep child away from mosquitoes". Ri-i-i-ght.

A 17 year old was brought by EMS with allergic reaction to a hornet sting; hives, swelling, itchy mouth, and epinephrine administered prior to her arrival. THIS, people, is the kind of thing that you SHOULD call 911 for. We watched her for a couple of hours while we waited for a parent to arrive. Nice kid, beautiful girl. A pleasure to care for.

Once the hornet sting was squared away, we get a very "interesting" 18 year old girl who "passed out" (at least twice) while lying down in the car on the way back from the beach. Huh huh. Her boyfriend came racing into the ambulance bay door; I was on the phone with Kerry at the time who had forgotten to tell me something when she left. I hung up on her and never did get back to her. Anyway, boyfriend looked to be about 35; scruffy; tattooed, body pierced and about the same age as her father, who was equally scruffy in appearance.

The young lady walked into the ER, albeit leaning heavily on the boyfriend. She lay down on the stretcher and immediately closed her eyes and pretended to be unconscious; I really hate that. Please don't waste my time and make me dig my knuckle into your sternum. We kicked out the rest of the young lady's fan club, started an IV and drew the appropriate labs (as well as a pregnancy test), all of which were entirely normal, of course. She complained and moaned about the IV so much I pulled it out and handed her a glass of water and told her to drink; I had long since lost interest in this "interesting" patient.

It must have been the heat that caused the co-worker of an 18 year old to pick him up and hurl him into a wall; a metal edged dry-wall wall. He had a 4 inch gash on his scalp which was easily fixed with about 11 staples. Gil of course asked him if he wanted the police notified. He did not, in part because it was a misunderstanding. Also, he had gotten up after being tossed around like a bean bag and clocked his assailant, splitting his lip. Gil jinxed us by joking that we would probably get the split lip as a patient, which we did. He didn't offer much information about the incident.

Hot weather brings out the nut bags; 95 degree heat is sure to inspire individuals to go to the ER with maladies they have suffered from for, oh, say 2 years. Like swelling in the head that was diagnosed as an infected hair follicle. The long list of psychiatric meds should have been a tip-off.

Cathy was taking care of a patient with chest pain, left over from day shift. We were waiting for an in patient bed assignment; yeah, that's not such a quick process. The day shift reported that the lady was on 2 1/2 pages of meds (never a good sign), had fibromyalgia (yawn) and a "mystery illness" that nobody could figure out (read: crayzee woman with vague nonsensical symptoms). This was confirmed when Cathy took her temperature, and it was a shade under 98.6. "That is usually a sign that something is seriously wrong!", the woman exclaimed. Clearly, with a laundry list of medical issues and drugs, and the dreaded mystery illness, it should have come as no surprise that she would obsess over a non-issue such as that.

Cathy had some insight. "You know, I read an article that it is no longer politically correct to call anyone a hypochondriac; they are individuals with 'heightened symptom awareness'. I blame the Internet".

" I think that it is a lot of non-medical people thinking up stupid names for garden-variety crayzee", I observed.

Yeah, it's gonna be hot again tomorrow.