Due to the vagaries of the scheduling fairies, I haven't worked since 9/7 night shift. I will return to Nashoba on Monday and then will be working 11 out of 15 nights. Never volunteer to work the holidays. A and I are in Starbucks while our housekeepers are earning their Christmas bonus.
No fantasies today. I am anchored in the reality of the present. A has been home, sick with the flu this past week. She did get a flu shot but only 1 1/2 weeks ago. Word to the wise, get your flu shot in September. The immunization takes up to 6 weeks to reach maximal effectiveness.
I felt sad on Thursday night. I was not in attendance at the LGH ER Xmas party. Sally's pictures were a bitter sweet reminder of happier times. I don't miss the chaos of the LGH ER, just the many wonderful people who work there.
I wonder if Nashoba's Christmas eve will be decked with sick kids and depressed patients. My thoughts will be with our friends the H's who host an annual "Feast of the Seven Fish" on Christmas eve. I am sure that my buddy Scott will send a care package with A for my Christmas day meal.
The World's Oldest ER Doc loves Christmas. The music, the food, the lights, "White Christmas", "It's a Wonderful Life", the spirit of good will, all make for a joyous holiday season. I reminisced with my mother yesterday about my childhood holiday memories: playing dreidl with the rolls of pennies and nickels from my Grandpa; sharing the wonderful food prepared by our neighbors the Pace's; hoping for snow on Christmas morning: and knowing that my mother, not Santa filled my stocking on Christmas eve.
To my friends, readers and people of the blogosphere. Have a wonderful Christmas, a happy Chanukah, a Kwanzaa with joy, and to all a Happy, Healthy, and safe 2012.
Saturday, December 17, 2011
Saturday, December 10, 2011
Doc Quixote Part 4
Despite signs to the contrary, I am not delusional. I am aware of the current year. It is my choice to view the world from a unique perspective. The age of my corpus is not the same as the age of my animus. The chivalry of my hero Don Quixote serves as a guide for my writing.
My aged mother, the duenna Dulce, resides in a residence for the elderly. Her physical and mental frailties are commensurate with her advanced years. We sat together in the sun room yesterday and I shared a cine of her great grandchildren dancing. Her creased face shone with joy. She was her usual pleasantly confused self. Her worsening memory, she counts as an asset, as she says that she doesn't remember the bad times. When I arrived at the elder hostel, she insists that she must attend to her hair. Only when she has brushed and combed her snow white locks, does she feel ready to face the day.
The shallowness of youth was the weapon that wounded a cherished friend. A former health giver at the hospice on the Merrimack, this sharp witted, compassionate, and scarlet haired damsel was wounded by a knave. The seniorita was betrayed by one she loved. The cad violated the trust that binds a couple beyond the formalities of the church or the state. My friend's heart will heal. My fondest wish is that someone worthy of her love will enter her life.
On arriving at the Hospice of the River Valley on a recent night, my presence was urgently requested at the bedside of one who's breathing tube had become dislodged. I rushed to the unit of intensive care and beheld a person of considerable weight. The short, thick neck and low level of oxygen gave me pause. The learned anesthesiologist, S Rao Mallampati and his associates had developed a score that predicts the difficulty in passing a breathing tube into a patient. The most challenging airway would rate a 4 on this classification. The unfortunate sufferer in front of me was a 4. The one advantage of my advanced years, is the more than three decades of experience that resides in my mens. With the assistance of the excellent nurses and respiratory therapist, I was able to insert the needed airway. I returned to my work station in the accident ward. Minutes later, the UIC called to tell me that the collar that seals the airway had failed. Once more I attended to the penitant's bedside and using a long wand placed through the defective tube, I removed that damaged hose and passed a new (carefully checked) tube over the wand.
Most nights at the Hospice of the River Valley, the penitants that seek care are few and their needs, though urgent to they and their loved ones, are usually not a threat to life or limb. My boon companions in the accident ward, the nurses and clerks, and I stand ready to offer relief, and compassion to those in need.
My aged mother, the duenna Dulce, resides in a residence for the elderly. Her physical and mental frailties are commensurate with her advanced years. We sat together in the sun room yesterday and I shared a cine of her great grandchildren dancing. Her creased face shone with joy. She was her usual pleasantly confused self. Her worsening memory, she counts as an asset, as she says that she doesn't remember the bad times. When I arrived at the elder hostel, she insists that she must attend to her hair. Only when she has brushed and combed her snow white locks, does she feel ready to face the day.
The shallowness of youth was the weapon that wounded a cherished friend. A former health giver at the hospice on the Merrimack, this sharp witted, compassionate, and scarlet haired damsel was wounded by a knave. The seniorita was betrayed by one she loved. The cad violated the trust that binds a couple beyond the formalities of the church or the state. My friend's heart will heal. My fondest wish is that someone worthy of her love will enter her life.
On arriving at the Hospice of the River Valley on a recent night, my presence was urgently requested at the bedside of one who's breathing tube had become dislodged. I rushed to the unit of intensive care and beheld a person of considerable weight. The short, thick neck and low level of oxygen gave me pause. The learned anesthesiologist, S Rao Mallampati and his associates had developed a score that predicts the difficulty in passing a breathing tube into a patient. The most challenging airway would rate a 4 on this classification. The unfortunate sufferer in front of me was a 4. The one advantage of my advanced years, is the more than three decades of experience that resides in my mens. With the assistance of the excellent nurses and respiratory therapist, I was able to insert the needed airway. I returned to my work station in the accident ward. Minutes later, the UIC called to tell me that the collar that seals the airway had failed. Once more I attended to the penitant's bedside and using a long wand placed through the defective tube, I removed that damaged hose and passed a new (carefully checked) tube over the wand.
Most nights at the Hospice of the River Valley, the penitants that seek care are few and their needs, though urgent to they and their loved ones, are usually not a threat to life or limb. My boon companions in the accident ward, the nurses and clerks, and I stand ready to offer relief, and compassion to those in need.
Wednesday, October 5, 2011
Doc Quixote, Part 1
Hello, my name is Miguel Dulce Cervantes. I am a healer of bodies and souls. In the land of La Massachusetts, I reside with my wife, Dulcinea, and my faithful companion Magnus Panza. Some say that I am delusional. They are wrong. My visions are real, and I act as befits a knight of the Brotherhood. There are ogres, trolls, and malevolent giants in this land.
When it is time to battle the forces of evil, I don my armament. My raiment, maroon or blue blouse and pantaloons, keep me safe from the microbes and fluids that afflict and ooze from those in need of my care. My coat of white, bears my name and title for all to see. I hide from no one, friend or foe. Lights of complex design, machines that make images, hearing devices and my strong but sensitive fingers allow me to delve into my patients soma and psyche.
My last campaign endured for nigh three decades. I fought alongside brave and compassionate allies. Ultimately, I was defeated by the White Wizard and his coven. The lies and perfidity of these spawn of pergatory, drove me from the field of battle and nearly crushed my heart. Others were cast out by the Wizard and his hand maidens. Wounded, the survivors of the battle kept their spirits up and continued their good deeds at other hamlets in the land. My dear Esmirelda suffered greatly at the gnarled hands of the Great Witch. Esmirelda of the Mountains persevered. She faced famine and poverty but prevailed.
My advancing age has diminished my strength and stamina. My hands and heart remain commited to the cause. I will continue to tilt at the giants with my lance, even when others see only windmills. In the course of time, I shall share my adventures with you. Adios!
When it is time to battle the forces of evil, I don my armament. My raiment, maroon or blue blouse and pantaloons, keep me safe from the microbes and fluids that afflict and ooze from those in need of my care. My coat of white, bears my name and title for all to see. I hide from no one, friend or foe. Lights of complex design, machines that make images, hearing devices and my strong but sensitive fingers allow me to delve into my patients soma and psyche.
My last campaign endured for nigh three decades. I fought alongside brave and compassionate allies. Ultimately, I was defeated by the White Wizard and his coven. The lies and perfidity of these spawn of pergatory, drove me from the field of battle and nearly crushed my heart. Others were cast out by the Wizard and his hand maidens. Wounded, the survivors of the battle kept their spirits up and continued their good deeds at other hamlets in the land. My dear Esmirelda suffered greatly at the gnarled hands of the Great Witch. Esmirelda of the Mountains persevered. She faced famine and poverty but prevailed.
My advancing age has diminished my strength and stamina. My hands and heart remain commited to the cause. I will continue to tilt at the giants with my lance, even when others see only windmills. In the course of time, I shall share my adventures with you. Adios!
Thursday, September 29, 2011
Achoo 2
In prior blogs from 4/2010 and 9/2010, I bloviated as to the signs and symptoms of colds and respiratory allergies. Recently I have seen patients and coworkers who were not sure if they had a cold or "hay fever".
Colds are upper respiratory tract infections caused by rhinoviruses, coronaviruses and adenoviruses. An adult may average 2-4 colds per year; school aged children up to 12 colds per year. The cold virus enters one's body as an aerosol of viral particle (think sneezes), or by touching a surface that has been contaminated with a cold virus and then touching your eyes or nose. The symptoms of a cold (runny nose, sore throat, cough and low grade fever) lasts 7-10 days but may persist for as long as 3 weeks.
Allergies to plant pollens trigger the misery of seasonal allergic rhinitis. Red, itchy eyes, runny and/or congested nose are the most common symptoms. Post-nasal drip may trigger a cough, especially at night. Sinus pressure and pain may develop as the turbinates (fleshy masses in the nose) swell and block the outflow tracts of the sinuses.
The presence of a fever would indicate that one has a cold. Nasal mucous that is thick and yellow is more common with a cold. Allergic rhinitis usually produces watery, clear drainage. Allergy symptoms come on abruptly after exposure. Brushing the dog may release pollen that has settled on Fido's fur and achoo.
Seasonal allergies occur when the source of pollen or other offending allergen are in the atmosphere. My personal pollen poison is ragweed from August until the first frost. Colds may strike at any time of the year but are more common in the Northern Hemisphere from September to April.
Over the counter cold and allergy preparations are equally effective (ineffective) for colds and allergy symptoms. Allergic rhinitis and conjunctivitis have prescription remedies that are not appropriate and may worsen or prolong a cold. Steroid nasal sprays are very effective in treating allergic rhinitis. They diminish the IgE release of histamine by MAST cells and certain white blood cells.
The use of Neti pots, echinacea, zinc sprays and lozenges, large doses of vitamin C and a steaming bowl of chicken soup have all been recommended as treatments for colds. All are probably harmless and useless. At least the chicken soup tastes good.
The ER sees lots of patients suffering from the annoying symptoms of colds and allergies. The 24/7 availability and the lack of primary care providers contribute to this use of the ER for non urgent problems. The caring ER staff stand ready with boxes of tissues and lots of compassion to help differentiate the cause of your nasal symptoms and prescribe the correct treatment.
Colds are upper respiratory tract infections caused by rhinoviruses, coronaviruses and adenoviruses. An adult may average 2-4 colds per year; school aged children up to 12 colds per year. The cold virus enters one's body as an aerosol of viral particle (think sneezes), or by touching a surface that has been contaminated with a cold virus and then touching your eyes or nose. The symptoms of a cold (runny nose, sore throat, cough and low grade fever) lasts 7-10 days but may persist for as long as 3 weeks.
Allergies to plant pollens trigger the misery of seasonal allergic rhinitis. Red, itchy eyes, runny and/or congested nose are the most common symptoms. Post-nasal drip may trigger a cough, especially at night. Sinus pressure and pain may develop as the turbinates (fleshy masses in the nose) swell and block the outflow tracts of the sinuses.
The presence of a fever would indicate that one has a cold. Nasal mucous that is thick and yellow is more common with a cold. Allergic rhinitis usually produces watery, clear drainage. Allergy symptoms come on abruptly after exposure. Brushing the dog may release pollen that has settled on Fido's fur and achoo.
Seasonal allergies occur when the source of pollen or other offending allergen are in the atmosphere. My personal pollen poison is ragweed from August until the first frost. Colds may strike at any time of the year but are more common in the Northern Hemisphere from September to April.
Over the counter cold and allergy preparations are equally effective (ineffective) for colds and allergy symptoms. Allergic rhinitis and conjunctivitis have prescription remedies that are not appropriate and may worsen or prolong a cold. Steroid nasal sprays are very effective in treating allergic rhinitis. They diminish the IgE release of histamine by MAST cells and certain white blood cells.
The use of Neti pots, echinacea, zinc sprays and lozenges, large doses of vitamin C and a steaming bowl of chicken soup have all been recommended as treatments for colds. All are probably harmless and useless. At least the chicken soup tastes good.
The ER sees lots of patients suffering from the annoying symptoms of colds and allergies. The 24/7 availability and the lack of primary care providers contribute to this use of the ER for non urgent problems. The caring ER staff stand ready with boxes of tissues and lots of compassion to help differentiate the cause of your nasal symptoms and prescribe the correct treatment.
Monday, September 26, 2011
STRESS
Everyone is stressed. The economy tanking, global warming, government failing, spouses, kids, in-laws, bosses UGH!!!
Animals, including we humans, have mechanisms in place to deal with stress. The classic example of an acute stress is the big dog coming at you. Fight or flight response originates in the hypothalamus. This area at the base of the brain releases hormones that start the body's response to stress. The adrenal glands pump out adrenalin, aka epinephrine, and cortisol. Heart rate and respiratory rate increase, blood pressure rises. Glycogen stores in the liver and muscles begin to release glucose into the blood stream. The immune system, digestion, reproduction and growth processes are all suppressed. This is a necessary survival mechanism. The acute stress response was very helpful when our ancestors lived a perilous existence on the plains of Africa or when involved in the innumerable wars humans have fought.
The sympathetic nervous system is responsible to turn on the fight or flight reaction and the parasympathetic system tamps the reaction down.
When the stress response is triggered by a deadline at work, or being stuck in a traffic jam the effects on one's body are deleterious. When stress is chronic because we are always behind at work, stuck in traffic, or in a toxic relationship, the damage to our body is real and potentially lethal. Chronic stress with its waves of stress hormones leads to heart disease, sleep disorders, digestive problems, depression, memory impairment and even worsening of certain skin diseases.
Some people are more vulnerable to stress because of genetic or environmental factors. Anxiety disorder, panic attacks, and depression have genetic components. These mental health conditions prime the pump of the stress response. Children who are neglected and/or abused are also more likely to have severe and persistent stress responses. Events in one's life such as being the victim or witness to trauma may lead to PTSD (post-traumatic stress disorder). High pressure jobs (ER doc, nurse, PA, tech, secretary) often lead to chronic stress. Loneliness, and social isolation also contribute to chronic stress.
There are things one can do to mitigate stress, short of living in a cabin in northern Maine with your family. Eating a healthy diet (skip the fried twinkies), exercising regularly, and getting adequate sleep would be an effective antidote to our modern stressful world. Being in a happy relationship, and having friends and family to share one's life are also helpful. Having a sense of humor and practicing relaxation techniques (such as yoga, meditation, tai chi, or just listening to music) have all been shown to lower blood pressure and heart rate and decrease the levels of stress hormones in the blood.
My stress levels have diminished since I was forced to leave my job at The Hospital. My beloved wife and caring daughter had been encouraging me to leave The Hospital because of the stress. I would arrive for work and find angry, stressed patients who had been waiting up to 6 hours to be seen by a physician. My new job is low volume and low acuity. My patients don't have to wait to be treated. I am mostly stress free. Maybe my hair will change back to black.
Illegitimi non carborundum, don't let the bastards grind you down!
Animals, including we humans, have mechanisms in place to deal with stress. The classic example of an acute stress is the big dog coming at you. Fight or flight response originates in the hypothalamus. This area at the base of the brain releases hormones that start the body's response to stress. The adrenal glands pump out adrenalin, aka epinephrine, and cortisol. Heart rate and respiratory rate increase, blood pressure rises. Glycogen stores in the liver and muscles begin to release glucose into the blood stream. The immune system, digestion, reproduction and growth processes are all suppressed. This is a necessary survival mechanism. The acute stress response was very helpful when our ancestors lived a perilous existence on the plains of Africa or when involved in the innumerable wars humans have fought.
The sympathetic nervous system is responsible to turn on the fight or flight reaction and the parasympathetic system tamps the reaction down.
When the stress response is triggered by a deadline at work, or being stuck in a traffic jam the effects on one's body are deleterious. When stress is chronic because we are always behind at work, stuck in traffic, or in a toxic relationship, the damage to our body is real and potentially lethal. Chronic stress with its waves of stress hormones leads to heart disease, sleep disorders, digestive problems, depression, memory impairment and even worsening of certain skin diseases.
Some people are more vulnerable to stress because of genetic or environmental factors. Anxiety disorder, panic attacks, and depression have genetic components. These mental health conditions prime the pump of the stress response. Children who are neglected and/or abused are also more likely to have severe and persistent stress responses. Events in one's life such as being the victim or witness to trauma may lead to PTSD (post-traumatic stress disorder). High pressure jobs (ER doc, nurse, PA, tech, secretary) often lead to chronic stress. Loneliness, and social isolation also contribute to chronic stress.
There are things one can do to mitigate stress, short of living in a cabin in northern Maine with your family. Eating a healthy diet (skip the fried twinkies), exercising regularly, and getting adequate sleep would be an effective antidote to our modern stressful world. Being in a happy relationship, and having friends and family to share one's life are also helpful. Having a sense of humor and practicing relaxation techniques (such as yoga, meditation, tai chi, or just listening to music) have all been shown to lower blood pressure and heart rate and decrease the levels of stress hormones in the blood.
My stress levels have diminished since I was forced to leave my job at The Hospital. My beloved wife and caring daughter had been encouraging me to leave The Hospital because of the stress. I would arrive for work and find angry, stressed patients who had been waiting up to 6 hours to be seen by a physician. My new job is low volume and low acuity. My patients don't have to wait to be treated. I am mostly stress free. Maybe my hair will change back to black.
Illegitimi non carborundum, don't let the bastards grind you down!
Saturday, August 27, 2011
Hype
All Irene, all the time. Hype. Snow storm, hurricane, heat wave; local news stations love a good/bad weather story. People are encouraged to prepare for Armageddon. The ER is effected by this hype. Every child with a fever must be checked out before the winds/ snow/ rain arrives. Local media hype medical issues as well.
Years ago I was in my final hour of a busy 10 hour shift. A mother arrived with her school age child and said she wanted her offspring to be checked for meningitis. There had been a recent local case of a teenager dying from bacterial meningitis. This distraught mother's child had not been exposed. Her concern was because the child had vomited once. She pointed out to me that vomiting was one of the signs of meningitis. She had watched the news broadcast the night before. I bit the inside of my cheek to keep from laughing. I asked the child, who was happily sucking on a popsicle, if he had a headache, or any pain, and if he felt nauseous. The answers to all my questions were in the negative. I was finally able to convince the mother that her precious did not need an lumbar puncture. I assured her that we would be ready if junior developed the headache, neck stiffness, fever, and vomiting that might indicate a diagnosis of meningitis.
The recent medical hype concerns the discovery of mosquitoes carrying the West Nile Virus (WNV). Lots of cans of insect repellant will be purchased to protect the citizenry from this disease. Some years, the mosquito-borne disease being hyped is EEE (eastern equine encephalitis).
Lets look at the facts. In 2009 there 720 cases of WNV in the entire US. The incidence of neuroinvasive disease (meningitis/encephalitis) was 0.13 per 100,000 people. The incubation period after exposure from an infected mosquito is 3-6 days. The number of cases of infection is very low compared to the number of people exposed. When someone develops encephalitis/meningitis, the fatality rate is 5-10%. The fatalities are mostly in the elderly. If a patient is in the 90-95% survival group, they usually make a complete recovery.
EEE tends to occur in outbreaks that may last for years. In 2005 Massachusetts and New Hampshire had a combined 11 cases of EEE. The 7 human cases in NH were the first cases in 41 years. Of the 11 patients who were diagnosed with EEE, 4 died. The incubation period for EEE is 5-10 days. There are about 20 cases in the US per year. The case fatality rate is 1:1000 for adults, 1:50 in children, and approaches 1:1 in infants. The overall case fatality rate is 50-75%. Most patients who survive EEE have permanent disability.
The treatment for both WNV and EEE is supportive. There is no specific medication or therapies. How high on one's list of health care problems are these 2 diseases? Next weekend is Labor Day. I predict that more people will die from accidents on the road and waters of Massachusetts than will be diagnosed with WNV and EEE combined.
I am in favor of educating people as to the risks of infectious diseases. Wearing long sleeves and long pants, using DEET containing insect repellants, and avoiding the peak times for mosquito activity are all good practices. When I walk my old pooch in the woods, I wear white scrub pants, and a long sleeve shirt that contains insect repellant. I tuck the pants into my white socks. This outfit serves the additional advantage of reducing my exposure to the deer ticks that carry Lyme disease (please refer to a recent blog on Lyme disease).
My concern is that exposure to the pesticides used to control mosquito populations may in the long run cause more wide spread neurological sequelae. There will always be risk. We must assess the degree of risk. The actions taken to mitigate the risk should be cost effective and not cause excessive damage to the environment or the people and animals in the area. As I have tried to stress in my blogs, be prepared. Read and listen to the media sources. Do your own research into the actual risks. Common sense approaches are your best protection.
Irene is now being downgraded as to wind velocities and rainfall amounts. The local food and home supply purveyors are counting the recent purchases made by the people who believed the hype. My wife and I have lots of snacks ready. We have a generator that runs on the natural gas. The ice/rain storm of December 2008 was not hyped as a severe storm. The power outages were devastating being both widespread and long lasting. Our house flooded because our trusty sump pump runs on electricity. Ready; come on Irene.
Years ago I was in my final hour of a busy 10 hour shift. A mother arrived with her school age child and said she wanted her offspring to be checked for meningitis. There had been a recent local case of a teenager dying from bacterial meningitis. This distraught mother's child had not been exposed. Her concern was because the child had vomited once. She pointed out to me that vomiting was one of the signs of meningitis. She had watched the news broadcast the night before. I bit the inside of my cheek to keep from laughing. I asked the child, who was happily sucking on a popsicle, if he had a headache, or any pain, and if he felt nauseous. The answers to all my questions were in the negative. I was finally able to convince the mother that her precious did not need an lumbar puncture. I assured her that we would be ready if junior developed the headache, neck stiffness, fever, and vomiting that might indicate a diagnosis of meningitis.
The recent medical hype concerns the discovery of mosquitoes carrying the West Nile Virus (WNV). Lots of cans of insect repellant will be purchased to protect the citizenry from this disease. Some years, the mosquito-borne disease being hyped is EEE (eastern equine encephalitis).
Lets look at the facts. In 2009 there 720 cases of WNV in the entire US. The incidence of neuroinvasive disease (meningitis/encephalitis) was 0.13 per 100,000 people. The incubation period after exposure from an infected mosquito is 3-6 days. The number of cases of infection is very low compared to the number of people exposed. When someone develops encephalitis/meningitis, the fatality rate is 5-10%. The fatalities are mostly in the elderly. If a patient is in the 90-95% survival group, they usually make a complete recovery.
EEE tends to occur in outbreaks that may last for years. In 2005 Massachusetts and New Hampshire had a combined 11 cases of EEE. The 7 human cases in NH were the first cases in 41 years. Of the 11 patients who were diagnosed with EEE, 4 died. The incubation period for EEE is 5-10 days. There are about 20 cases in the US per year. The case fatality rate is 1:1000 for adults, 1:50 in children, and approaches 1:1 in infants. The overall case fatality rate is 50-75%. Most patients who survive EEE have permanent disability.
The treatment for both WNV and EEE is supportive. There is no specific medication or therapies. How high on one's list of health care problems are these 2 diseases? Next weekend is Labor Day. I predict that more people will die from accidents on the road and waters of Massachusetts than will be diagnosed with WNV and EEE combined.
I am in favor of educating people as to the risks of infectious diseases. Wearing long sleeves and long pants, using DEET containing insect repellants, and avoiding the peak times for mosquito activity are all good practices. When I walk my old pooch in the woods, I wear white scrub pants, and a long sleeve shirt that contains insect repellant. I tuck the pants into my white socks. This outfit serves the additional advantage of reducing my exposure to the deer ticks that carry Lyme disease (please refer to a recent blog on Lyme disease).
My concern is that exposure to the pesticides used to control mosquito populations may in the long run cause more wide spread neurological sequelae. There will always be risk. We must assess the degree of risk. The actions taken to mitigate the risk should be cost effective and not cause excessive damage to the environment or the people and animals in the area. As I have tried to stress in my blogs, be prepared. Read and listen to the media sources. Do your own research into the actual risks. Common sense approaches are your best protection.
Irene is now being downgraded as to wind velocities and rainfall amounts. The local food and home supply purveyors are counting the recent purchases made by the people who believed the hype. My wife and I have lots of snacks ready. We have a generator that runs on the natural gas. The ice/rain storm of December 2008 was not hyped as a severe storm. The power outages were devastating being both widespread and long lasting. Our house flooded because our trusty sump pump runs on electricity. Ready; come on Irene.
Sunday, August 21, 2011
Nosce te ipsum
Nosce te ipsum, know thyself. Self-knowledge seems so obvious. Look in the mirror, et voila! We have all seen people on the beach or in the workplace who made us wonder if they even owned a mirror. Being self-aware is much more complicated than mirror gazing. How do others view us? Coworkers, family, friends may all contribute to the portrait we carry in our mind. Check list: man, middle aged, thin, tall, husband, son, brother, uncle, cousin, friend, ER doc. The shading in my portrait contains experiences, education, books, music, art, travel...life.
Why the existential angst? The new job and my place in the medical community. What is an ER doc? The American College of Emergency Physicians would define an ER doc as one who has completed an approved residency in Emergency Medicine, been board certified by passing the written and oral parts of the American Board of Emergency Medicine examination, and who works in an Emergency Department. Paying your yearly dues is also important to ACEP.
I have met the above criteria and have recertified every 10 years to maintain my status with the ABEM. When I worked at LGH, I never questioned my professional self as an ER doc. I saw lots of patients from neonates to the very elderly. I treated patients in labor, having heart attacks, in respiratory failure, with traumatic injuries, suicidal depression, psychosis, and life-threatening infection at both extremes of age. I supervised PA's, taught PA students, mentored young ER docs, and tried to impart some of my thirty years of ER experience to the nurses, EMT's and paramedics who worked on the patients in the ER. Arriving at 2030 hrs for my 2100 hours start time, I would scan the lists of 20-30 patients waiting up to 5 hours for treatment. After a ten (shortened to 8 just before my forced exit from LGH) hour slog, the waiting room would be close to empty.
Tonight I will leave my house at 2230 for my 2300 hour start time. There may be a few patients waiting. I will see an average of 5-6 patients during my 8 hour shift. In the month since I began working at NMC, I have treated few children and very few infants as NMC has no in-patient pediatric beds. I have seen so major trauma patients. Pregnant patients do not use NMC as there is no obstetrical services. NMC is a small community hospital in a somewhat isolated location.
Am I still an ER doc? The nurses, secretaries, (lab, radiology, and respiratory) technicians and other physicians in the ER, the hospital and in the community are smart, hard working and dedicated to providing great patient care. I have been welcomed with friendship and respect. My patients look to me as an ER doc. They wish relief from their pain and answers to their questions. The slower pace and lower acuity allow me to spend more time talking with and examining my patients. Maybe I am still an ER doc.
Whether in a 9,000 per year ER in a small town or a 250,000 visit per year ER in a large city, if you provide care to ER patients, you are an ER doc. Listen, empathize, comfort and use all your self knowledge to be the best ER doc you can be.
Why the existential angst? The new job and my place in the medical community. What is an ER doc? The American College of Emergency Physicians would define an ER doc as one who has completed an approved residency in Emergency Medicine, been board certified by passing the written and oral parts of the American Board of Emergency Medicine examination, and who works in an Emergency Department. Paying your yearly dues is also important to ACEP.
I have met the above criteria and have recertified every 10 years to maintain my status with the ABEM. When I worked at LGH, I never questioned my professional self as an ER doc. I saw lots of patients from neonates to the very elderly. I treated patients in labor, having heart attacks, in respiratory failure, with traumatic injuries, suicidal depression, psychosis, and life-threatening infection at both extremes of age. I supervised PA's, taught PA students, mentored young ER docs, and tried to impart some of my thirty years of ER experience to the nurses, EMT's and paramedics who worked on the patients in the ER. Arriving at 2030 hrs for my 2100 hours start time, I would scan the lists of 20-30 patients waiting up to 5 hours for treatment. After a ten (shortened to 8 just before my forced exit from LGH) hour slog, the waiting room would be close to empty.
Tonight I will leave my house at 2230 for my 2300 hour start time. There may be a few patients waiting. I will see an average of 5-6 patients during my 8 hour shift. In the month since I began working at NMC, I have treated few children and very few infants as NMC has no in-patient pediatric beds. I have seen so major trauma patients. Pregnant patients do not use NMC as there is no obstetrical services. NMC is a small community hospital in a somewhat isolated location.
Am I still an ER doc? The nurses, secretaries, (lab, radiology, and respiratory) technicians and other physicians in the ER, the hospital and in the community are smart, hard working and dedicated to providing great patient care. I have been welcomed with friendship and respect. My patients look to me as an ER doc. They wish relief from their pain and answers to their questions. The slower pace and lower acuity allow me to spend more time talking with and examining my patients. Maybe I am still an ER doc.
Whether in a 9,000 per year ER in a small town or a 250,000 visit per year ER in a large city, if you provide care to ER patients, you are an ER doc. Listen, empathize, comfort and use all your self knowledge to be the best ER doc you can be.
Wednesday, August 10, 2011
Adjusting
I have worked two doubles, a triple and a quadruple at my new job. At LGH I had stopped working 4 nights when I turned 55. By the fourth night I would be physically,and mentally spent and rather cranky. Not so at NVMC. Average night shift census is about 6 patients. Although I have not been sleeping any better between shifts, I am not STRESSED as before. I do miss my friends and coworkers at LGH. I received a call from Robin, my trustworthy PA today and my sense of loss was palpable. Don't we all feel that we are irreplacable? The staffing of the ER at LGH has been difficult since my forced departure. The remaining docs have had to go back to longer shifts. I like to soothe my ego, by thinking that the powers-that-be regret their active or passive complicity in my termination.
My daily routine has been adapted to my new circumstances. I have a snack and my coffee before I leave the house. My wife and I now have some quality time together even on my work nights. The drive is a pleasant 10.3 miles of countrified roads with a single traffic signal. Leaving the house at 10:25 PM allows me to listen to jazz on WGBH-FM on the ride into work. There is a fair amount of time to pass during the 8 hour shift. My newish 4G phone has been packed with 2 versions of "Angry Birds", "Bejeweled", "Scrabble", Mah-jong tiles, poker, backgammon, multiple solitaire variations, newspapers, magazines, etc.
The patient population is quite different from LGH. I have yet to use the translation phone. In three weeks, I have only treated one child under the age of 2. There is little trauma. The patients have been as pleasant as any at LGH but I am able to spend much more time with the patients and their families. If NVMC uses Press-Ganey surveys, I feel that I will consistently be in the top percentile. The fact that my patients are not waiting 2-5 hours before being evaluated by a physician, makes them much less cranky.
The nurse and secretaries have been most welcoming and are very good at their jobs. Last night the nursing supervisor brought in a cake to celebrate the birthday of one of the ER night nurses. I have made friends with the security guards, night housekeeper, and the sargeant of the local town police department on the overnight shift.
After the last 2 weeks of financial shock to my retirement funds, I will be working for the next 8 years. Is NVMC my final destination? Only time will tell. For now, I will improve my gaming skills, enjoy spending time with my patients, and be a relatively stress free "world's oldest ER doc". Thanks to my friend Wendell for his sage wisdom, when he told me that would be life after LGH.
My daily routine has been adapted to my new circumstances. I have a snack and my coffee before I leave the house. My wife and I now have some quality time together even on my work nights. The drive is a pleasant 10.3 miles of countrified roads with a single traffic signal. Leaving the house at 10:25 PM allows me to listen to jazz on WGBH-FM on the ride into work. There is a fair amount of time to pass during the 8 hour shift. My newish 4G phone has been packed with 2 versions of "Angry Birds", "Bejeweled", "Scrabble", Mah-jong tiles, poker, backgammon, multiple solitaire variations, newspapers, magazines, etc.
The patient population is quite different from LGH. I have yet to use the translation phone. In three weeks, I have only treated one child under the age of 2. There is little trauma. The patients have been as pleasant as any at LGH but I am able to spend much more time with the patients and their families. If NVMC uses Press-Ganey surveys, I feel that I will consistently be in the top percentile. The fact that my patients are not waiting 2-5 hours before being evaluated by a physician, makes them much less cranky.
The nurse and secretaries have been most welcoming and are very good at their jobs. Last night the nursing supervisor brought in a cake to celebrate the birthday of one of the ER night nurses. I have made friends with the security guards, night housekeeper, and the sargeant of the local town police department on the overnight shift.
After the last 2 weeks of financial shock to my retirement funds, I will be working for the next 8 years. Is NVMC my final destination? Only time will tell. For now, I will improve my gaming skills, enjoy spending time with my patients, and be a relatively stress free "world's oldest ER doc". Thanks to my friend Wendell for his sage wisdom, when he told me that would be life after LGH.
Friday, July 22, 2011
Skin deep
There are only a few true dermatological emergencies, but skin problems are a common cause of ER visits. Red, scaly, itchy, painful, blistered are all part of the skin game.
Toxic epidermal necrolysis is a life threatening skin problem. It is seen in Steven-Johnson syndrome, a hypersenitivity reaction that may be caused by many commonly used medications. The skin and mucous membranes are effected and the treatment is similar to that for severe burns. Scalded skin syndrome, caused by certain staphylococcal infections is characterized by fluid filled blisters as the outer layer of skin separates from the deeper layers. This separation with only slight pressure is referred to as Nikolsky's sign. This condition is also treated in a burn center.Pemphigous is an autoimmune disease that also presents with painful blisters. It may be associated with certain cancers.
Skin infections are often seen in the ER. Fungal infections of the skin are caused by dermatophytes. Ringworm, athlete's foot, and jock itch are all common names for fungal skin infections. Tinea versicolor presents with patches of of skin that are a different color than the normal surrounding skin. Tinea pedis, pubis and capitis refer to fungal infection from the bottom, middle and top of the body. While not life-threatening, the ER docs and PA's can initiate treatment for these conditions.
Viral skin infections are potentially more serious. Herpes infections caused by herpes simplex either types 1 or 2 are painful eruptions of small blisters (vesicles) around the mouth or genitals. Occasionally a herpetic whitlow presents as painful vessicles on a finger tip from the patient contaminating his or hers finger from touching/scratching vesicles around the mouth or genitals. Shingles is caused by the herpes zoster virus. This virus is also the cause of varicella (chicken pox). Many species of herpes virus have the ability to "hide" in ones body and recur years after the initial infection. Shingles describes a recurrence along the distribution area of a nerve. It is almost always unilateral and looks like a patch or swath of vesicles on a red base. The incidence of shingles increases as we age. It is a very painful condition and the pain often persists even after the rash clears. Fortunately there a booster vaccination for patients older than 60 that has been shown to decrease the incidence of shingles and to both shorten the course and the postherpetic neuralgia (nerve pain) if shingles does occur.
Many diseases have distinctive rashes as part of the illness. Measles, chicken pox, rubella, Rocky Mountain spotted fever, Lyme disease and many other viral and bacterial infections will have rashes as part of the signs of the illness.
Bacterial skin infections are common and need urgent treatment. Erysipelas is a painful skin eruption caused by strep. pyogenes. Impetigo is a common childhood skin infection caused when scratching by the patient, breaks the surface of the skin and strep or staph bacteria are inoculated into the skin. Impetigo is often seen in sports where skin to skin contact occurs, such as wrestling. Cellulitis presents as a localized red, warm and tender skin. The margin of the cellulitis is often elevated above the normal skin. Staph and strep bacteria are the most common organisms. Impaired immunity because of medications or diabetes increases the incidence and severity of cellulitis.
By far the most common dermatological conditions seen in the ER are those caused by inflammation. Contact dermatitis by irritants such as solvents, alkalies, latex and plants presents with area of small vesicles, sometimes "weeping". Allergic dermatitis looks similar and is most often seen with exposure to poison ivy, oak, sumac and metals such as nickel. That gold or silver jewelry you are wearing may contain nickel as a hardener. Photodermatitis occurs when an irritant or allergen is on the skin or has been ingested (many medications) and the ultraviolet light from sun exposure triggers a reaction.
Eczema is a chronic form of dermatitis that may present with some combination of redness, itching, dryness, crusting, flaking, blistering, cracking, oozing or bleeding. Eczema like contact dermatitis is treated with topically applied or orally administered corticosteroids.
Psoriasis is a chronic immune mediated skin disease. Thick flaky patches may occur anywhere on the body. Topical steroids may help with an acute flair up. PUVA (psoralens and ultraviolet A phototherapy) and immune modulators such as methotrexate or cyclosporin are used to treat this chronic condition.
Patients with sunburns are frequently seen in the ER at this time of the year. Moisturizers, pain medications and occasionally corticosteroids are prescribed. Prevention by limiting ones exposure, and using sunblock are the preferred method of not getting burned. Apply copious amounts of at least SPF 30 sun block, twenty minutes before sun exposure. Reapply every 2 hours or more frequently if swimming or sweating. As I found out on while snorkeling on the island of Anguilla, remember to protect ones bald spot.
World's oldest ER doc update: I have begun the next phase of my ER career. I am now working at a low volume/ low acuity community hospital. Although this move was forced on me by the adminstration of my former hospital, the slower pace and reduced stress will allow me to reach my goal of 40 years as an ER doc.
Saturday, June 25, 2011
Last Dance
This is it. Last night at LGH. 28 years. I have mixed emotions. LGH was more than a job. My family and I were all treated as patients in this hospital. My father-in-law died here. I made friends who have proved tried and true in my times of need. I have worked with and treated generations of people at LGH. The current administration felt that I needed to leave. I will join a list of nurses, techs, aides, and secretaries who were also shown the door. The criteria for hiring and firing people seems to have more to do with personality conflicts than competency. The upside of leaving is a blessed lessening of my stress level. The lack of space and personnel relative to the volume and acuity of our patients, has made this ER a risky place to be a worker or a patient.
There are kind, smart, hard working nurses, doctors, physician assistants, techs, and support staff. They will provide our patients with very good, if slow care. They deserve to be recognized by there leaders for the extraordinary work that they do. Good luck to all my friends.
A special thanks to Sue G, Deb, Sandi, Kristen, Jess, Fo, Donna S, Marie P, Donna B, Jackie, the Rachels, Heidi, Bubba, Lisa B, Leza, Kellie, Dawna T, Mel, Brandy, Tara and all the folks on nights. I will miss my partners. I leave the night shift in the strong hands of my brother, Chris K.
The world's oldest ER doc will continue to blog but at a new lodge of the B.O.N.E.R. docs
Sunday, June 19, 2011
Lyme Disease
Time to walk the dog. Hot and humid conditions but I don a long sleeve shirt treated with insect repellent and long white pants. I tuck the cuffs of the pants into heavy white socks. Why? Ticks!
Deer ticks of the genus Ixodes may transmit Lyme disease with a bite. A spirochete (spiral shaped bacterium), Borrelia burgdorferi is the causative organism. The tiny deer tick must be attached for at 36 hours before transmitting the pathogen. In the ER a single dose of antibiotic may be given if the tick bitten patient meets certain criteria. Most important is that the tick is identified as a deer tick and not the more common dog tick. The deer tick must have been attached for at least 36 hours and the antibiotics be given with 72 hours of removing the tick. The preferred antibiotic is doxycycline. For children, women who are pregnant or breast feeding, or those patients allergic to tetracycline, another antibiotic will be used.
Early Lyme disease is characterized by flulike symptoms. The patient often has chills, a low grade fever, headache, muscle aches, tiredness, joint aches, and less frequently nausea and vomiting. These symptoms appear within 30 days of the initial bite. A characteristic rash, erythema migrans (EM), occurs in 80% of Lyme disease patients, on average 7-10 days post bite. It is flat and red and spreads out from the center. 40% of the cases of erythema migrans show clearing of the redness staring in the center and moving to the edges. 20% of patients with EM will have separate lesions, thought to be from spread of the bacteria via the blood stream.
Stage 2 Lyme disease is also referred to early disseminated. Neurological, joint and cardiac manifestations of Lyme disease are present. Cardiac problems occur in less than 10% of stage 2 and 3 Lyme patients. Palpitations, syncope (sudden loss of consciousness) and chest pains are the symptoms of borrelia infection of the heart. Damage to the conducting cells in the heart may lead to dangerously slow heart rates. Infection with inflammation of the heart muscle and/or the membrane covering the heart chest pain from myocarditis or pericarditis respectively.
Joint pains or arthralgias are common in both stage 1 and 2 of Lyme disease. Actual inflammation of the joints, arthritis is more commonly seen in stage 3. Bursitis, myositis, sinovitis, and tendonitis causes pains of muscles, tendons and bursae.
Infection of the cornea or uvea of the eye may lead to eye pain and visual changes in some Lyme patients.
Stage 2 disease occurs weeks to months after the initial bite. The neuropsychiatric symptoms of stage 2 Lyme are varied and mimic other diseases. Decreased concentration, memory disorders, numbness, nerve pains, sleep disorders, paralysis of facial muscles and visual changes have all been reported. 25% of Lyme patients with a facial palsy will have the condition on both sides of the face. Headache and neck pain and stiffness are symptoms of Lyme meningitis.
Other signs of Lyme disease may include an enlarged liver or spleen and enlarged lymph nodes. Blood tests starting with the ELISA for Lyme will be sent. A Western Blot test may be used to confirm the diagnosis. A lumbar puncture will be done if there are signs of meningitis or neurological symptoms of Lyme disease.
Stage 3 Lyme disease, or tertiary Lyme occurs months to years after the initial bite. This may happen because the initial disease wasn't treated at all or inadequately. There is some experimental evidence that the spirochete may persist intracellularly in fibroblasts despite adequate antibiotic treatment. Arthritis of the knees and other large joints is evident in tertiary Lyme. Cardiac symptoms as noted earlier are also occasionally found in stage 3. Fatigue, chronic headaches, memory loss, sleep disorders, abnormal sensitivity to light, confusion, decreased levels of consciousness and numbness and tingling are all neurological signs of tertiary Lyme disease.
Chronic Lyme disease is reported by some patients. This may represent an autoimmune phenomenon. Molecular mimicry occurs when one's immune system attacks one's body because of similarity to molecular components of the Borrelia spirochete. Some physician treat chronic Lyme patients with antibiotics for many months to years. There is no experimental proof that this treatment is effective.
As with many of life's unpleasant diseases, prevention is the best weapon. Risks of exposure to deer ticks are gardening, hiking, hunting, walking in high grass and pet ownership. My bizarre attire when dog walking is just what is recommended. Long sleeves and pants. Insect repellent sprays. Light colored clothes to more easily spot the tiny ticks. Use of tick and flea treatments for outdoor pets is also a good idea. There is a veterinary vaccine for Lyme but its effectiveness is questionable. Have a great summer.
Sunday, June 12, 2011
E Coli
Scary stories about E coli outbreaks appear in the news regularly. The most recent occurrence in Germany is worrisome because of the deaths of younger healthier women and the lack of an obvious source.
E coli is a resident bacteria of the human GI tract. One's personal inhabiting specie rarely causes problems. The proximity of the rectum and vagina in women make E coli a common cause of urinary tract infections. E coli may infrequentlt cause pneumonia and meningitis in neonates, long-term care residents and hospitalized patients. The bacteria may infect diabetic and decubitus (pressure sores) ulcers and causes up to 10% of bacterial bone infections in the vertebrae. The newsworthy danger arises when one is exposed to a strain of the bug that produces toxins that cause harm to the human host.
The most familiar of these toxin producing strains of E coli is the enterotoxigenic variety. Euphemisms such as traveler's diarrhea or Montezuma's revenge make the illness seem trivial. Bouts of watery diarrhea are no fun. Treatment however is relatively simple; rehydrate with fluids and Pepto Bismol in large quantities.
STEC/EHEC refers to strains of coliforms that produce a Shiga toxin. Shigella bacteria are another cause of gastrointestinal infection. The shiga toxin invades the lining of the intestinal tract and enters the blood stream. Unrelated species of bacteria may "share" genetic material by exchanging plasmids. Plasmids are packages of genes that may encode for resistance to antibiotics or production of a toxic protein.
Shiga toxin targets the endothelial cells that line blood vessels. The resulting damage is referred to as microangiopathy. The red blood cells and platelets (clotting cells) are injured as they pass through the damaged blood vessels. Hemolytic anemia (low RBC's from lysis or rupture) and TTP (low platelet counts from consumption of the platelets in clotting) cause the life-threatening consequences of HUS, hemolytic uremic syndrome.
The kidneys main function is filtering out toxic products from metabolism. They are highly vascular. In the kidney cells, the Shiga toxin inhibits protein synthesis, eventually leading to apoptosis (cell death). The lysis of RBC's, the direct damage to renal blood vessels and renal cell apoptosis may lead to kidney failure, i.e. HUS. If recognized early, intravenous fluids may prevent renal failure. Once established, renal failure is treated with hemodialysis until the kidneys recover. The kidney failure may be permanent and lead to a life of thrice weekly dialysis while awaiting a kidney transplant.
The early symptoms of STEC/EHEC are bloody stools, fever, lethargy, vomiting and weakness. Diarrhea, vomiting and increased irritability may be the only early symptoms in babies. Later in the course of the illness, patients may have bruising, decreased level of consciousness, low or no urine output, pallor, petechiae (small red or purple skin lesions) and jaundice. HUS is most common at the extremes of age. The very young and the elderly are usually most at risk.
In the USA, outbreaks of HUS from enteroinvasive strains of E coli have come from contaminated meat (especially hamburger) and vegetables contaminated by irrigation water that had been fouled by animal waste. Thoroughly cooking meat eliminates the risk but washing vegetables does not. There have been proposals to irradiate food products to kill the bacteria in and on the food. Irradiation does not make the food radioactive but it may alter the taste or texture of the food.
The most useful thing that we can all do to prevent the spread of food borne illnesses is good hand washing. Fecal-oral spread sounds gross but is all too frequently the source of both viral and bacterial gastroenteritis. Reminding children to wash their hands after going to the bathroom is a must. I have been tempted to expose people that I have seen leaving public bathrooms without washing their hands.
Use warm water, soap, and scrub for at least a minute, use paper towels to dry your hands and also to shut off the water and open the door. Any ground meat must be cooked completely. A hamburger with a red center is a "crap" shoot.
Saturday, May 28, 2011
Cramp Champ
After 33 years of being an ER doc, I had a first time chief complaint. A 60+ year old patient came to the ER around 0400 complaining of painful leg cramps. The patient reeked of Ben-Gay and it took a great deal of control, to not start laughing at the less than urgent nature of the patient's problem. As an example of Karma, I spent my first not at home (after my usual three 10 hour nights from hell) walking around the house trying to relieve my own painful calf and foot cramps. I especially hated the fact that my left big toe was painfully sticking up like a flag pole.
Leg cramps, aka Charley horse, are not restless leg syndrome. RLS is a movement disorder that is treated with meds for Parkinson's disease. Although RLS is uncomfortable and may be associated with some muscle cramping, it is not nocturnal leg cramps. Cramps are painful contractions of the thigh, calf and/or foot muscles.
Any athlete will recognize the painful muscle cramping that occurs during or immediately after heavy exercise, especially in hot weather. Dehydration, electrolyte loss through sweating, and the build up of lactic acid in the muscles from anaerobic metabolism can lead to these painful muscle contractions, sometimes referred to as heat cramps. When the diaphragm is involved the dolorous spasm may be called a "stitch".
Nocturnal leg cramps have been linked to sitting for long periods of time, dehydration, overuse of the muscles, standing or working on concrete floors and a number of medications. The list of prescriptions medication includes diuretics, statins, lithium, and morphine. The incidence of nocturnal leg cramps increases with age and is occasionally associated with diabetes and peripheral vascular disease and infrequently with endocrine disorders such as hypothyroidism and hypoglycemia.
There is no well established treatment for nocturnal leg cramps. Good hydration, stretching of the calf muscles before bed, having loose bed clothes and linen, even riding an exercise bike have been proposed as preventatives. Eating potassium rich foods, such as bananas and oranges is recommended. Drinking water before bed may be helpful but, will lead to another night problem for men in my age demographic.
Quinine is a medication that was (and sometimes still is) used to treat malaria. As a doctor back in the 70's, many of the elderly patients that I treated were taking quinine nightly to prevent leg cramps. There is no double blind study that definitely shows improvement in the frequency or intensity of leg cramps by taking quinine. Anecdotal reports have perpetrated the continued use of quinine for this condition. My patient had taken quinine sulfate when he was awakened by his painful cramps. The down side of quinine is significant. Side effects include headache and tinnitus (ringing in the ears), thrombocytopenia (low platelet count), cardiac rhythm disturbances, and fatal hypersenitivity reactions.
Diltiazem, a calcium channel blocker used to treat hypertension and rapid heart rates, has been tried with some success to treat nocturnal leg cramps. Vitamin B6 30 mg daily has also been proffered as a treatment option. Neither has been subjected to a well controlled study.
So it is 3 AM and you are awakened by painful cramps in your lower extremities; what do you do? First, get out of bed and begin to walk around. Drink some water. Gently massage the involved muscles. Take a warm shower or bath. Do some stretching of your calves.
If you are plagued with frequent nocturnal leg cramps, talk to your primary care doctor. A check of your electrolyte levels, thyroid function and possibly even EMG (electromyelography) may be helpful in finding a treatable cause.
Update on my status: I have 12 shifts left at the General Hospital. Working another Sunday- Tuesday for the Memorial Day Weekend, will reinforce the need to find greener (less stressful) pastures. The new night shift at The General will commence in June. The hours will be 10PM to 6AM. I have nine of these truncated shifts before my final night on June 25. I will begin my new job around July 18th. My schedule will be 11PM to 7 AM working 12 shifts per month. The night shift census is 4-6 patients. I have been averaging 25 patients per 10 hour night at The General.
Saturday, April 23, 2011
APAP
APAP is short for acetaminophen, the active ingredient in Tylenol and Feveral. APAP is used to treat fever and pain. It is found as a single drug and in combination with other medications in cold and flu treatments. I touched on APAP in a prior post titled OD. A recent patient and a memory from the past led to today's blog.
APAP toxicity is primary from injury and death of hepatocytes, liver cells. NAPQI is a metabolite, an altered form of APAP as is metabolized by the liver. NAPQI depletes the liver's store of glutathione, an antioxidant. Once the supply of glutathione is exhausted, the hepatocytes are unable to repair the damage caused by NAPQI. Alcohol and medications that use the same pathway for liver metabolism, will exacerbate the toxic effects of APAP. Isoniazid, which is used to treat tuberculosis, and phenobarbital and carbamazipine, both anticonvulsants, are in this group of medications.
In an acute overdose of APAP, either as a suicide attempt or inadvertent excessive dose given by a parent, well established toxic levels are predictable. 200 mg per Kg of body weight is enough to cause liver damage. The level of APAP at 4 hours after a single ingestion can be plotted on the Rumack-Matthew nomogram to help the ER doc decide if the patient requires treatment. Many times we see patients who have been taking excessive amounts of APAP over days. The nomogram is not helpful in these patients.
The early signs of hepatic injury from APAP are not very specific. The patient may have some right upper abdominal discomfort and complain of nausea and vomiting. As the liver is crucial for the maintenance of glucose levels, low blood sugar may be found. Easy bruising is also a sign of liver injury, as the liver manufactures proteins involved in the clotting of blood. As the levels of nitrogen containing toxins, such as ammonia, build up in the blood, the patient may show signs of hepatic encephalopathy. Confusion, problems walking, and lethargy are all signs of effects of these toxins on the brain. A healthy liver normally clears these products of protein metabolism and absorbed toxins from the gastrointestinal track.
Lab tests will reveal elevated liver enzymes, transaminases. Bilirubin may be above normal and later in the course of the disease, abnormal kidney function will be noted. The prothrombin time, a measure of the clotting cascade will begin to rise. The key to a successful outcome is to initiate treatment as soon as possible, preferably before the patient is in significant liver failure.
N-acetylcysteine or NAC is the antidote for APAP damage to the liver. There is an intravenous form of NAC that is sold as Acetadote in the US. Prior to its introduction, NAC had to be given orally. This was a problem because the patients often had vomiting from liver injury and the oral form of NAC smells like rotten eggs. If liver failure has progressed too far, only a liver transplant will save the patient.
Early in my long career, I examined a toddler who looked gravely ill. The child was jaundiced, dehydrated, unresponsive and bled excessively from attempts to establish an IV and draw blood. The lab tests showed all the signs of liver failure. I began NAC by a nasogastric tube as the IV form was not available at that time. The child was transferred to a major pediatric hospital but died from liver failure. The child had been treated for a viral infection with APAP by the parents. The pediatrician had told the parents to give one teaspoon of children's APAP, which contains 160 mg of the drug, every four hours as needed for fever. The problem arose because the parents mistakenly gave one teaspoon of infant APAP, which contains 500 mg, every four hours.
More recently a patient was seen in the ER who was taking more than the maximally recommended dose of APAP for chronic pain. The doses taken were 25-33% above the maximal dose but over many days the liver began to be effected. This patient was started on Acetadote and made a full recovery.
Update:
My mother-in-law is, in the words of the hospice nurse, actively dying. She is unresponsive and hasn't had any oral intake in several days. We are amazed that she is still alive. My wife and I are with mother as I write this post.
The next phase of my career will begin in July. I will be leaving the ER I have called home for the past 28 years. My departure was forced by the hospital administration's displeasure with my relationship with the nursing staff. The outpouring of support from current and former ER nurses, my colleagues in the ER and on the medical staff, EMS personnel, local police officers and firefighters, and my patients has been heartening.
I have decided to remain a B.O.N.E.R. doc. I will stay on nights but in a much less busy ER. The privilege of providing care to those most in need, is my motivation. Stay tuned.
APAP toxicity is primary from injury and death of hepatocytes, liver cells. NAPQI is a metabolite, an altered form of APAP as is metabolized by the liver. NAPQI depletes the liver's store of glutathione, an antioxidant. Once the supply of glutathione is exhausted, the hepatocytes are unable to repair the damage caused by NAPQI. Alcohol and medications that use the same pathway for liver metabolism, will exacerbate the toxic effects of APAP. Isoniazid, which is used to treat tuberculosis, and phenobarbital and carbamazipine, both anticonvulsants, are in this group of medications.
In an acute overdose of APAP, either as a suicide attempt or inadvertent excessive dose given by a parent, well established toxic levels are predictable. 200 mg per Kg of body weight is enough to cause liver damage. The level of APAP at 4 hours after a single ingestion can be plotted on the Rumack-Matthew nomogram to help the ER doc decide if the patient requires treatment. Many times we see patients who have been taking excessive amounts of APAP over days. The nomogram is not helpful in these patients.
The early signs of hepatic injury from APAP are not very specific. The patient may have some right upper abdominal discomfort and complain of nausea and vomiting. As the liver is crucial for the maintenance of glucose levels, low blood sugar may be found. Easy bruising is also a sign of liver injury, as the liver manufactures proteins involved in the clotting of blood. As the levels of nitrogen containing toxins, such as ammonia, build up in the blood, the patient may show signs of hepatic encephalopathy. Confusion, problems walking, and lethargy are all signs of effects of these toxins on the brain. A healthy liver normally clears these products of protein metabolism and absorbed toxins from the gastrointestinal track.
Lab tests will reveal elevated liver enzymes, transaminases. Bilirubin may be above normal and later in the course of the disease, abnormal kidney function will be noted. The prothrombin time, a measure of the clotting cascade will begin to rise. The key to a successful outcome is to initiate treatment as soon as possible, preferably before the patient is in significant liver failure.
N-acetylcysteine or NAC is the antidote for APAP damage to the liver. There is an intravenous form of NAC that is sold as Acetadote in the US. Prior to its introduction, NAC had to be given orally. This was a problem because the patients often had vomiting from liver injury and the oral form of NAC smells like rotten eggs. If liver failure has progressed too far, only a liver transplant will save the patient.
Early in my long career, I examined a toddler who looked gravely ill. The child was jaundiced, dehydrated, unresponsive and bled excessively from attempts to establish an IV and draw blood. The lab tests showed all the signs of liver failure. I began NAC by a nasogastric tube as the IV form was not available at that time. The child was transferred to a major pediatric hospital but died from liver failure. The child had been treated for a viral infection with APAP by the parents. The pediatrician had told the parents to give one teaspoon of children's APAP, which contains 160 mg of the drug, every four hours as needed for fever. The problem arose because the parents mistakenly gave one teaspoon of infant APAP, which contains 500 mg, every four hours.
More recently a patient was seen in the ER who was taking more than the maximally recommended dose of APAP for chronic pain. The doses taken were 25-33% above the maximal dose but over many days the liver began to be effected. This patient was started on Acetadote and made a full recovery.
Update:
My mother-in-law is, in the words of the hospice nurse, actively dying. She is unresponsive and hasn't had any oral intake in several days. We are amazed that she is still alive. My wife and I are with mother as I write this post.
The next phase of my career will begin in July. I will be leaving the ER I have called home for the past 28 years. My departure was forced by the hospital administration's displeasure with my relationship with the nursing staff. The outpouring of support from current and former ER nurses, my colleagues in the ER and on the medical staff, EMS personnel, local police officers and firefighters, and my patients has been heartening.
I have decided to remain a B.O.N.E.R. doc. I will stay on nights but in a much less busy ER. The privilege of providing care to those most in need, is my motivation. Stay tuned.
Friday, April 1, 2011
April Fool's Day
As I write this posting, I am looking out at several inches of heavy snow. April Fools indeed. The ER is a place where pranks occur almost daily. The odd, unexpected, quirky and bizarre arrive by foot, wheelchair and ambulance stretcher. The intentional April Fool's day prank are rare and amateurish. Painted on rashes and fake aliens erupting from the body are not going to fool the world's oldest ER doc.
It is the unintentional gag that makes the job fun. Many years ago I was confronted with a mother dragging her 6 year old into the ER screaming that he couldn't breath and was turning blue. A quick glance revealed a smurf like coloration of the hands and face but the child was breathing calmly. I pulled an alcohol wipe from my coat pocket and removed the blue dye that had bled from the child's new sweatshirt. The mother's mouth gaped and she left the ER without saying another word. The rare and unexpected finding keeps me on my toes. When I have completed a history and physical exam and reviewed any records in the hospital's EMR, I form my differential diagnosis. The labs, x-rays, CT's, EKG, and ultrasound should yield findings that I hope I have anticipated. The patient with crushing chest pain and difficulty breathing, who is diaphoretic and whose lungs are congested is probably having an myocardial infarction. The EKG should reveal changes that are consistent with an injury to the heart. The chest x-ray should show evidence of congestive heart failure. The labs tests are likely to show elevation on the CPK I and troponin, markers for myocardial damage. Recently I examined a pleasant octogenarian. She was in obvious distress. She described her abdominal pain and vomiting. Her distended abdomen was very quiet to auscultation. She had diffuse but only mild tenderness. She had an intestinal obstruction by clinical criteria. The possible causes of any presenting complaint are prioritized by likelihood of death or disability. Vascular causes are usually first on the differential diagnosis list. Does this woman have a leaking aneurysm, or a blocked mesenteric artery? The patient was given medications for pain and nausea and labs where sent off. I also ordered a CT of her abdomen without IV or oral contrast. My radiology colleagues would not be happy but I felt that her kidneys would be damaged by the IV dye and she would not be able to tolerate drinking a liter of oral contrast with a bowel obstruction. Her lab tests where abnormal but not specific. As I looked at the CT images, I was stunned. There are diseases that all doctors learn about but rarely encounter. Gall stone ileus is one of those conditions. The gall bladder is a storage tank for bile. When one eats a meal containing fat, the stomach releases a hormone, cholecystokinin. This messenger travels through the veins of the abdomen and stimulates the muscles in the wall of the gall bladder to contract and send bile down the bile duct to the small intestine. The bile will aid in the digestion and absorption of the fat content of a meal. Bile can become like sludge. Stones of bile salts, cholesterol and calcium salts may form in the gall bladder. Long term irritation of the gall bladder wall by gall stones may lead to a connection (fistula) between the gall bladder and the duodenum, the first section of the small intestine. In this patient, that is what had developed. A 2.8 cm gall stone had passed from the gall bladder directly into the small intestine. It meandered down the intestine until it became stuck. The blockage of the intestine by a gall stone is a gall stone ileus. The CT images were identical to ones I had seen in a radiology textbook many years ago. The patient was transferred to a major academic hospital. I am sure that the young doctors will provide excellent care and have a story to tell when they reminisce about their fascinating cases. Unfortunately the unexpected findings may be bad news for the patient. When I was an attending in a teaching hospital, a resident presented a case of a young woman he had evaluated and was ready to send home. The complaint was of vaginal redness and discharge. The evidence of a yeast infection was obvious on physical exam and KOH prep. I introduced myself to the patient and was shocked by her pallor. She denied any sexual experience, or antibiotic use. I told the patient that we were going to do some blood tests. The resident had made the correct diagnosis of the presenting complaint but had ignored the obvious anemic condition of this unfortunate woman. A CBC came back with severe anemia, and a markedly elevated white blood cell count with evidence of leukemic cells. The oncology service was consulted and the patient was admitted. Her impaired immune system from the leukemia had led to the yeast infection. All ER docs have had the experience of treating a child brought in for a "stomach bug". The persistent vomiting and impending dehydration led the parents to seek help. The child shows clear signs of dehydration but the respiratory rate of 40 fills me with dread. A check of the chemistries reveals a diagnosis of diabetes; treatable but a life altering diagnosis. The practice of emergency medicine is controlled chaos. Being rather compulsive and definitely controlling, I may have been better served in another field of medicine. I considered becoming a pathologist when I was a medical student. My advisor told me: internists knew much and do little; surgeons knew little but did much; pathologists knew all, but too late. His opinion of emergency medicine (this was in the mid 1970's), was that it was not a valid career choice. 34 years later I am still an ER doc.Saturday, March 26, 2011
E
With Mother. She is sleeping more. Her intake and output is diminishing. She is not in pain or anxious. The aides and nurses from hospice have been wonderful.
I received a call today from E. E worked with me on nights for many years. She retired and enjoys her life. She has had some health concerns and we had a good conversation. She advised me that I should follow my heart and head in deciding how to adapt to the rest of my career.
In the day, there was E and L, an aide and me. Our friend S was our night x-ray tech and our friend D was in the lab. E had trained at the world's best pediatric hospital and her partner L was an experienced critical care nurse. E reminded me that even in those quieter times I could be a PITA. She reminisced how she or L would give me a verbal or physical smack upside my head when necessary.
Two years ago E called to tell me of some disturbing symptoms. She correctly diagnosed her own disease and I arranged for one of my partners to treat her in the ER. An recent alarming visit to an ER where she lives during the winter, was precipitated by chest pains and severe hypertension. She was treated and is doing well.
Last week I cared for two patients with intracerebral hemorrhages (ICH). The first patient was 61 years old. The family found the patient on the floor with evidence of having vomited and unresponsive to voice or touch. The paramedics did a great job of entubating and stabilizing the patient. A CT scan revealed a large ICH that was distorting the normal brain anatomy. I stabilized the patient's blood pressure and transferred her to a tertiary care hospital. The family told us that the patient had been complaining of a headache for a couple of days. The patient had no medical history, but had seen a doctor regularly for check ups. The prognosis is not good.
The second patient was an octagenarian who walked in with symptoms of an episode of confusion and possibly some slurred speech. The patient complained of a worsening headache for a few days. The patient was on coumadin for an irregular heart beat. CT scanning and labs were ordered. The INR was above the therapeutic level and the CT showed a small ICH. There was no evidence of a shift of the normal brain structures. Arrangements were made to transfer the patient to a tertiary care hospital and I started medication to control her blood pressure and gave fresh frozen plasma to reverse her clotting abnormality. The prognosis is good.
My brother-in-law has arrived and we have the golf tournament on the TV. Mother was an avid golfer. Her father and husband were also devoted to the game. She told me that they were disappointed, when I began dating their daughter, because I had no interest in golf. The sounds of the tournament brought a smile to her face.
In the near future I will be enbarking on the next stage of my career. The world's oldest ER doc will become a part timer. Shorter hours, a less busy ER, and fewer or maybe no nights are my goals. I think that with this change I can make it to 40 years in emergency medicine. For now I will enjoy spending time with the extraordinary woman who I am fortunate to have as my mother-in-law.
I received a call today from E. E worked with me on nights for many years. She retired and enjoys her life. She has had some health concerns and we had a good conversation. She advised me that I should follow my heart and head in deciding how to adapt to the rest of my career.
In the day, there was E and L, an aide and me. Our friend S was our night x-ray tech and our friend D was in the lab. E had trained at the world's best pediatric hospital and her partner L was an experienced critical care nurse. E reminded me that even in those quieter times I could be a PITA. She reminisced how she or L would give me a verbal or physical smack upside my head when necessary.
Two years ago E called to tell me of some disturbing symptoms. She correctly diagnosed her own disease and I arranged for one of my partners to treat her in the ER. An recent alarming visit to an ER where she lives during the winter, was precipitated by chest pains and severe hypertension. She was treated and is doing well.
Last week I cared for two patients with intracerebral hemorrhages (ICH). The first patient was 61 years old. The family found the patient on the floor with evidence of having vomited and unresponsive to voice or touch. The paramedics did a great job of entubating and stabilizing the patient. A CT scan revealed a large ICH that was distorting the normal brain anatomy. I stabilized the patient's blood pressure and transferred her to a tertiary care hospital. The family told us that the patient had been complaining of a headache for a couple of days. The patient had no medical history, but had seen a doctor regularly for check ups. The prognosis is not good.
The second patient was an octagenarian who walked in with symptoms of an episode of confusion and possibly some slurred speech. The patient complained of a worsening headache for a few days. The patient was on coumadin for an irregular heart beat. CT scanning and labs were ordered. The INR was above the therapeutic level and the CT showed a small ICH. There was no evidence of a shift of the normal brain structures. Arrangements were made to transfer the patient to a tertiary care hospital and I started medication to control her blood pressure and gave fresh frozen plasma to reverse her clotting abnormality. The prognosis is good.
My brother-in-law has arrived and we have the golf tournament on the TV. Mother was an avid golfer. Her father and husband were also devoted to the game. She told me that they were disappointed, when I began dating their daughter, because I had no interest in golf. The sounds of the tournament brought a smile to her face.
In the near future I will be enbarking on the next stage of my career. The world's oldest ER doc will become a part timer. Shorter hours, a less busy ER, and fewer or maybe no nights are my goals. I think that with this change I can make it to 40 years in emergency medicine. For now I will enjoy spending time with the extraordinary woman who I am fortunate to have as my mother-in-law.
Thursday, March 24, 2011
C'est La Vie
It's Life! The founder of the Brotherhood Of Nocturnal Emergency Room doctors has made a decision. It is time to get off nights. I am at peace with the decision. The lack of sleep, the volume of patients, the constant stress has effected me mentally, physically and emotionally. The nursing staff has rightly complained about by surly and disruptive behavior. Patients who wait hours before seeing a physician or PA do not care about an old and tired ER doc's problems.
As I write this posting, I am waiting to find out my fate. Will I be allowed to stay at the hospital where I have worked for 29 years, or will my unprofessional actions send me on a job search? Retirement is not an option. A less stressful work situation is in order. Another physician in my group has been advocating for 8 hour night shifts for years. My fellow B.O.N.E.R. doc, Zorba and I have stubbornly clung to our 10 hour nights. Pride, arrogance, and hubris all contributed to my insistence on maintaining my schedule even as my health and interpersonal relationships suffered.
My problems are trivial compared to the fate of my mother and mother-in-law. Nearing 92 years of age, my mother has settled into her life in a nursing home. The facility is clean, well staffed and maintained, and Ma is safe and secure. That doesn't totally free me of the guilt of only seeing her once a week. My schedule and the distance between my home and the nursing home makes once a week visits all I can give. Ma is pleasantly confused. Her short term memory is impaired but she knows her family and friends and enjoys visitors, phone calls, and activities.
The exotic woman of indeterminate age, who is my wife, has a equally extraordinary mother. I met my mother-in-law some 40 years ago. She was intelligent, attractive and strong willed. My Dad advised to check out the mother of the women I dated. His words of wisdom proved fateful. Mother has lived a life of honor. She loved and cared for her husband as he became disabled from a progressive neurological disease. She loved her children and grandchildren. She and my wife travelled together, saw shows and had a wonderful mother-daughter relationship. Mother gave love and support to her sister, niece and nephew, friends and coworkers. She was still working in retail 32 hours a week when she was diagnosed with pancreatic cancer.
Mother has survived breast and uterine cancer with attendent surgeries. She had one hip replaced twice and the other hip once. Osteoarthritis became another challenge to overcome. She kept in touch with old friends and made new friends as she moved and worked in different locations. Impeccably dressed and coifed, she exemplified class.
Since the last paragraph, I have left Starbucks and my meeting with the director of my group. I am sitting a few feet from Mother. She is resting comfortably. She smiled when I arrived and gave her a kiss. She wishes to die with dignity. She left the hospital for the last time and is home with hospice care. She is surrounded by her familiar belongings including furniture, pictures and her beloved collection of elephants. Her family will be with her until the end and honor her wishes.
Our family will continue our lives. We will be bereft but inspired by Mother's life.
The world's oldest ER doc will eventually get off the night shift. I will remain a B.O.N.E.R. doc in my heart. B.O.N.E.R. doc emeritus.
As I write this posting, I am waiting to find out my fate. Will I be allowed to stay at the hospital where I have worked for 29 years, or will my unprofessional actions send me on a job search? Retirement is not an option. A less stressful work situation is in order. Another physician in my group has been advocating for 8 hour night shifts for years. My fellow B.O.N.E.R. doc, Zorba and I have stubbornly clung to our 10 hour nights. Pride, arrogance, and hubris all contributed to my insistence on maintaining my schedule even as my health and interpersonal relationships suffered.
My problems are trivial compared to the fate of my mother and mother-in-law. Nearing 92 years of age, my mother has settled into her life in a nursing home. The facility is clean, well staffed and maintained, and Ma is safe and secure. That doesn't totally free me of the guilt of only seeing her once a week. My schedule and the distance between my home and the nursing home makes once a week visits all I can give. Ma is pleasantly confused. Her short term memory is impaired but she knows her family and friends and enjoys visitors, phone calls, and activities.
The exotic woman of indeterminate age, who is my wife, has a equally extraordinary mother. I met my mother-in-law some 40 years ago. She was intelligent, attractive and strong willed. My Dad advised to check out the mother of the women I dated. His words of wisdom proved fateful. Mother has lived a life of honor. She loved and cared for her husband as he became disabled from a progressive neurological disease. She loved her children and grandchildren. She and my wife travelled together, saw shows and had a wonderful mother-daughter relationship. Mother gave love and support to her sister, niece and nephew, friends and coworkers. She was still working in retail 32 hours a week when she was diagnosed with pancreatic cancer.
Mother has survived breast and uterine cancer with attendent surgeries. She had one hip replaced twice and the other hip once. Osteoarthritis became another challenge to overcome. She kept in touch with old friends and made new friends as she moved and worked in different locations. Impeccably dressed and coifed, she exemplified class.
Since the last paragraph, I have left Starbucks and my meeting with the director of my group. I am sitting a few feet from Mother. She is resting comfortably. She smiled when I arrived and gave her a kiss. She wishes to die with dignity. She left the hospital for the last time and is home with hospice care. She is surrounded by her familiar belongings including furniture, pictures and her beloved collection of elephants. Her family will be with her until the end and honor her wishes.
Our family will continue our lives. We will be bereft but inspired by Mother's life.
The world's oldest ER doc will eventually get off the night shift. I will remain a B.O.N.E.R. doc in my heart. B.O.N.E.R. doc emeritus.
Friday, March 11, 2011
Clusters
The world's oldest ER doc has survived another winter. Too much snow, leaking roofs, freezing temperatures and no Caribbean vacation made this a particularly onerous winter. The continuously rising ER census added to my SAD.
My beloved wife booked us for a three night escape in VERMONT. It snowed 12 inches the day after our arrival and I had extreme flop sweat driving home in an ice storm. We returned to the hacienda to find 6 inches of wet heavy snow. We did discover the joy of snowshoeing but a beach in Puerto Rico would have been oh so therapeutic.
What does this have to do with clusters? Nothing, I just needed to vent. Before getting to clusters, she, who is an exotic woman of indeterminate age, made a scheduling conflict. This deprived me of my one excuse to take the tuxedo out of mothballs. We missed the black tie charity ball. The upside was that our grandniece, along with her mother, grandmother and grand aunt, got to enjoy a sophisticated night of dinner and "Mary Poppins".
Epidemiology is the study of the spread and control of diseases. A cluster is a "pocket" of a disease or condition that is statistically aberrant. A person of my acquaintance recently pointed out that her neighborhood had a large number of young people with learning disabilities and or mental illness. The cause was not evident to her but she suspected that neurological Lyme disease might play a role.
The incident of a disease in a population can be easily enumerated. One in a hundred or one in 10,000 are derived from the number of cases of an illness in a given population. The geographic distribution of these cases may not be even, i.e., clusters. Clusters of cases may represent a local factor that contributes to the disease or be totally random.
Bacterial meningitis has a definable incidence in the US. The clustering of cases in military installations and college communities is real and represents the grouping of large numbers of potentially susceptible people in a small area.
When an an unusually rare disease suddenly appears in a narrow population, there is often a specific cause. Clear cell carcinoma of the vagina began to appear in young women back in the sixties and seventies. An epidemiological examination revealed that all the young woman had been exposed to DES in utero. Diethylstilbesterol was given to women at risk for miscarriage in the fifties and sixties. It did not prevent miscarriage but did induce abnormalities in the genitourinary tracts of the exposed children.
The virus that caused HIV was found after the disease AIDS was recognized. Unusual pneumonias, rare cancers, and early deaths sparked the epidemiologists to uncover the roots of the AIDS epidemic and led to the successful isolating of the HIV and the treatments that have prolonged the lives of these patients. Our blood supply is constantly being screened for transmissible diseases, thanks to the work of medical sleuths in epidemiology and medical research labs.
A disturbing trend among well intentioned parents, is to not vaccinate their children. The rationale for this dangerous decision is the belief that vaccines may cause autism. The facts are that the incident of children diagnosed with autism is climbing. There are any number of reasons for this rise in cases of autism. Better knowledge of the variety of conditions in the autism spectrum by physician and the general public accounts for some of the increase. The miasma of chemicals in our environment from PCB's, phthalates, hormones fed to animals, and industrial and agricultural run off, may all cause damage to developing nervous systems. There is no evidence that the MMR or other vaccination causes autism.
The human brain looks for patterns. Seeing the image of Abe Lincoln in a potato chip illustrates this phenomenon. The danger lies in not remaining scientifically skeptical in the pursuit of seemingly significant clusters of disease. Don't believe everything you read on the internet. This blogger tries to be accurate. I use information from peer reviewed scientific literature, not Wikipedia.
Stay informed, be skeptical.
I saw my first robin yesterday, and I heard the congaree of the redwing blackbird last weekend. Spring is here. Rejoice!
My beloved wife booked us for a three night escape in VERMONT. It snowed 12 inches the day after our arrival and I had extreme flop sweat driving home in an ice storm. We returned to the hacienda to find 6 inches of wet heavy snow. We did discover the joy of snowshoeing but a beach in Puerto Rico would have been oh so therapeutic.
What does this have to do with clusters? Nothing, I just needed to vent. Before getting to clusters, she, who is an exotic woman of indeterminate age, made a scheduling conflict. This deprived me of my one excuse to take the tuxedo out of mothballs. We missed the black tie charity ball. The upside was that our grandniece, along with her mother, grandmother and grand aunt, got to enjoy a sophisticated night of dinner and "Mary Poppins".
Epidemiology is the study of the spread and control of diseases. A cluster is a "pocket" of a disease or condition that is statistically aberrant. A person of my acquaintance recently pointed out that her neighborhood had a large number of young people with learning disabilities and or mental illness. The cause was not evident to her but she suspected that neurological Lyme disease might play a role.
The incident of a disease in a population can be easily enumerated. One in a hundred or one in 10,000 are derived from the number of cases of an illness in a given population. The geographic distribution of these cases may not be even, i.e., clusters. Clusters of cases may represent a local factor that contributes to the disease or be totally random.
Bacterial meningitis has a definable incidence in the US. The clustering of cases in military installations and college communities is real and represents the grouping of large numbers of potentially susceptible people in a small area.
When an an unusually rare disease suddenly appears in a narrow population, there is often a specific cause. Clear cell carcinoma of the vagina began to appear in young women back in the sixties and seventies. An epidemiological examination revealed that all the young woman had been exposed to DES in utero. Diethylstilbesterol was given to women at risk for miscarriage in the fifties and sixties. It did not prevent miscarriage but did induce abnormalities in the genitourinary tracts of the exposed children.
The virus that caused HIV was found after the disease AIDS was recognized. Unusual pneumonias, rare cancers, and early deaths sparked the epidemiologists to uncover the roots of the AIDS epidemic and led to the successful isolating of the HIV and the treatments that have prolonged the lives of these patients. Our blood supply is constantly being screened for transmissible diseases, thanks to the work of medical sleuths in epidemiology and medical research labs.
A disturbing trend among well intentioned parents, is to not vaccinate their children. The rationale for this dangerous decision is the belief that vaccines may cause autism. The facts are that the incident of children diagnosed with autism is climbing. There are any number of reasons for this rise in cases of autism. Better knowledge of the variety of conditions in the autism spectrum by physician and the general public accounts for some of the increase. The miasma of chemicals in our environment from PCB's, phthalates, hormones fed to animals, and industrial and agricultural run off, may all cause damage to developing nervous systems. There is no evidence that the MMR or other vaccination causes autism.
The human brain looks for patterns. Seeing the image of Abe Lincoln in a potato chip illustrates this phenomenon. The danger lies in not remaining scientifically skeptical in the pursuit of seemingly significant clusters of disease. Don't believe everything you read on the internet. This blogger tries to be accurate. I use information from peer reviewed scientific literature, not Wikipedia.
Stay informed, be skeptical.
I saw my first robin yesterday, and I heard the congaree of the redwing blackbird last weekend. Spring is here. Rejoice!
Saturday, February 19, 2011
Chronic
A young woman came to the ER this past week with a number of vague complaints. She had lightheadedness when she stood up, occasional nausea and had done several home pregnancy tests which were all negative. She had had these complaints for weeks. She had state based health insurance. Unlike those of us with commercial insurance, she didn't have to make a copayment for using the ER as a walk-in clinic. In her defense, she had been unable to find a primary-care physician willing to accept her insurance.
The issue of why she was triaged as a priority 3, which put her on the physician side of the ER instead of the "fast track" for the PA's to evaluate, is a subject for another blog. Her vital signs were normal. She was fit, healthy looking and a cursory exam revealed no evidence of any disease process. A review of symptoms was unhelpful. This pleasant woman asked if I would do some blood tests. I was tempted to decline any testing as unnecessary and more appropriate for a primary care setting. The problem of a dearth of available options for this patient led me to acquiesce to her request. Her EKG, chem panel, thyroid screen and complete blood count were all normal. I referred her to the local health clinic knowing that they would accept her insurance but that she would be given an appointment several months in the future.
This is not an isolated occurrence in the ER. Every shift, I see many patients who could easily be assessed and treated in a physician's office or clinic. The ER staff tries to cope with these less than urgent cases along with the truly sick and injured patients that require emergent treatment.
Chronic pains, persistent skin conditions, medication refills, and management of long-term illnesses such as hypertension and diabetes make up some of the non-urgent problems arriving in the ER. Patients with a physician inexplicably show up in the ER within 24 hours of a scheduled appointment to deal with their problem. This pattern will be familiar to anyone who works in an ER.
Over scheduled primary care offices send patients to the ER as a convenient source of labs, x-rays and treatment. Call a pediatrician at 2:00 AM and tell him or her that little Johnny or Susie has a fever and more likely than not the concerned parent will be told to go to the ER. The reasoning is understandable. The doctor may have a full office the next day or it is the weekend and the office is closed. Fear of a malpractice suit based on advising the parent by phone and the child does poorly or dies, is also a valid reason to direct the parents and child to the ER.
Patients arrive in the ER by ambulance and through the front door. The ambulance patients are usually more seriously ill or injured. A significant percentage of ambulance patients simply use the ambulance as a free taxi ride. One's insurance determines who ultimately pays for inappropriate ambulance use. The non urgent patient who arrives by ambulance often expects the hospital to pay for a taxi to return them home. This cost is not recouped. The federally mandated requirement to provide translation services to all patients is also not compensated. The financial viability of community hospitals is tenuous. Free care, expensive "language lines", feeding and warehousing psychiatric patients for days, and taxi vouchers all adversely effect a hospital's bottom line.
Like all my readers, I am a tax paying citizen of this wonderful country. I vote in all elections. I make use of written and electronic sources of information to keep current. Local and national politician make laws that effect my own health care insurance and the way I practice my profession. No editorial comments will be offered by this writer. I am simply reporting the truths of the ER as I perceive them.
The issue of why she was triaged as a priority 3, which put her on the physician side of the ER instead of the "fast track" for the PA's to evaluate, is a subject for another blog. Her vital signs were normal. She was fit, healthy looking and a cursory exam revealed no evidence of any disease process. A review of symptoms was unhelpful. This pleasant woman asked if I would do some blood tests. I was tempted to decline any testing as unnecessary and more appropriate for a primary care setting. The problem of a dearth of available options for this patient led me to acquiesce to her request. Her EKG, chem panel, thyroid screen and complete blood count were all normal. I referred her to the local health clinic knowing that they would accept her insurance but that she would be given an appointment several months in the future.
This is not an isolated occurrence in the ER. Every shift, I see many patients who could easily be assessed and treated in a physician's office or clinic. The ER staff tries to cope with these less than urgent cases along with the truly sick and injured patients that require emergent treatment.
Chronic pains, persistent skin conditions, medication refills, and management of long-term illnesses such as hypertension and diabetes make up some of the non-urgent problems arriving in the ER. Patients with a physician inexplicably show up in the ER within 24 hours of a scheduled appointment to deal with their problem. This pattern will be familiar to anyone who works in an ER.
Over scheduled primary care offices send patients to the ER as a convenient source of labs, x-rays and treatment. Call a pediatrician at 2:00 AM and tell him or her that little Johnny or Susie has a fever and more likely than not the concerned parent will be told to go to the ER. The reasoning is understandable. The doctor may have a full office the next day or it is the weekend and the office is closed. Fear of a malpractice suit based on advising the parent by phone and the child does poorly or dies, is also a valid reason to direct the parents and child to the ER.
Patients arrive in the ER by ambulance and through the front door. The ambulance patients are usually more seriously ill or injured. A significant percentage of ambulance patients simply use the ambulance as a free taxi ride. One's insurance determines who ultimately pays for inappropriate ambulance use. The non urgent patient who arrives by ambulance often expects the hospital to pay for a taxi to return them home. This cost is not recouped. The federally mandated requirement to provide translation services to all patients is also not compensated. The financial viability of community hospitals is tenuous. Free care, expensive "language lines", feeding and warehousing psychiatric patients for days, and taxi vouchers all adversely effect a hospital's bottom line.
Like all my readers, I am a tax paying citizen of this wonderful country. I vote in all elections. I make use of written and electronic sources of information to keep current. Local and national politician make laws that effect my own health care insurance and the way I practice my profession. No editorial comments will be offered by this writer. I am simply reporting the truths of the ER as I perceive them.
Sunday, February 6, 2011
SUPER BOWL
One hour to kickoff for SB XLV. I worked the past 2 Sundays so that I can be home to watch the Big Game. The ER staff has lots of "rules" regarding events and holidays and even astronomical occurrences.
Let's start with tonight. No men between 16 and 60 will come to the ER until after the game. "When did your chest pains begin Mr Smith?" "After the first quarter, but I assumed that it was the buffalo wings." Women and children and the elderly will still arrive for real and trivial problems. After the game, the menfolk will come in for stomachs aches, chest pains and injuries sustained from heated debate during or after the game.
The full moon is allegedly associated with an increase in psychiatric complaints. The word lunacy is derived from the Latin word for the moon. The phases of the moon exert gravitational effects on the tides but have no biological effect on humans, except of course for werewolves.
The night before major holidays such as Christmas, Thanksgiving and Easter leads to a never ending stream of sick children who need to be cured before the night ends. After the holiday feast the overeating and suspension of dietary restrictions will produce patients with GI problems or congestive heart failure from excessive salt intake.
Saint Patrick's Day celebrants may drink a wee bit too much and suffer the direct deleterious side effects of alcohol poisoning. The disinhibition of alcohol increases the number of assault victims.
July 4th is sure to bring in hand injuries from exploding fireworks. One fourth of July I treated 2 geniuses who filled inflatable pool floats with acetylene gas. When the toys exploded, their eye and ear trauma was severe.
An increase in suicide ideation and attempts occurs with most major holidays. The upcoming Valentine's Day may be a very lonely day if one doesn't have a valentine.
The beer is chilled. The chili and chocolate cookies are prepared. The Chinese take-out and the guests will be arriving soon. Kick off in 20 minutes. GO ______!
Let's start with tonight. No men between 16 and 60 will come to the ER until after the game. "When did your chest pains begin Mr Smith?" "After the first quarter, but I assumed that it was the buffalo wings." Women and children and the elderly will still arrive for real and trivial problems. After the game, the menfolk will come in for stomachs aches, chest pains and injuries sustained from heated debate during or after the game.
The full moon is allegedly associated with an increase in psychiatric complaints. The word lunacy is derived from the Latin word for the moon. The phases of the moon exert gravitational effects on the tides but have no biological effect on humans, except of course for werewolves.
The night before major holidays such as Christmas, Thanksgiving and Easter leads to a never ending stream of sick children who need to be cured before the night ends. After the holiday feast the overeating and suspension of dietary restrictions will produce patients with GI problems or congestive heart failure from excessive salt intake.
Saint Patrick's Day celebrants may drink a wee bit too much and suffer the direct deleterious side effects of alcohol poisoning. The disinhibition of alcohol increases the number of assault victims.
July 4th is sure to bring in hand injuries from exploding fireworks. One fourth of July I treated 2 geniuses who filled inflatable pool floats with acetylene gas. When the toys exploded, their eye and ear trauma was severe.
An increase in suicide ideation and attempts occurs with most major holidays. The upcoming Valentine's Day may be a very lonely day if one doesn't have a valentine.
The beer is chilled. The chili and chocolate cookies are prepared. The Chinese take-out and the guests will be arriving soon. Kick off in 20 minutes. GO ______!
Saturday, February 5, 2011
Writer's Block
As I stare at my laptop and pray to St Francis de Sales (patron saint of writers) for inspiration, I realize that I have writer's block. The fact that I am not Catholic, highlights my dilemma. Hermes, Thoth, Kuan Yu or Ganesha are all deities that might heed the desperation of a blocked writer.Then I remember that I am an ER doctor who enjoys writing and my block was relieved.
A not uncommon presenting complaint in Emergency Medicine is constipation . Bowel complaints may be either the main problem, a symptom of a disease process or an issue revealed during the ROS (review of symptoms).
First it is necessary to define our terminology. Constipation is very patient sensitive. Missing part of the GI tract due to congenital or surgical reasons leads to "dumping syndrome". Normal number of bowel movements per day for these people may be 1-20. Many people have a single BMPD. Other perfectly healthy individuals may only have 2-3 BM's per week. Therefore the question I ask is "has there been a change in your bowel habits".
A brief aside is needed to deal with euphemisms. Bowel movement is a somewhat stilted term for a universal bodily function. Dumps, poops, cacas, number 2's, craps, and sh_ts are all acceptable ways of addressing the concept of fecal elimination. Similarly diarrhea may be referred to as the trots, runs, or squirts. My brother-in-law likes to say he is peeing out of his ass.
The extremes of age constitute most patients with a main complaint of constipation. The elderly have less vigorous contractions of the muscles of the large intestine. This problem is aggravated by many of the medications that the older patients may be taking. Medications for asthma, emphysema, COPD, Parkinson's disease, glaucoma, hypertension, insomnia, anemia, depression, psychosis, pain and nonprescription meds for colds and the flu may all lead to constipation. Decreased thirst and lack of access to water in the nursing home patient may also contribute to constipation.
Mothers frequently bring in their babies with a chief complaint of no stools in (_) number of days. A quick examination of the abdomen and possibly the taking of a rectal temperature may cure the problem. Changes in formula or powdered formula that is not diluted with the recommended amount of water may make the stools hard and difficult to pass. In the newborn, congenital problems with the coordination of the nervous and muscular components of the intestines must be considered.
Diseases of the spinal cord may present with constipation. Spinal stenosis, multiple sclerosis, arthritis of the vertebrae, infections near the cord and intervertebral disc disease may all cause constipation. A careful history and physical exam should help in diagnosing these serious conditions. Imaging studies, especially MRI of the spine will confirm the ER doc's suspicions.
The etymology of the word impaction comes from Latin impingere, to impinge. In the ER impaction may refer to third molars (wisdom teeth) growing into the second molar. A fracture of a bone is said to be impacted if the two ends of the fractured bones are jambed together, i.e. impinged. The use of the word impaction that makes even the most seasoned ER doc cringe is fecal impaction.
When a patient with constipation has a mass of dense stool that is too large and/or too hard to pass, he or she has a fecal impaction. Sometimes a thin liquid stool may ooze past the impaction and the patient has both symptoms of constipation and diarrhea.
My PA, Robin and I try to take turns "curing" the dreaded fecal impaction. One prepares for disimpaction by donning a barrier gown, and double gloves. My armament includes a mask with a dab of Tiger Balm applied to the inside. This gingery scented ointment counteracts the inevitable odor emanating from the patient. Sedation is beneficial as disimpacting is a painful procedure.
Ah, I feel relieved. Treat your digestive system well. Eat lots of fruits and vegetables. Exercise daily. Whole grains are the bowel's friends. Don't abuse laxatives.
A not uncommon presenting complaint in Emergency Medicine is constipation . Bowel complaints may be either the main problem, a symptom of a disease process or an issue revealed during the ROS (review of symptoms).
First it is necessary to define our terminology. Constipation is very patient sensitive. Missing part of the GI tract due to congenital or surgical reasons leads to "dumping syndrome". Normal number of bowel movements per day for these people may be 1-20. Many people have a single BMPD. Other perfectly healthy individuals may only have 2-3 BM's per week. Therefore the question I ask is "has there been a change in your bowel habits".
A brief aside is needed to deal with euphemisms. Bowel movement is a somewhat stilted term for a universal bodily function. Dumps, poops, cacas, number 2's, craps, and sh_ts are all acceptable ways of addressing the concept of fecal elimination. Similarly diarrhea may be referred to as the trots, runs, or squirts. My brother-in-law likes to say he is peeing out of his ass.
The extremes of age constitute most patients with a main complaint of constipation. The elderly have less vigorous contractions of the muscles of the large intestine. This problem is aggravated by many of the medications that the older patients may be taking. Medications for asthma, emphysema, COPD, Parkinson's disease, glaucoma, hypertension, insomnia, anemia, depression, psychosis, pain and nonprescription meds for colds and the flu may all lead to constipation. Decreased thirst and lack of access to water in the nursing home patient may also contribute to constipation.
Mothers frequently bring in their babies with a chief complaint of no stools in (_) number of days. A quick examination of the abdomen and possibly the taking of a rectal temperature may cure the problem. Changes in formula or powdered formula that is not diluted with the recommended amount of water may make the stools hard and difficult to pass. In the newborn, congenital problems with the coordination of the nervous and muscular components of the intestines must be considered.
Diseases of the spinal cord may present with constipation. Spinal stenosis, multiple sclerosis, arthritis of the vertebrae, infections near the cord and intervertebral disc disease may all cause constipation. A careful history and physical exam should help in diagnosing these serious conditions. Imaging studies, especially MRI of the spine will confirm the ER doc's suspicions.
The etymology of the word impaction comes from Latin impingere, to impinge. In the ER impaction may refer to third molars (wisdom teeth) growing into the second molar. A fracture of a bone is said to be impacted if the two ends of the fractured bones are jambed together, i.e. impinged. The use of the word impaction that makes even the most seasoned ER doc cringe is fecal impaction.
When a patient with constipation has a mass of dense stool that is too large and/or too hard to pass, he or she has a fecal impaction. Sometimes a thin liquid stool may ooze past the impaction and the patient has both symptoms of constipation and diarrhea.
My PA, Robin and I try to take turns "curing" the dreaded fecal impaction. One prepares for disimpaction by donning a barrier gown, and double gloves. My armament includes a mask with a dab of Tiger Balm applied to the inside. This gingery scented ointment counteracts the inevitable odor emanating from the patient. Sedation is beneficial as disimpacting is a painful procedure.
Ah, I feel relieved. Treat your digestive system well. Eat lots of fruits and vegetables. Exercise daily. Whole grains are the bowel's friends. Don't abuse laxatives.
Saturday, January 29, 2011
The Home
It happens most nights in the ER. One of the many nursing homes, that channel their residents to my hospital, calls about a pending transfer. GGB (geriatric go boom)? Difficulty breathing, fever, chest pain, vomiting and or diarrhea, altered mental status are all possible reasons. The first thing the ER staff wants to know is the patient's code status. DNI, DNR, DNH. It is not unusual to get a patient that the NH says is a full code who is actually a do not resuscitate. If the patient recently arrived in the NH and the DNI/DNR forms haven't been signed by the NH doctor, the patient, despite the patient and family's wishes is sent to me as a full code. DNH patients are essentially on hospice care. They are not to be transferred to a hospital without the consent of the health care proxy. Surprise, the NH staff sends the patient without calling the family.
Many NH patients have multiple medical problems and frequently have some degree of diminished mental functioning if not diagnosed dementia. This makes it difficult for the ER staff to get any history as to the presenting complaint's onset, progress or associated symptoms. For a patient with dementia, the trauma of being taken from their bed, loaded into an ambulance and transported to the hospital is frightening and disorienting. The patient's agitation may make the patient violent towards the ER personnel.
EKG's, IV's, rectal temps, catheter placements, examinations, hard stretchers, lights, and noise all add to the stress on the NH patient. This is usually occurring in the middle of the night. The disturbance of the patient's normal sleep schedule is an additional factor in their discomfort.
For me, it is now personal. My elderly, somewhat demented mother resides in a NH. The facility is clean, well staffed and offers stimulating programs for the residents. My siblings and extended family visit my mother frequently. She is still able to use a telephone to call family and friends. As with most patients with dementia, my mother's demeanor can change rather suddenly. Her lack of short term memory leads to her attempting to make sense of changes in her environment. She can become angry and lash out verbally at her children and the NH staff. Other times she is her usual sweet and loving self.
I admit that I do not see my mother as often as I should. Distance and my own health issues limit my visits to at most a once a week schedule. Being a physician, I cannot help but observe the physical condition of the the other residents of my mother's NH. Her tablemate for meals is a fairly young person who has both physical and mental limitations. Traumatic brain injury, post encephalitis, and multiple sclerosis are all possible etiologies. This patient is also delightful. Smiling, laughing and singing are this person's usual responses. My mother's roommate is sadly not very lively. This patient has had what appears to be a dominant hemisphere stroke and is aphasic and hemiplegic (nonverbal and paralyzed on one side).
Other residents are limited by arthritis, minor residual stroke symptoms, severe lung disease or congestive heart failure. One young person is clearly the victim of a traumatic brain injury, brain tumor or hemorrhagic event. I can see the evidence of a craniotomy on this patient's scalp. A few residents defy my powers of observation as to why they reside in a skilled NH facility. Chronic mental health issues may be the issue that led to them being patients in this NH.
As complicated, challenging, and frustating as these patients can be, they are still human. The care given by the ER techs and nurses is amazing. I think we all see our own elderly family members and even our future selves in these patients. My mother, in a very lucid state during yesterday's visit, told me something that may be a common desire in NH patients. She said that the staff was very good, even the food was OK, but that this was no life for her. Her wish and prayer is that at age 91, she wants to go to sleep and not awaken.
Many NH patients have multiple medical problems and frequently have some degree of diminished mental functioning if not diagnosed dementia. This makes it difficult for the ER staff to get any history as to the presenting complaint's onset, progress or associated symptoms. For a patient with dementia, the trauma of being taken from their bed, loaded into an ambulance and transported to the hospital is frightening and disorienting. The patient's agitation may make the patient violent towards the ER personnel.
EKG's, IV's, rectal temps, catheter placements, examinations, hard stretchers, lights, and noise all add to the stress on the NH patient. This is usually occurring in the middle of the night. The disturbance of the patient's normal sleep schedule is an additional factor in their discomfort.
For me, it is now personal. My elderly, somewhat demented mother resides in a NH. The facility is clean, well staffed and offers stimulating programs for the residents. My siblings and extended family visit my mother frequently. She is still able to use a telephone to call family and friends. As with most patients with dementia, my mother's demeanor can change rather suddenly. Her lack of short term memory leads to her attempting to make sense of changes in her environment. She can become angry and lash out verbally at her children and the NH staff. Other times she is her usual sweet and loving self.
I admit that I do not see my mother as often as I should. Distance and my own health issues limit my visits to at most a once a week schedule. Being a physician, I cannot help but observe the physical condition of the the other residents of my mother's NH. Her tablemate for meals is a fairly young person who has both physical and mental limitations. Traumatic brain injury, post encephalitis, and multiple sclerosis are all possible etiologies. This patient is also delightful. Smiling, laughing and singing are this person's usual responses. My mother's roommate is sadly not very lively. This patient has had what appears to be a dominant hemisphere stroke and is aphasic and hemiplegic (nonverbal and paralyzed on one side).
Other residents are limited by arthritis, minor residual stroke symptoms, severe lung disease or congestive heart failure. One young person is clearly the victim of a traumatic brain injury, brain tumor or hemorrhagic event. I can see the evidence of a craniotomy on this patient's scalp. A few residents defy my powers of observation as to why they reside in a skilled NH facility. Chronic mental health issues may be the issue that led to them being patients in this NH.
As complicated, challenging, and frustating as these patients can be, they are still human. The care given by the ER techs and nurses is amazing. I think we all see our own elderly family members and even our future selves in these patients. My mother, in a very lucid state during yesterday's visit, told me something that may be a common desire in NH patients. She said that the staff was very good, even the food was OK, but that this was no life for her. Her wish and prayer is that at age 91, she wants to go to sleep and not awaken.
Friday, January 21, 2011
Stopping by woods
Sitting and drinking coffee watching the snow fall. Did my 30 minutes on the rowing ergometer. Abs and obliques have been tuned. The old hound and I walked in the snow and he did his business (I scooped and dumped). Waiting for the snow to stop so I can shovel out. I am trying to remember why I never bought a snow blower.
The ER has been busy despite the frequent snow storms. Nothing keeps my patient from their ER visits. A disturbing trend has been an uptick in the number of overdoses both intentional and accidental. The quality of injectable opiates varies greatly. Just a slight increase in the purity of the heroin leads to a bump in OD's. The cynical and jaded would say that this is social Darwinism at work. I try to keep the thought in my mind that every junkie is someone's friend, son, daughter, parent, etc.
Straight opiate overdoses from oxycodone, hydrocodone, heroin, methadone and others respond rapidly to Narcan. This antidote may be injected into a vein or a muscle and rapidly reverses the sedating effect of the opiate. It has the deleterious side effect of inducing immediate opiate withdrawal. A gown, mask and shoe covers are recommended for the ER team as the addict often vomits like an open fire hydrant.
Cocaine is toxic in any dose. Snorted, shot or smoked the effects are immediate and protean. Chest pains, arrythmias, strokes, nose bleeds, lung damage are all possible presenting complaints for the cocaine user. The major weapon in the ER doc's bag of tricks is lorazepam. Sedation and lots of it is the standard of care. A high degree of vigilance is needed to assure a safe outcome for the patient and the ER staff.
The real challenge is an overdose involving medications and household or industrial chemicals. In my younger days, the assessment, decontamination and treatment of such ingestions or exposures was hit or miss. The concept of a centralized source of information for treating toxic ingestions or exposures began in Colorado with Dr Barry Rumack. The info was stored on microfiches. For the Google generation, a microfiche was a sheet of clear plastic that contained very small printing and was read with a special reader. Regional Poison Control centers are still available by phone 24/7. The internet is also a great source of info for ER staff.
Toxidromes are groups of symptoms associated with specific classes of medications. Every med student, PA and resident has learned the acronyms for these toxidromes. An example is MUDPILES. Many toxins and diseases can present with metabolic acidosis with a high anion gap. The pH of human blood is normally 7.4. When the pH goes lower that is acidosis. I will spare my nonmedical readers a boring dissertation on the Henderson-Hasselbalch equation. The acronym is an aid to remember the causes of this toxidrome and aid in a search for the agent or disease process and guide the treatment.
Acetaminophen (Tylenol and other brands), aspirin, ibuprofen (Advil, etc.), nonprescription sleep meds, cold meds, rubbing alcohol all can be dangerous and even lethal in high enough doses. Many young people take an overdose as a cry for help and/or attention. They are unaware of the toxicity of the common nonprescription medications they ingest.
Acetaminophen interferes with a metabolic process in the liver. As few as thirty 500 mg Tylenol tablets can lead to liver damage and death. The toxic dose is weight related and the time after ingestion guides the treatment. An effective treatment is available and effective if given before permanent liver damage has occurred. N-acetylcysteine is the antidote. There is an IV form of the chemical that makes treatment easy and rapid. The oral form of the chemical was noxious to the patient and the health care workers as it smells like rotten eggs. Thank goodness for progress.
Antihistamines (eg Benadryl) are found in sleep aids, cold and flu formulations and allergy medications. Although they are safe and effective when used in recommended doses, they can be very dangerous in large amounts. The mnemonic that I learned back in the dark ages was: mad as a hatter, hot as a hen, red as a beet, dry as a bone. The symptoms of anticholinergic poisoning include hallucinations, fever, flushing, and dry skin thus the mnemonic. Tachycardia, seizures and coma are also seen in OD's of antihistamines. Jimson weed (Datura stramonium) is smoked and made into a tea as a mild hallucinogen. Too much can cause anticholingeric toxic symptoms.
For parents of small children (or adventurous/suicidal adolescents and teens) the recommendation for home treatment has changed. Giving Ipecac to induce vomiting is no longer the treatment of choice. Activated charcoal is the best option. It binds most medications and therefore limits the amount of the drug that can be absorbed from the GI tract. Check your medicine cabinets. Safely dispose of any medication that you are not currently using. Use child-proof containers. Consider locks on medicine cabinets. As little a single pill of some prescription medications may be a fatal overdose in a toddler.
The snow is still coming down but it should end soon. Let the shovelling begin. I think tonight I will have Hiberian Cure-all, single malt scotch and ibuprofen.
The ER has been busy despite the frequent snow storms. Nothing keeps my patient from their ER visits. A disturbing trend has been an uptick in the number of overdoses both intentional and accidental. The quality of injectable opiates varies greatly. Just a slight increase in the purity of the heroin leads to a bump in OD's. The cynical and jaded would say that this is social Darwinism at work. I try to keep the thought in my mind that every junkie is someone's friend, son, daughter, parent, etc.
Straight opiate overdoses from oxycodone, hydrocodone, heroin, methadone and others respond rapidly to Narcan. This antidote may be injected into a vein or a muscle and rapidly reverses the sedating effect of the opiate. It has the deleterious side effect of inducing immediate opiate withdrawal. A gown, mask and shoe covers are recommended for the ER team as the addict often vomits like an open fire hydrant.
Cocaine is toxic in any dose. Snorted, shot or smoked the effects are immediate and protean. Chest pains, arrythmias, strokes, nose bleeds, lung damage are all possible presenting complaints for the cocaine user. The major weapon in the ER doc's bag of tricks is lorazepam. Sedation and lots of it is the standard of care. A high degree of vigilance is needed to assure a safe outcome for the patient and the ER staff.
The real challenge is an overdose involving medications and household or industrial chemicals. In my younger days, the assessment, decontamination and treatment of such ingestions or exposures was hit or miss. The concept of a centralized source of information for treating toxic ingestions or exposures began in Colorado with Dr Barry Rumack. The info was stored on microfiches. For the Google generation, a microfiche was a sheet of clear plastic that contained very small printing and was read with a special reader. Regional Poison Control centers are still available by phone 24/7. The internet is also a great source of info for ER staff.
Toxidromes are groups of symptoms associated with specific classes of medications. Every med student, PA and resident has learned the acronyms for these toxidromes. An example is MUDPILES. Many toxins and diseases can present with metabolic acidosis with a high anion gap. The pH of human blood is normally 7.4. When the pH goes lower that is acidosis. I will spare my nonmedical readers a boring dissertation on the Henderson-Hasselbalch equation. The acronym is an aid to remember the causes of this toxidrome and aid in a search for the agent or disease process and guide the treatment.
Acetaminophen (Tylenol and other brands), aspirin, ibuprofen (Advil, etc.), nonprescription sleep meds, cold meds, rubbing alcohol all can be dangerous and even lethal in high enough doses. Many young people take an overdose as a cry for help and/or attention. They are unaware of the toxicity of the common nonprescription medications they ingest.
Acetaminophen interferes with a metabolic process in the liver. As few as thirty 500 mg Tylenol tablets can lead to liver damage and death. The toxic dose is weight related and the time after ingestion guides the treatment. An effective treatment is available and effective if given before permanent liver damage has occurred. N-acetylcysteine is the antidote. There is an IV form of the chemical that makes treatment easy and rapid. The oral form of the chemical was noxious to the patient and the health care workers as it smells like rotten eggs. Thank goodness for progress.
Antihistamines (eg Benadryl) are found in sleep aids, cold and flu formulations and allergy medications. Although they are safe and effective when used in recommended doses, they can be very dangerous in large amounts. The mnemonic that I learned back in the dark ages was: mad as a hatter, hot as a hen, red as a beet, dry as a bone. The symptoms of anticholinergic poisoning include hallucinations, fever, flushing, and dry skin thus the mnemonic. Tachycardia, seizures and coma are also seen in OD's of antihistamines. Jimson weed (Datura stramonium) is smoked and made into a tea as a mild hallucinogen. Too much can cause anticholingeric toxic symptoms.
For parents of small children (or adventurous/suicidal adolescents and teens) the recommendation for home treatment has changed. Giving Ipecac to induce vomiting is no longer the treatment of choice. Activated charcoal is the best option. It binds most medications and therefore limits the amount of the drug that can be absorbed from the GI tract. Check your medicine cabinets. Safely dispose of any medication that you are not currently using. Use child-proof containers. Consider locks on medicine cabinets. As little a single pill of some prescription medications may be a fatal overdose in a toddler.
The snow is still coming down but it should end soon. Let the shovelling begin. I think tonight I will have Hiberian Cure-all, single malt scotch and ibuprofen.
Saturday, January 8, 2011
A Day in the Life of Mikhail Jizniovitch
With apologies to the fictional Ivan Denisovitch and his creator Aleksandr Solzhenitsyn
My name is Mikhail Jizniovitch. I am a prisoner in the gulag. The gulags are also known as hospitals. The masters of the gulag have many names: Medicaid, Medicare, Red Cross/Red Shield and others. We, the inmates, toil to do the bidding of our masters. We dole out health care to the proletariat.
Today is Tuesday. The gulag must function 24 hours a day, seven days a week, always we must be of service to the people and our masters. I work every Tuesday night in my capacity as a healer in the Urgent Center of my gulag. Many other prisoners labor in the Urgent Center. My healer assistant is Robina Popova. The nurse comrades and technician comrades have also been sentenced to serve the health care bureaucracy.
I arrive at 2030 hours to relieve my fellow comrade healer of his difficulties. Comrade healer tells me of the illnesses and plans to treat our comrade patients. Scanning my computer screen makes me sigh. There are 8 patients on racks awaiting their care. Many more peasants sit in the holding area seeking help for their pain and suffering.
Before I can see a single patient, the Emergency Medico Serfdom (EMS) rolls to the door with an unfortunate who is vomiting into a blue bag and groans in pain. The nurse commandant and her minions struggle to make room for this arriving sufferer. My list of patients must be amended to place the new patient in the order of prioritized illnesses.
The patients electronic dossiers are read. Examinations performed and histories obtained, I order tests and medications. My dear coworkers struggle to meet the demands of the patients and their families. Monitors send off alarms, patient call buttons emit piercing klaxons; chaos is our ever present companion.
In the local region of our province we are the gulag for the victims of violence. Members of the rank and file, who have been injured by automobile collisions, knives, guns, predation of parental, sexual and criminal types, arrive walking, limping, or carried by EMS. We also minister to children and expectant mothers of the region. Those who suffer from diseases of the mind or the ravages of old age are preferentially depositing in this gulag's Urgent Center.
Chest pain, abdominal pain, headaches, weakness, depression, delusions, fever, coughs, bumps, twists, deformities, wounds; blood and/or drainage from noses, genitals, mouths, rectums; boils, sores, rashes, imbibers of vodka and other intoxicants; shortness of breath, lethargy, confusion; births and deaths.
I have served 30 years of a life sentence. My needs for shelter, food and even the pleasures of my life are met by the rewards bestowed by the masters of the gulags. My actions are closely scrutinized. I may be summoned before the politburo at any time. I am tired in body and spirit. The true payment is in the camaraderie of my fellow inmates and the gratitude of the masses who turn to the gulag's Urgent Center for relief.
My name is Mikhail Jizniovitch. I am a prisoner in the gulag. The gulags are also known as hospitals. The masters of the gulag have many names: Medicaid, Medicare, Red Cross/Red Shield and others. We, the inmates, toil to do the bidding of our masters. We dole out health care to the proletariat.
Today is Tuesday. The gulag must function 24 hours a day, seven days a week, always we must be of service to the people and our masters. I work every Tuesday night in my capacity as a healer in the Urgent Center of my gulag. Many other prisoners labor in the Urgent Center. My healer assistant is Robina Popova. The nurse comrades and technician comrades have also been sentenced to serve the health care bureaucracy.
I arrive at 2030 hours to relieve my fellow comrade healer of his difficulties. Comrade healer tells me of the illnesses and plans to treat our comrade patients. Scanning my computer screen makes me sigh. There are 8 patients on racks awaiting their care. Many more peasants sit in the holding area seeking help for their pain and suffering.
Before I can see a single patient, the Emergency Medico Serfdom (EMS) rolls to the door with an unfortunate who is vomiting into a blue bag and groans in pain. The nurse commandant and her minions struggle to make room for this arriving sufferer. My list of patients must be amended to place the new patient in the order of prioritized illnesses.
The patients electronic dossiers are read. Examinations performed and histories obtained, I order tests and medications. My dear coworkers struggle to meet the demands of the patients and their families. Monitors send off alarms, patient call buttons emit piercing klaxons; chaos is our ever present companion.
In the local region of our province we are the gulag for the victims of violence. Members of the rank and file, who have been injured by automobile collisions, knives, guns, predation of parental, sexual and criminal types, arrive walking, limping, or carried by EMS. We also minister to children and expectant mothers of the region. Those who suffer from diseases of the mind or the ravages of old age are preferentially depositing in this gulag's Urgent Center.
Chest pain, abdominal pain, headaches, weakness, depression, delusions, fever, coughs, bumps, twists, deformities, wounds; blood and/or drainage from noses, genitals, mouths, rectums; boils, sores, rashes, imbibers of vodka and other intoxicants; shortness of breath, lethargy, confusion; births and deaths.
I have served 30 years of a life sentence. My needs for shelter, food and even the pleasures of my life are met by the rewards bestowed by the masters of the gulags. My actions are closely scrutinized. I may be summoned before the politburo at any time. I am tired in body and spirit. The true payment is in the camaraderie of my fellow inmates and the gratitude of the masses who turn to the gulag's Urgent Center for relief.
Saturday, January 1, 2011
Auld Lang Syne
DNR. DNI. DNH. These are abbreviations for advanced directives(do not resuscitate, intubate or hospitalize, respectively). Patients, family members, health care proxies, and guardians may decide in advance the level of medical care the patient wishes during a health emergency. The ER staff is often faced with issues related to these choices. A patient from a nursing home or assisted living facility should have a copy of the patient's advance directives (AD) available on arrival in the ER. I stress the should, because there have been many instances in which erroneous information led to unwanted and futile resuscitation efforts.
This past week I went in to examine a septuagenarian who was in severe respiratory distress when he arrived from a nursing home. The EMT's told me the patient was a full code. Thanks to the hospital's EMR (electronic medical record) system I knew that the patient had chronic pulmonary and cardiac problems and suffered from dementia. A DNR was found in the pile of forms sent with the patient. I treated the patient with medications and when his family arrived they confirmed his DNI/DNR status and were grateful that we had given him some relief without compromising his AD.
Many years ago when the ER was not as busy as now, I went into to see an elderly man who was near death. There was no AD. His daughter arrived and I explained that even with intubation and ventilator support, her father's prognosis was poor. She asked me what I would choose if this was my father. My father died at home under hospice care with metastatic renal cell carcinoma. He died peacefully and in accord with his wish to die at home. I shared my experience with this woman. Together, we decided to let the natural course of the father's disease go untreated except for some mild sedation. She held one hand of her father and I held the other. He died peacefully in less than 15 minutes. She and I shared some tears and honored our fathers.
This past week I experienced the reverse of this outcome. An elderly man arrived in distress. His health care proxy and guardian was a cousin near to my age. There was no AD. When I explained the problem and offered care and comfort, she opted for full resuscitation. Respecting the family's wishes, I intubated the patient, put him on a ventilator and admitted him to the ICU. Primum non nocere. "First do no harm" is part of the Hippocratic Oath. I felt that instead of relieving this gentleman's suffering, I had prolonged his existence but not his life. I believe that family's request were given in good faith and in the belief that the patient should be given every chance of continued life.
A recent controversy, in reimbursement for primary care doctors, is whether the physician should be compensated for the time needed to help families making end of life care choices. It is frustrating for ER docs that during a crisis, my colleagues and I must ascertain from a distraught family as to how aggressively we should treat the patient. The time for an individual to make decisions about end of life care is when they are healthy. A trusted family doctor can be of great help to a person and his or her family in making informed AD.
My 91 year old mother resides in a nursing home. Three years ago it had become apparent to my siblings and me that she was not safe living alone. A clean, attractive and well managed assisted care facility was found and my mother moved into her "apartment". Several months later, Ma fell and broke her hip. She was trying to get a good seat at the movie being shown and had neglected to use her walker. One month later after successful surgery and rehab, she was back in her apartment. In early November 2010, she fell again and fractured her "good" leg. Do to advancing age, increasing dementia, and physical problems she was not able to return to assisted living and will need care in a nursing home.
My mother had made it clear to her children, after my father's death, that she did not wish to receive any resuscitation if she suffered a cardiac arrest. She was of sound mind and body, 77, and still working when she made this choice. When she was in preop this past November for the repair of her second hip fracture, I was by her side. The hospital and physicians had her DNR/DNI documents. I signed her operative and anesthesia consents. I told the anesthesiologist that no cardiac compressions should be given, even if she had a cardiac arrest under sedation. He protested and said that the anesthesiology department's practice was to perform CPR, even in patients who were DNR/DNI, if the cardiac event occurred during the surgical procedure. I was grateful that this physician promised to respect my mother's wishes and that my mother's surgery went well.
We are born and we die. All religions include some variation of life after death. Resurrection, reincarnation, or nirvana are all comforting to mortals. When I get home in the early morning after a ten hour night shift, my wife (if she hasn't left for work) asks me how the night went. I usually give a simple answer, "no one died". There are those patients who die under my care, and I can say "he/she had a good death".
This past week I went in to examine a septuagenarian who was in severe respiratory distress when he arrived from a nursing home. The EMT's told me the patient was a full code. Thanks to the hospital's EMR (electronic medical record) system I knew that the patient had chronic pulmonary and cardiac problems and suffered from dementia. A DNR was found in the pile of forms sent with the patient. I treated the patient with medications and when his family arrived they confirmed his DNI/DNR status and were grateful that we had given him some relief without compromising his AD.
Many years ago when the ER was not as busy as now, I went into to see an elderly man who was near death. There was no AD. His daughter arrived and I explained that even with intubation and ventilator support, her father's prognosis was poor. She asked me what I would choose if this was my father. My father died at home under hospice care with metastatic renal cell carcinoma. He died peacefully and in accord with his wish to die at home. I shared my experience with this woman. Together, we decided to let the natural course of the father's disease go untreated except for some mild sedation. She held one hand of her father and I held the other. He died peacefully in less than 15 minutes. She and I shared some tears and honored our fathers.
This past week I experienced the reverse of this outcome. An elderly man arrived in distress. His health care proxy and guardian was a cousin near to my age. There was no AD. When I explained the problem and offered care and comfort, she opted for full resuscitation. Respecting the family's wishes, I intubated the patient, put him on a ventilator and admitted him to the ICU. Primum non nocere. "First do no harm" is part of the Hippocratic Oath. I felt that instead of relieving this gentleman's suffering, I had prolonged his existence but not his life. I believe that family's request were given in good faith and in the belief that the patient should be given every chance of continued life.
A recent controversy, in reimbursement for primary care doctors, is whether the physician should be compensated for the time needed to help families making end of life care choices. It is frustrating for ER docs that during a crisis, my colleagues and I must ascertain from a distraught family as to how aggressively we should treat the patient. The time for an individual to make decisions about end of life care is when they are healthy. A trusted family doctor can be of great help to a person and his or her family in making informed AD.
My 91 year old mother resides in a nursing home. Three years ago it had become apparent to my siblings and me that she was not safe living alone. A clean, attractive and well managed assisted care facility was found and my mother moved into her "apartment". Several months later, Ma fell and broke her hip. She was trying to get a good seat at the movie being shown and had neglected to use her walker. One month later after successful surgery and rehab, she was back in her apartment. In early November 2010, she fell again and fractured her "good" leg. Do to advancing age, increasing dementia, and physical problems she was not able to return to assisted living and will need care in a nursing home.
My mother had made it clear to her children, after my father's death, that she did not wish to receive any resuscitation if she suffered a cardiac arrest. She was of sound mind and body, 77, and still working when she made this choice. When she was in preop this past November for the repair of her second hip fracture, I was by her side. The hospital and physicians had her DNR/DNI documents. I signed her operative and anesthesia consents. I told the anesthesiologist that no cardiac compressions should be given, even if she had a cardiac arrest under sedation. He protested and said that the anesthesiology department's practice was to perform CPR, even in patients who were DNR/DNI, if the cardiac event occurred during the surgical procedure. I was grateful that this physician promised to respect my mother's wishes and that my mother's surgery went well.
We are born and we die. All religions include some variation of life after death. Resurrection, reincarnation, or nirvana are all comforting to mortals. When I get home in the early morning after a ten hour night shift, my wife (if she hasn't left for work) asks me how the night went. I usually give a simple answer, "no one died". There are those patients who die under my care, and I can say "he/she had a good death".
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