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!
Wednesday, October 5, 2011
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.
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