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.
Saturday, March 26, 2011
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.
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