Category: Allegory, parable, rhetoric

Communication is Important, For the Record

7/2017

Communication is important in the effective practice of medicine.  Ergo the medical record.  It is a way for one physician to inform other physicians and staff what is being done for this patient by a physician.  One area of importance in the medical record is the “Problem List”.  This is where one can go to look for all the active problems that are being addressed by all of the different physicians treating a patient.  It sort of weeds out all of the old stuff, the fake stuff and the errors and such.

But alas, social media has arrived to the EMR (electronic medical record).

One of my patients, tonight, had 3 listings for a severe medical problem that had a direct impact on what I did or didn’t do.  Listed below in exact representation from the EMR are the following:

1. liver transplant
2. Liver Transplant
3. Unspecified organ or tissue transplant

This may seem confusing and complicated to those not highly trained in the medical profession.

1.  “liver transplant” implies that the patient has had a complete failure of his natural liver and a liver from another individual was transplanted into his body, in a casual voice.

2.  “Liver Transplant” implies that the patient has had a complete failure of his natural liver and a liver from another individual was transplanted into his body, in a firmer, louder voice, but not shouting.  (That would be LIVER TRANSPLANT)

3.  “Unspecified organ or tissue transplant” is a little more complicated. It could mean that the surgeon doing the transplant was totally clueless as to what he was harvesting from the donor and where it was going in the recipient, like in the book Catch Me If You Can, about the Doctor/Airline Pilot impersonator. Or, it could mean that the surgery was done in Colorado or California and that the surgeon was a die-hard Cheech and Chong fan, striving to carry on the principals espoused in Up In Smoke (1978).

To think that the U.S. Congress mandates that we use this efficient, productive and safe method of physician-to-physician communication boggles the mind.

Delusions in the pursuit of absurdity from your grumpy Uncle/Brother Dave.

Weary.

Transportation Safety

7/2017

The April 14, 2014 issue of Time has a brief note about GM and faulty ignition switches.  CEO Mary Barra stated in a Congressional hearing, “We will hold ourselves fully accountable.”  This was about faulty ignition switches that “caused” 13 deaths.  With a great deal of imagination, I guess I could figure a way an ignition switch could cause death, but it would take some time.  No pun intended.

In 2010, GM sold (not made) 8,389,769 vehicles representing about a 12% increase from 2009. We will assume that sales continued to rise, but at a slightly more conservative rate (although there is evidence that the rate of sales increased during this time period).  Progression analysis at a rate of 10% per year yields 2013 sales at 8,643,986 vehicles.  Given 13 deaths out of 8,643,986 possible ignition switch failures, the rate of failure is 1.5 x 10 -6. That is 1 in 664,922 vehicles.

For those not remembering their high school algebra, that is a .0000015 % chance to have a failure of the ignition switch that would cause death.  Those are pretty fine tolerances to hold anyone accountable for, in any industry.  I never thought I’d be defending GM after their bailout fiasco, but daymnnn!

Sure am glad Congress is keeping a lid on transportation safety!

From your grumpy Uncle/Brother Dave.

Weary.

Small Towns

7/2017

As my wife came home today and after passing our neighbors, over the hill and down to the bottom, there was a vacant car parked.  It was almost in the middle of the road with the driver’s door and the trunk open and nobody around.  It was a mid-nineties 4 door sedan, yeah a grannie car.

Right about here, most women would immediately change into a cut off T-shirt and panties and go looking for Freddy Kruger. And that’s just what my wife did, figuratively speaking.

An elderly woman came walking out of the woods with several trash bags in her hand and using a cane.  By woods, I mean undeveloped brush and bramble, poison ivy and sumac, wait-a-minutes, cat claws, deadfall thick enough to stop a turkey hunter kind of woods.  My wife inquired if she needed help?

“No, but I’ll bet you’re wondering why I have these trash bags in my hand?” she said. “I’m so-and-so (mentioning her last name), but I’m really a so-and-so (mentioning her maiden name). And who are you?”

So, my wife told her who she was married to and that she lived right over there.

“I know who you are, you married that Doctor that works in St. Joe?”, she said. “I come out here to dump my leaves. There isn’t any place to dump leaves in town anymore. All the neighbors leaves end up in my yard and I have to clean them up and bring them out here to dump them. I’m 93 years old and had new knees in ’07 and fell down and broke my pelvis a couple of years ago. That’s why I use this cane. Now, who are you?”

So, my wife told her who she was married to and a brief local family lineage.

“Oh, that Doctor that works in St. Joe, huh. I knew his Mom, we went to school together.”

I don’t know how it ended, but Angie didn’t come home with any knife wounds and the car is now gone.

Small town happenings from your grumpy Uncle/Brother Dave.

Weary

Salt Poisoning

7/2017

One might think that the Emergency Department is for emergencies.  It may be, but one man’s trash is another man’s treasure.  So to speak.

At homeless shelters, it is typical that they are on lockdown at night. There is a lot of alcoholism and drug use among the clients and after the evening meal, they typically will not let anyone in. The residents can leave but they cannot come back in until the next day, often not until late in the afternoon.  So if you missed supper, want a snack or something to drink or whatever, you are out of luck.  Almost.

So my patient this particular night was staying at the YWCA.  Whatever she had eaten for the evening meal apparently was quite salty.  She came in by ambulance complaining that she had salt poisoning.  She said that whenever she ingested large amounts of salt, her throat closed up and she couldn’t swallow.  She was sitting on a stretcher, kind of hunched over and drooling copiously on herself.

This isn’t a common encounter for Docs these days because for the last 30 years there has been a huge amount of public attention on salt intake and how bad it is for everyone.  I was a tad bit skeptical.  But, it didn’t make any difference because I’d already been scammed by now anyway.

I told her that I would order a blood test of the salt content in her blood.  She said that in the past that ice had helped her throat swelling and wanted some while waiting for the test results.  I didn’t see any harm so I had one of the ED techs bring her a cup of ice.  She promptly filled it with water and gulped it down. She said thanks and walked out.

See, the only way to get back in the shelter after lockdown is if you left to go to the hospital.

Sometimes the ingenuity of people amazes me.  All she wanted was a drink of ice water (which she couldn’t get at the shelter)  and still be able to sleep in the shelter and off the street.

From your grumpy Uncle/Brother Dave.

Weary

Robo-tripin

7/2017

Robitussin is an over-the-counter cough medication which contains the drug dextromethorphan.  This is a response to a recent e-mail I received on the subject.

I’ve previously mentioned some of my experiences with “robo-tripin” patients.  I’ve been seeing this for many years now.  The article is pretty good, except for one aspect. (1)  In my experience, chronic dextromethorphan/codeine use does not induce aggressive behavior.  It might lower inhibitions like alcohol but it is very different from the rage/anger/aggression of amphetamines (speed, cocaine, meth, crack…).  It’s my opinion that this incident was caused by poor upbringing, bad entitlement and racial attitude and homophobia if dextromethorphan was the only drug on board.

Dextromethorphan has been available over the counter for 50 years or more.  The fact that dextromethorphan differs in structure from codeine by 2 hydroxy (one oxygen attached to 2 hydrogen) groups became known on the streets and users found that they can get similar effects using dextromethorphan (legal and available without a prescription) as codeine (requires a prescription) by just increasing the dose.

Codeine-like drugs have way overtaken valium-like drugs as the most common prescribed drug in America.  They are not stimulants but depressants in their general mechanism of action.

Codeine and its synthetic variants, hydrocodone, methadone, hydromorphone and oxycodone, are legal for the person to whom the prescription was written.  There is a billion dollar industry in the US for legal and illegal codeine obtained in various ways.

For instance, a team may go to a medium-large town and break into a doctor’s office.  They forge scripts found in the office and distribute them to street people to have filled.  “Organizers”, kinda like what Obama was (but not necessarily implying Obama pushed drugs), go to derelict areas of a town and recruit low life types to hit the Emergency Departments with feigned and real complaints.  Casts are cut off freshly broken extremities and the person is sent to the ED as if it was a fresh injury, then to the next ED and so on.  Salvation Army and like shelters, food kitchens, and welfare housing are recruitment centers for these people.

The Urban Dictionary is indispensable, entertaining and scary.  Slang used by kids changes, sometimes daily.  I would venture to guess that 90% of the population below the age of 19 know of this use of dextromethorphan.  Those that disagree just don’t realize the kid is lying.

Here is my most often told story of Robo-tripin.

One evening at work, a respiratory therapist came to me and said, “Doctor, you need to come to see this patient now.  He isn’t breathing very good.”

I checked the patient out and sure enough, he wasn’t breathing at all!  We quickly grabbed an Ambu bag and started to breathe for him.  During my exam, I noted that he did have a pulse but was otherwise unresponsive.  To determine unresponsiveness, the examiner inflicts painful stimuli and notes the response.  Yup, I can make anyone wince and sometimes it’s even part of my job.  He had no response.  This was a young guy, 19-20 or so.  So I said, “Looks like I’m going to have to intubate this fella.”  At this point, I knew that he was in a coma but didn’t know why.

To intubate a patient, I put a plastic tube down their trachea which allows us to breathe for him/her until we can identify and hopefully reverse the problem.  So I take my handy dandy laryngoscope (with decoder ring optional), which is basically a flashlight with the bulb at the end of a tongue blade extension at right angles to the handle, and insert it into the oral cavity.  This guy’s muscles were flaccid and he offered no resistance.  The blade-like portion is used to move the tongue out of the way (seems a problem with us humans that our tongue seems to get in the way of life all the time) and allows the provider a view of the vocal cords.  The mission is to pass the plastic tube between the vocal cords when they open and into the trachea just below.  The vocal cords are touched by the tube as it passes through.

Under normal circumstances, when that happens a nerve is stimulated and it sends a signal to the brain that results in a violent and forceful cough response.  Think eating cookies and accidentally inhaling crumbs into the windpipe.  In a comatose patient, the response does not happen.

Well, Robotrucker here, responded when I touched his vocal cords.  He reached up (none of the others nor I expected this comatose patient to respond at all) and smacked the tube and laryngoscope from my hands and sat up.  “Don’t do that!”, he exclaimed.  He walked out of the ED under his own power about 45 minutes later.

This was an extremely unexpected event, but it has since happened to me several times.  Something about this laryngeal reflex pops them right out of a coma.  Not every time mind you, and not every patient is lucky enough to be found in time.

Life in the emergency department from your grumpy Uncle/Brother Dave.

  1.  http://theconservativetreehouse.com/2012/05/24/update-26-part-2-trayvon-martin-shooting-a-year-of-drug-use-culminates-in-predictable-violence

Weary