Monthly Archives: January 2011

>A Few Random Thoughts

>I just finished my four weeks of outpatient family medicine. And if I can successfully rearrange the rest of my schedule, this past month will be my final set of patient interactions in med school. Kinda exciting, kinda scary all at the same time. 

A few random thoughts over the past month. 
- I may have actually learned something in med school. Not quite sure how it happened, but I would say I successfully wrote an A&P for all my patients that 95% of the time got an “I agree with the above” addendum by the attending. This is a new feeling for me. Up to this point, I’ve rather felt like I was just keeping my head above water, always amazed every time I passed an exam, or got high marks on a rotation. But I guess some of the stuff stuck over the past four years. What a relief! haha
- I found a few things to be personally challenging this past month. 
1) There was one young man to whom I had to explain his HIV screen and western blot results to. This guy had dropped out of school before 8th grade and had little to no scientific education. Using terms like sensitivity and specificity….might as well be speaking Japanese to him. He actually got really angry because his HIV screen was positive but he blot was negative. “I’m gong to sue you guys for putting me through all this for nothing”. I got through it, he calmed down and by the end of the interview we had a good rapport such that he brought up several other personal issues that he was having.  But it made me think, as part of our medical school training, they should make us play a game of Medical Taboo. You know the game where you have to get your team to say a word without using several closely related words. For example, you team has to say “car” without you using the words “tires, engine, drive”.  It makes you think of alternative ways of conveying an idea, which would have been useful in this situation. This man and I were working with different sets of vocabulary, in effect, I couldn’t use any medical jargon, kinda like a game of taboo. 
2) Babies with rashes scare me. This is still an area I feel I know absolutely nothing about.
3) The language line. I just hate having to use it. So many things just don’t translate.
4) I still despise well visits. Especially for kids. Nothing bores me more than asking about how many blocks your kid can stack or if they can color within the lines. 
Rank lists due soon! (minor panic)

>My foot is delicious

>This morning I saw a female patient that was heading down to South America to do some missionary work, but she also happened to have some bacterial vaginosis going on.

As I walked out of the room at the end of the visit, I said “Good luck with everything down there”. I can only hope she realized which “down there” I was talking about.

>A Fine Line II

>I’ve been on the road 5 hours in the past 24 going to and from an interview, so I’ve had some idle time to think things over as I drove home and these were some of the ideas swimming around my head


I realized that as I walked into the ED today for my interview, there was a large sign on the door, in big block 1 foot high letters, “SAFE HAVEN”. Is that not what we strive to provide for all our patients? Not just new mothers and their unwanted newborns, not just well behaved, well mannered, the sober, well dressed and clean smelling patients?


I don’t plan to make responding to comments in a post a regular habit, but I think this whole thing is a discussion worth continuing, and I’m glad its generated a few comments, even if they don’t agree with what I have to say.
(comments from the previous post)

“As a medical student who has never really practiced medicine and you have no idea what health care and the public are like. Perhaps you should withhold judgement until you actually get out there.”





I may be a medical student but I’m not wet behind the ears by any stretch. I took several years off  between college and med school, many of them serving in law enforcement, so to say I have no idea what the public is like would be an inaccurate statement. I know first hand how frustrating the type of patients described above can be. My 31 years of life experience let me know most people are not cruel and mean by nature. Perhaps they were harmed in their past, abused or neglected, or maybe they drink because they can’t  face their problems, perhaps they take drugs because they never had the chance to develop the ability to cope, maybe they yell because they are frustrated, or they smell bad because they don’t have the capacity to care for themselves.


But as you point out, I don’t have the experience working in the E.D. that some of the other writers do, but in a way, maybe that makes me more like a patient than like a provider, so maybe if I am finding some of the things being said a breach of trust, maybe our patients are too. All I am asking is that people think about the impact the things we are writing about may have on others.


“I think that you should decide what you write about and others should decide what they write about. If you don’t like what others write don’t read them. You are being judgemental. Its their blog not yours.” 


Its not that simple. We’re not just blogging about cookie recipes here, We have a responsibility to those we serve. We’ve taken an oath to protect them, to put their needs before ours. Further, we as physicians are a community, together we work to serve the greater good, so what others say and do is important to me. In fact, I think we should all at least occasionally read and listen to things we don’t like to hear, both in medicine and in life as it’s important to challenge ourselves, hear what the other side has to say, and to be made to think critically. 




“Its really not cool to quote another bloggers post and criticize them.” 


While you think it may not be cool to quote another bloggers post and criticize them, I think it would be less cool to stand by mute when you feel something should be said. I’m not critizing ERstoryteller, he’s a great writer, and clearly cares about his patients, his job and his family. This is not about him, its about all of us. Even great, stand up people occasionally make mistakes, they occasionally say something perhaps they should not have.  I think this was one of those occasions. But maybe I am wrong. The rest of the blogosphere is welcome to disagree. I hope its clear that I not trying to call the author out individually, but unfortunately I am using his post as an example of what I am frequently seeing in the blogosphere, and I don’t think its right, and I think something needs to be said.


Basically, after much mulling and marinating,  I think it all boils down to this. I know when talking about patients we all do our best to make it anonymous. But what if it wasn’t anonymous. What if the patient was sent a copy of what we wrote and it had their name stamped on it. Would they be upset by what we wrote? Would the patient lose faith in us? Would they feel violated if they knew what we had said about them? If the answer is yes, then I think we need to think twice about saying it somewhere that is 100% open like the internet, regardless of how anonymous it is. Patients and the public will see and know that we are talking about them in a disparaging manner. Saying something or telling a story to your colleagues in the break room, or over a beer after a hard shift is one thing, I totally understand and support us all blowing off some steam. I bitch and moan about the things that drive me crazy just like everyone does. We just need to watch where and when we do it. There are ears and eyes listening, even if they don’t belong to the patient you are talking about. If you wouldn’t say it in a crowded elevator, don’t say it here on the worlds largest public elevator either.


I welcome any additional feedback and perspectives on this.

>A Fine Line

>Since writing it, I’ve been thinking more about my New Year’s resolution and what it means to me and what I am going to write about here. But since it’s been on my mind, I’ve also been noticing a lot of what other people are writing out there the medical blogosphere. One post in particular really struck a chord with me in regards to the type of posts I wanted to be careful about. In general, the author of the below blog is an excellent, thoughtful and compassionate writer and physician. But I think a line was crossed in this post. (Full Post)


On their cot, obviously intoxicated, sat a peroxide-blond female, in her mid-twenties, with her head slumped to her right side and her breasts barely contained by her skimpy halter. Her hair was messed, the hairspray she spritzed earlier in the evening unintentionally spiking clumps in all directions. Her face was streaked with tears, darkened trails of waterproof-less mascara collecting at her chin. Drool gathered at her mouth’s angles.

As the nurse removed this patient’s clothing to put her in a gown, we discovered that the patient had on three layers of compression garments around her middle–a spanx, a girdle, followed by another spanx. For those of you not familiar with spanx (and I wasn’t, so the nursing staff kindly informed me), it is a stretchy, spandex-type piece that, after you hold your breath and squeeze yourself into it, acts like a casing to your sausage body. Miraculously, you look thinner and more fit. Without going to the gym or watching your diet. Your difficulty breathing, profuse sweating, and pinched-up, cyanotic face, though, might just be dead-giveaways that you are wearing one.

“Why in God’s name,” Barb continued, not learning her lesson about asking questions from before, “are you wearing three of these? I’ve never seen anything like this.”

“Well, duh,” the patient answered again, “maybe so I can get laid by a guy who likes skinny girls.” I get it–three layers tripled her chances.

I’m assuming that she was assuming that she looked more attractive all squished into her itty-bitty jeans and shirt with the help of her garments, but really? Did she think this situation through? What guy, one who was probably out drinking at the same bar as her, would be able to remove three of these things? Would the effort be worth it? Would his spanx-removal talent have a big payoff? Sober, I doubt any guy would be able to succeed in getting this patient out of her spanx, but throw some drinks into the equation and what do you have? Besides the fumbling, frustrated fingers of her date? Failure, through and through. 


Finally, though, my biggest shock of the evening came from what the nurse shared with me. It seems that as the tech and nurse finished undressing the patient for observation, they were unpleasantly surprised to find this patient and all her southern female parts barely covered by her thong underwear.

Her American flag thong underwear!!! Three square inches of red, white, and blue fabric.

I was never less proud to be an American…


Is this inappropriate to write about? I feel like it is and I’ll try to explain why. While these types of posts are entertaining to tell and read, and details are changed to protect identity, I sometimes wonder what happens when members outside our community read such postings? For example, I showed the above post to V and her response was along the lines of “If I have to worry in the slightest that something I saw or share with my doctor, or god forbid what kind of underwear I have on, might end up as fodder for an internet post, you can bet that I’ll never share anything with them again” And I think she’s right. Even if the women above was completely shitfaced, acting like a total ass, I think its unprofessional to talk about it in such a forum as the internet. I know black humor is part of the job, and I’m not saying we need to get rid of that. I’m guilty of it myself and we all need a way to blow off steam, but a 100% open to the world forum such as a blog, is not the place for us in the medical community to do it. 

As a reminder, from the oath we all took (or are going to shortly in my case)…

“Whatever, in connection with my profession service, or not in connection with it, I see or hear, in the life of men, which out not to be spoken abroad, I will divulge, as reckoning that all such should be kept secret. Those things which are sacred, are to be imparted only to sacred person; and it is not lawful to impart them to the profane until they have been initiated into the mysteries of the science”

I’m sure your hospital has those same signs in the elevator that mine does. “Please do not discuss patient details in the elevelator.” If someone overheard two doctors having a conversation similar to the one above in the elevator, what do you think their reaction would be? Would anyone find it egregious? Would anyone actually argue that it was acceptable and profession behavior. I don’t care if patient details were changed or not, I personally find it disconcerning to discuss a patient in a derogatory way such as above, in the world’s largest elevator, the internet. Blowing off steam to colleagues in a private environment is one thing, posting your vent for anyone with an internet connection to see is another.  

What do you think? Is this even a discussion worth having? What should I do about it? 






>Tobacco Smoke Enema

>From http://lifeinthefastlane.com

From ER Jedi

  • The tobacco enema was used to infuse tobacco smoke into a patient’s rectum for various medical purposes, primarily the resuscitation of drowning victims.
  • A rectal tube inserted into the anus was connected to a fumigator and bellows that forced the smoke towards the rectum – the warmth of the smoke was thought to promote respiration…

>Workup for First Time Seizure

>Another great card from the gang at ALIEM

Workup for First Time Seizure

>Psychatron ft Blake Baxter – She is Music (Hypnogroove Mix)

>

>Brace Yourself

>So last week our governor added 95,000 people to medical assistance…. Who is going to take care of these people? Most of them will probably be in the city I live in. There is a shortage of primary care physicians across the country. I think its a good idea for more people to have health care, but all of those people are being added to a failing health care system. Guess where they are going to end up when primary care clinics refuse to see them? Yup. ER.

Keep in mind that these are people who have probably neglected their health. They are not people who have had physicals, preventive medicine. They probably aren’t in very good shape many of them. This is the first wave of the coming tidal wave of people into the health care system in the next few years. (borrowed from
Madness: Tales of an Emergency Room Nurse)



This made me think, what are we supposed to say to our patients when they have to wait 5 or 6 hours in a crowded lobby to get seen back in the ER? I’m just a frustrated by it as they are. I wonder if I would be reprimanded by saying “Sir, I’m sorry you had to wait so long today, but to be honest, this is a problem that’s not going to change any time soon. If next time you don’t want to wait, here is some literature about how you can get involved in health care reform and become an active participant in making a difference” (of course saying that with my most patronizing smile).


I’m fairly certain not a single person would actually take that literature gratefully, much less read it and get involved.  And frankly, I’m not as worried about this problem as some people are. At the risk of sounding like I don’t think highly of my fellow human beings, I would not be surprised if proving insurance to the masses would make a huge dent in people seeking health care. I suspect, that changing people’s attitudes about their health would play a much larger role in they achieving good health, rather than making health care “more affordable”. I say this because, more often then not I see something along the lines of the following…


Patient: I can’t afford that medication doc
Me in my head: You can’t afford this $4 medication, but yet you find a way to pay for your satellite television and your unlimited data phone plan? 



We need more attitude and outlook reform, less healthcare reform.

>Suture Material

>Another great PV card from the the folks at ALIEM.

Know which suture material to use

>Cure for Stinky Feet in the ED

>1) Double bag the offending stinky socks, etc.
2) Make up a mixture of warm water, betadine, peroxide and hibiclens,
3) Soak two towels (or even pillow cases if laundry hasn’t brought you towels), and wrap each foot in one of said soaked and loosely wrung out towels, then wrap each foot with a blue pad. After 15 or 20 minutes the offending feet are much more fragrant.


This procedure really doesn’t take long and is a win-win for both the patient and anyone else around.

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