What is up with this? Two cases this week? See the abnormality above? I feel like the friggin’ grim reaper!!!!

Again I had to tell a guy he is totally screwed. Even though he had quite smoking 5 years ago when he was forty, the damage of doing that for 25 years was done…..

I am used to gross stuff. I see it every day. But still, there are times I just do a double take and almost throw up a little in my mouth. The other day a youngish woman came with “sores on the leg”. Much to my horror, when I asked to see the sores, she obliged. She spread open her legs to reveal a 4cm circular, necrotic, ulcerating abscess about 1 inch below her vulva on the inner thigh. To add to that, she had severe psoriasis all over her body. The stuff coming from the wound smelled like a freshly killed corpse rotting in a World War I trench.

Of course after a few seconds to compose myself, I ordered a few things then went off to eat my Chicken Tarragon I had for lunch…..

I understand cultural sensitivity. I know some people consider their cultural heritage and traditions to be very important to them - religious based or not. However, there are times when people have to decide what is more important. Attending a special event or performing some culturally-ordained task, or taking care of one’s self.

The other day an older man came in with chest pain. He looked kinda bad. Sweaty and uncomfortable. His EKG was abnormal (although it did not show an acute heart attack). He had a lot of cardiac risk factors. He needed to stay in the hospital. End of story. However, during almost the entire history and exam, the patient’s supremely irritating wife kept interjecting with “He is NOT going to be admitted, he has a briss to go to tomorrow!!!!” about a dozen times. The man seemed to not be wearing the pants in this relationship and pretty much just looked sheepish- and uncomfortable.

It was only after an annoying amount of discussion of risks - such as “YOU ARE GOING TO HAVE A HEART ATTACK!” and finally “If you keel over and die at the briss, I am sure it will cast a dark pall over the normally joyous occasion” did his wife agree to let him stay in the hospital.

I was almost going to look up the name of the Mohel and call him asking if he knew CPR if this guy had signed out AMA…..

I thought he was a piece of steak! Man opens door to his hotel room and is beaten with bottle of Worcestershire sauce, then “tenderized” with a fire extinguisher. Ends up in the ED and then admitted to the hospital for “curing”.

The big get bigger. LA County spends $322 million to replace Harbor-UCLA Medical Center’s emergency department.

Man sues law firm for malpractice after law firm dismisses his medical malpractice complaint and he is not permitted to re-file it.
The man initially alleged that a surgeon missed diagnosing an anal fistula and also damaged his anal sphincter. The things that struck me odd were all the allegations of damages in the complaint, to wit: “Because of the incident, [the patient] claims he became sick, sore, lame and disordered; experienced fecal incontinence, pain, suffering, disfigurement, disability and a loss of his enjoyment of life; and incurred medical costs.” Wow. Remind me never to have my hemorrhoids out if this can happen.

This news article notes that more and more uninsured and underinsured are going to emergency departments because they don’t have any other choice for medical care.

Increasing numbers of people on state assistance for medical care are having their benefits cut. Utah cuts stipend to poor and disabled that patients were using to help cover their medical costs. If patients get subsidies for purchasing insurance in the current health care plan, I foresee the same thing happening to federal subsidies once the plan is in place.

Utah also passes Senate bill to cap medical malpractice awards for pain and suffering at $450,000. Part of the legislation is a “stand down” agreement to create a 4 year moratorium on any further tort reform efforts. Four years. Isn’t that the length of an election cycle?

Speaking about medical malpractice caps, Illinois lawmakers plan their next move after medical malpractice caps were shot down in that state.

Man I know it sucks.  You came in for cough for several weeks and feeling “like crap”. You were told you had a sinus infection (which you probably did) but are not better.

The x-ray I did shows a nasty -assed thing in your lungs (see it on the x-ray?) which as it turns out is lung cancer as confirmed by its appearance on CT scan.  It also looks like it has spread to your liver.  This means you have stage four lung cancer and are dead.

I know you are only 42 but no one said that smoking for 20+ years was not bad for you.

BTW, I was interviewed for an article for Reader’s Digest about the Emergency Room - I am quoted as “Emergency Doctor in the Northeast”.  Pick one up at the newstand today!

15% off Studio B
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Sometimes life deals you a bad one-two punch. For this unfortunate elderly lady it was in the form of falling on her left side and smashing both her hip AND her humerus.  Talk about some rehab time.

Me: OK, why?

Patient: I don’t know, he just said I should.

Me: OK, who is your doctor?

Patient: I don’t remember.

Me. When did you see him?

Patient: I have no idea.

Me: OK, who did he say you were supposed to see?

Patient: I don’t know, I think it is supposed to be a neurologist.

Me: OK, we’ll take care of you.

Nurse: “She is on break.”

Me: “OK, who is covering her?”

Nurse: “I am not sure but I think she also just went to break.”

Me: Bangs head on desk.

Quick rant here. I read with expected horror yet another article about how religious (and many political) conservatives mostly clustered in Southern states (what a surprise) have been introducing and pushing educational bills through their various state legislatures which champion “theories” of intelligent design, creationism, as well as questioning global warming. Probably spurred on by the mentally disturbed like Glen Beck, they want teachers to either give equal time to these antiquated theories or to overtly question mainstream science in their classrooms. These fundamentalist Christians ultimately want to end the separation of church and state. Next thing you know bills will be passed down there that mandate teaching that homosexuality is a disease, that sex is evil, and that women who wear makeup are “trollops”.

This just strikes fear into me. Fear that a large portion of our children in this country may be left in the scientific backwater created by these regressive thinkers. They will believe in long dis-proven or impossible to prove ideas of how our world and bodies work. They will forever be the laughing stock of the rest of the educated world. They will continue to vote for politicians who think it is the 1600’s and that the Sun revolves around the earth. They will continue to stifle intellectual progress in our country when they grow up.

If you want to teach this stuff in Church or in Sunday School, fine. It is a free country. However, I would be DAMNED if my children went to a public school that I was supporting with tax dollars that forced this junk down their throats. Religious teaching belongs in religious schools and facilities - or at least Universities where students have a choice was to what to study, not public schools where Jews, Muslims, Atheists, Agnostics, Hindus, and every one else may send their children.

Please I entreat you, any religious minorities, atheists, agnostics, and other free thinkers, PLEASE run for office in these states! I know it will be a hard road but eventually some of you may win. Eventually you may balance out these zealots who in my opinion should be concentrating on bills that provide jobs, tax breaks, medical coverage, and infrastructure improvement over ones that appease their desire to prosthetise the world.

OK, I am done. Thanks and sorry if I offended. Back to your regularly scheduled medical stuff tomorrow.

He’s done.

He spent a large part of his 46 years hittin’ the bottle.  He spent the last year or so in and out of the hospital with GI bleeding, cirrhosis, Hepatic Encephalopathy, and infections.  he spent the last night of his life intubated while a gastroenterologist worked furiously to stop bleeding in his esophagus.

Alas, he arrested and was cooked.

Lets see, you’re a 43 year old woman and in my ER with recurrent facial abscesses. You have celulitis all over your cheek which is very puffy. Your teeth are rotted. You have snorted massive amounts of cocaine for more than 20 years and now your entire nasal septum is gone and the resulting cavernous space is contiguous with your mouth via a coin-sized hole that has eroded in your hard palate. You are a set up for infections as food continuously ends up in your nose. Your lacrimal duct is frequently blocked and tears drain out your eye pretty much 24 hours a day. Because of the palate defect, you speak with a lisp.

Sorry if I say that I find it hard to believe that you “used to be really attractive back in the day!!!”

Why? Because every frickin’ shift I HAVE SOMEONE WITH A BIG HEAD BLEED!

And of course the neurosurgeons say “sorry Charlie, too old, too far gone, yada yada yada, not an operative candidate”!

Yes, we may laugh at that vintage Life Alert commercial but sometimes it is for real. A woman pushed her button just like in that classic (although the dude going “I’m having ack!!! Chest pain!!!” is pretty funny in a morbid way too!) after she fell. Unfortunately, the CT above is what was going on in her head.

GCS of 5. Not too much we can do….

I have posted on this before but it bears repeating. I love the snow - and it is not because I am a skier. I also don’t mean I love it when I am driving (although it is more because of all the traffic and others who flail about without snow tires getting stuck and spinning around). I mean I love it when I am working! Why? Major snow storms are always slow days in the ER. People just seem to be willing to hunker down and deal with their problems I guess. They wait til it is over and then start pouring in. The other night was a major snow storm and it was slow as I predicted. However, there was the usual smallish parade of stupid, time-wasting cases.

A. A 5 year old with a “fever” of 100.3 for 12 hours.

B. A young woman with numbness in her fingers for a week

C. A sprained ankle that the person was walking on fine but just wanted to get checked out

D. Abdominal pain for two weeks in a 18 year old male

E. A woman in cardiac arrest

Oh yeah, that last one was a real case!

I don’t know but I guess I can understand. Some people define themselves by their career. When they retire, they essentially lose their identity and get really depressed. Still, I think it gets to the point where you need to turn your stethoscope and enjoy other aspects of life. I know for sure the last thing I am going to be doing when I am nearly 90 years old is working 40 hours a week. I plan to be making trouble in other ways!

The other day an elderly man was sitting at the nurses station fiddling with some papers. He got up and started to walk but appeared to be stumbling. One of the nurses asked him if he was OK or needed assistance. He held up his hand to pause her and reached into his pocket, emerging with his dentures. He put them in and asked her if she could go over the admission orders he was going to write! It was only then that she realised he was a doctor! As he wrote the orders, it was noticed that he drooled on the phone receiver and that his handwriting was utterly illegible.

I then realised that this was a doctor who had practised at my hospital since the late 50’s and was pushing 90! I had heard about him and assumed he was dead but there he was in the flesh. After he left, the nurse came over to me and told me the orders were useless and incomplete. We were able to figure out that he wanted a cardiology consult so I called the guy he asked for. Arrangements were made to put the patient onto the cardiologist’s service for her health and safety!

Should doctors who provide emergency medical care and on-call specialists to everyone receive special protections from liability?
Georgia has such a law right now - requiring medical malpractice plaintiffs to prove “gross negligence.” The Georgia Supreme Court is considering whether the Georgia law is unconstitutional. Legislators vow to re-write the law if the court throws it out.

Good advice on how to decrease and/or dispute your medical bills.

New Washington State hospital opens, but staff needs 8 days of practice treating simulated patients before going live? At first I thought “WTF”, but then saw that this emergency department has four nursing stations and everyone communicates by cell phones. At least they had a simulated drunk requiring restraints. No word on how many of the actors had chronic back pain and whose family physicians were out of town and whose dog ate their prescription for Norco.
Best part about the facility … it is “known more formally as the Emergency Department.”

OK, both of you stop and ask each other: “Are you sure you want to do that?” Patient sues his psychiatrist after his psychiatrist began dating the patient’s ex-wife - the person who allegedly caused the patient’s “adverse mental condition.”

At least his Press Ganey scores were good … Michigan emergency physician is arrested and charged with distributing too much Dilaudid to a patient … who also happened to be his girlfriend. Pharmacist also arrested and charged for filling the prescriptions. Both professionals lost their licenses.

The next day you are found aspirating on your own vomit with decorticate posturing and right gaze preference. Shortly afterwards EMS intubates you and your are on a vent in the ER. Your blood work is horrible (renal failure and white blood count over 20K). You might think you are lucky that your head CT is OK, but no, you are not. You have trouble maintaining your blood pressure without Levophed and your pupils are only sluggishly reactive. You get contorted into a foetal position for a lumbar puncture (luckily you have no idea what is going on) and nearly spray frankly purulent cerebrospinal fluid into the face of the doctor doing the tap. Your CSF shows 160,000 WBC’s and a glucose of 2. The gram stain shows gram negative cocci. Everyone panics in the ER and many people are now getting a dose of Cipro to prevent getting what you have.

From what I hear, you sound like a nice guy. It is very sad, but you are going to die - people will miss you.