The patient’s boyfriend noted leg swelling, dizzy/fainting spells, and severe shortness of breath in a woman on birth control. If someone becomes acutely short of breath, this is not normal, and it really needs to be checked out.
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The season finale of Lost was amazing, but could we get some wound eversion for Jack’s laceration repair, TV ER doctor? Hell, that little thing could be dermabonded. And while we’re at it, you might not want to use absorbable, practically transparent suture since those need to come out in 3 days to prevent scarring. Snark off.
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Was waiting for the bus to the hospital yesterday in my scrubs (last time I do that) when I walked past a disheveled man sleeping on the street. Had my Ipod on and went up to the bus stop. As I had just picked up a “man down” earlier, I turned around again just to double-check that his chest wall was moving.
Two women yelled over to me, “I don’t think he’s breathing,” and I said, “Yeah, he is, I just checked.” Initially I found this incredibly strange–strangers waiting for the bus never talk to each other. I’ve walked past homeless people sleeping while waiting for the bus. Never a peep from anyone. It’s a social taboo or something. But then I realized: the scrubs. They figured I was some sort of medical person (a doctor, nurse, tech, housekeeper?) and decided to alert someone who, just by the clothes he was wearing, might know something more about dead or not breathing people than themselves.
While I was doing my ride along, I was wearing jeans, a blue polo shirt, and some brown street shoes. No nametag, no ID. I walked into countless ERs and homes and residential facilities with the paramedics, and was never asked a single word about who I was or why I was there. Why? I had a stethoscope around my neck and sometimes latex gloves on my hands. (For one family, they often looked at me when answering questions asked by the paramedic, probably just because I had my stethoscope twisted around my neck.)
Never underestimate the power of the white coat or its accessories.
Very interesting new program San Francisco is doing for its IV drug users–after taking a basic course and getting certified, IV drug users can get 2 bottles of Narcan (naloxone) for if their friends overdose. They’re told to just keep it in the bathroom cabinet and use it if their friends stop breathing or responding.
This was after administrators found out deaths were so high because users a) didn’t want to call 911 and have the cops show up and b) were trying things to revive their friends that didn’t work, like ice baths, hot showers, and injecting them with milk .
As we helped from-the-East-Coast, intoxicated Ray into the ambulance, he began to harmlessly flirt with one of the paramedics, referring to her as Sugar, but slurring his speech through and through. We’d received a “man down” call–our last of the day–after a cellphone Samaritan had been driving by and saw him on his side lying on the sidewalk. The paramedic told him someone thought he was dead.
Ray had been drinking, so he staggered into the ambulance as we took him to the sobering center–basically, a facility with 24 beds and rubber sheet-coated mattresses for drunk people to sleep off their alcohol and get them in off the streets. As we took Ray’s vitals, I started up a conversation with him, asking him what he typically drank in an average day. “I start with a quart of Listerine,” he began, “and then a couple pints of vodka, an 18-pack of beer, and then I mix some Listerine with the vodka so it tastes better.”
“Listerine?” I questioned, probably with much more judgment in my voice than I had wished.
Ray kind of trailed off, and then became tearful as the rig started its engine. He told me of his 18 months in Vietnam–drafted when he was a mere 19 years old–and of the horrors that he witnessed, a few stray tears collecting at the corners of his eyes. Stories of 6 men he had killed, of friends he had loved dearly who had taken bullets to the head from snipers right in front of his face. Atrocities. Terrible things. The other paramedic thanked him for his service to our country. I told him I couldn’t imagine having to go through such a thing, and that no one should have to.
I asked him if alcoholism ran in his family. “No, not anywhere,” he told me. “Not my mother, not my father, not my brothers–nobody. I drink because it’s so hard to forget everything that happened over there. I blame that war.”
He had started drinking after he had returned from Vietnam. “My first night back, me and 8 buddies went to a bar, and do you know what they said to us? They called us baby killers,” he said, his voice quivering. “Baby killers. On my first day back to my country.” He recounted the huge bar brawl that ensued.
Ray’s whole experience hurt to hear. It certainly hurt to know that Ray has been on the streets and drinking for 40 years, and still doesn’t want to quit, and that he had to experience all that he has.
But I think it hurt even more to think that 40 years from now, a medical student will be doing a ride along with the paramedics, harmlessly start up a conversation with an intoxicated gentleman, and will hear the exact same story from a veteran of Iraq.
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Shadowed/eavesdropped on calls today at the California Poison Control Center , which was pretty cool. The center here in SF shares the duties with 3 other centers in the state, operating the 24 hour, toll-free number to answer pretty much any question and either make sure people get the right treatment or some needed reassurance. Each state has its own poison control center and the people are incredibly helpful, knowledgeable and friendly–definitely call if you have any questions.
My one experience with it involved my mother making some sort of pasta or tuna salad, while also getting out some hydrocortisone cream for a rash or something, with a tiny bit of the steroid cream ending up in the bowl. Don’t ask me how this happened. I just remember my brother and I freaking out and SCREAMING for her to throw out the entire bowl of food, not wanting our mother to die. She called poison control and they said it would be fine (she’s a nurse so she knew this anyway) but I think we put up such a fit she tossed it anyway. (Or at least she told us she did.) So everyone does silly things, and children eat everything. No matter how silly, it’s no reason not to call. The call centers have heard everything.
Most calls dealt with toddlers eating pills. One “licked the coating off a bunch of Advil and Tylenol.” One important point: Tylenol is actually incredibly dangerous in overdoses–which is hard to do unintentionally in adults–but isn’t so difficult for small children, since overdoses are generally based on weight. Tylenol in overdose has been bad enough to cause patients to go into liver failure and require a liver transplant. Keep pills out of the reach of kids!
Oh, interesting fact: Those little freshness packets in shoe boxes that say “don’t ingest?” They’re just silica, and non-toxic. It’s like eating sand, apparently. (This is not medical advice!) Update from the comments:: Silica gel, the desiccant in “freshness packets,” isn’t always harmless. Sometimes it’s packaged with a moisture indicator and some of those are quite toxic.
Panda commits an error probably all too common for ER physicians: patients are how they are because they are who they are, and their situation and environment has but a small impact. Fundamental attribution error well at work.
Mr. P. Bear believes that doctors are helpless to help their patients and improve their health outside of the hospital or office–and even argues that advocacy work somehow “dilute[s] the only real authority they [doctors] have, the authority to make medical decisions on behalf of the small subset of the population who are their actual patients.” (I swear, Panda and I are opposite ends of a magnet.) To say that physicians are powerless to improve people’s lives is laughable, ridiculous, and more an effort to ignore our responsibility to do so than anything. Distributive justice is one of the four pillars of medical ethics, and I don’t know how Panda can so quickly write it off. I don’t care how hard we work, we are our patients’ advocates, and we should be demanding that they receive not only the best care possible but that they should have healthy environments outside of the realm of doctor’s office or hospital.
Panda Bear says “We have no special powers of persuasion denied to the general population… we are not magicians.” I beg to differ. The Cochrane Database reports that even “brief advice” from a physician increases the likelihood that a smoker will quit smoking, leading to a absolute reduction of smokers by 2.5%. If you consider all the cost and suffering continued smoking will cause, that’s not bad for “brief advice.” We are seen as knowers of the body and authorities of health. When doctors talk, patients do listen. It’s like when my dental hygenist puts the fear of god into me for not flossing enough and threatening me with a deep cleaning: she knows about oral health. I listen and try to change my behavior. (Flossing daily now, thank you very much.)
Doctors’ beliefs and advocacy does not fall on deaf ears. When doctors speak, people are happy and eager to listen. Often it is the opposite–they know that doctors’ time is valuable and rare, so any issue that physicians choose to spend their time on is even that more important. One of the great memories that has driven me through med school is a meeting with pediatricians, Chicago aldermen, and researchers at Children’s Memorial Hospital in Chicago . The pediatricians were upset that lead levels in many communities were on the rise, and wanted to bring the issue to the attention of the aldermen. They knew that no, they couldn’t go into their patients’ houses and make sure that they were eating healthy, balanced meals, but they also realized that their patients were being affected by an environmental hazard that lowered their IQs and made them chronically ill. So they decided to do something about it.
Who are people going to listen to on health matters? A physician, or an individual parent or patient? If you say anything but the former, you’re kidding yourself. We have so much power and influence when compared to most of our patients that to not speak for them is an injustice and an abdication of our responsibility as physicians.
Can we fix everything about our patients’ lives? Of course not. But are there areas where we as physicians can truly make a difference? Absolutely. Just because we can’t do everything doesn’t mean we shouldn’t do something.
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Back in 2nd year of med school, I thought learning about tertiary syphilis was rather silly. I figured people would definitely get treated once they had a chancre or any signs of secondary syphilis . (Speaking about US-only right now.) Turns out patients don’t read the textbooks, and don’t live in my little imaginary medical bubble world. Life always comes back and bites you on the ass.
About two months ago, I open up a chart and see: “Patient here for lab results positive for neurosyphilis .”
Graham’s law: The disease you don’t study, or decide that you’ll read about tomorrow is the disease a patient will come in with today. It’s happened to me so many times I’ve lost count. Always makes me read that one extra chapter, ’cause I figure I’ll get burned if I don’t.
