Medicine | Agraphia

10Oct/1110

Water Poisoning

I had the most endearing interaction I think I've ever had today with a patient. He was an extremely polite schizophrenic man who came in because he was convinced his water supply was being poisoned.

Me: What makes you think your water is being poisoned?

Him: Well, my girlfriend, she told me to drink less water. She thinks I have too much every day, so she told me to drink less. I'm pretty sure she poisoned it.

Me: Why would she want to do that?

Him: To get me to drink less, of course.

The logical explanation lies with his past medical history; he suffers from a condition known as potomania - overactive thirst - which can cause significant electrolyte imbalances in the body with too much water ingestion. The treatment is to drink less water; his girlfriend was actually looking out for him.

For a moment, I entertained the fallacy of his reasoning. "Why on earth," I thought to myself, "would your girlfriend poison your entire water supply? This is the schizo talking."

Then, I thought back a couple of weeks. In the middle of a particularly hectic shift I took care of an autistic kid who kept coming up to the physician's desk asking the same question over and over again. "Can I get my medication refill now? Please, I want my medication refill now. Now? Now." I finally lost my temper and snapped, "Listen, kid. I'll get to it when I have the time. Right now I have more important things to do than refill your meds."

I saw the hurt in his eyes and immediately regretted my words. One of our child life specialists who I deeply respect pulled me aside and admonished me. "Zac. He's scared, it's loud in the ER and he needs help. He's autistic and he's already out of his comfort zone. I know you're busy, but don't lose your compassion."

Fast forward to today. "Tell you what, boss," I said, "why don't I do a good physical exam and we'll make sure you didn't get water poisoning?"

"That would be great," he said, "I've been so worried."

I've been reading Cutting For Stone by Abraham Verghese, a physician at Stanford well known for his veneration of the physical exam. Dr. Verghese gave an incredible TED talk about the powerful bond a careful exam creates between physician and patient.

So, finding myself with a few extra minutes in my day, I examined my schizophrenic patient in minute detail. I tested for nystagmus, checked Romberg and Babinskis, carefully listened for the slightest of cardiac murmurs, and checked his ears for wax. And, after a normal exam:

"Good news, I don't think your water was poisoned!"

His response was wonderful. "Doctor, thank you so much. You've put my mind at rest. It was going round and round like a carousel and I couldn't seem to get off the ride."

I suppose a physician's touch - even in a busy ER - is still a valuable tool.

Filed under: Medicine 10 Comments

7Sep/115

Changing Roles

I'm really enjoying being a senior resident. This month I'm mentoring our medical students, and it's been loads of fun so far.

Today we had a "simple" laceration that needed closing. Typically this is the medical student's job, since the residents have traumas and coding patients to take care of. I sent Medical Student to sew up the lac, but two minutes later he came out of the room, pale-faced and nervous.

"Dr. Zac... I took off this guy's pressure dressing and he's kind of... bleeding out from his wound. Like, sort of spurting blood. Kind of everywhere. I think I need help."

I'm a pretty laid-back guy, but years of emergency training have instilled a GO switch in me. I immediately popped in the room. Sure enough, this guy was hemorrhaging blood from multiple severed arteries in his leg. I grabbed Med Student's gloved hand and shoved it in the wound.

"You feel where that's pulsing? I want you to keep your fingers right there and hold pressure. I'll be right back."

There are varying degrees of emergency; this is one that can be fatal if left unchecked. I ran out of the room, grabbing the necessary equipment and sutures. Med Student seemed quite relieved when I returned. Quickly I tied off the bleeding arteries while explaining what I was doing (throw your stitch under the artery, loop back around again, and tie it off. This is called a figure-of-eight suture and it will save your ass in a pinch). Within a minute I had the bleeding stopped. Med Student appeared impressed.

Suddenly, it was a simple laceration repair again. I supervised him closing the wound with little teaching points along the way, and to his credit, he did a fantastic job. It will look great when it heals.

The patient's wife pulled me aside later. "Doc, you really seem like a fantastic teacher. We were both so reassured that you were there. Thank you so much for taking such great care of us!"

It was a great day, and it's been a wonderful month so far. If the rest of my life is like this, I'll be a very happy physician.

Tagged as: good mood, growing up 5 Comments

26Aug/117

Command Center… ONLINE!

Our emergency department just switched over to a new EMR. The transition has gone quite well - my charting has gotten faster and better overnight, orders are infinitely easier to put in the system, and I have more time to spend with patients. All in all, I could not be happier.

One thing in particular stands out with sheer awesomeness. We can make macros. For the less-technically inclined, macros are simply a way of automating something you do often. For a computer nerd/engineering type like myself... well, I've made some improvements.

All I need to do is pick up the dictaphone and say "Computer, activate command center." I then walk away and see my first patient.

Within seconds it boots up all of my patient records, EKG-reading software, radiology images, drug databases, and email. Then it opens up another window and prints out:

"Command center online, Dr. Zac.  Have a wonderful day!"

It's really the greatest thing that's happened to me since... well, ever.

I have my very own HAL-9000!

Filed under: Medicine 7 Comments

26Jul/116

The Grind

Being an ER doctor isn't all fun and games. Well, it's usually fun, and mostly games, but really we're at the mercy of the city and its drunk and dying denizens. When two trauma 1's roll through the door at the same time, a scattering of chest pains and GI bleeders are still waiting to be seen in the back rooms, and the hallways are filled to the brim with gurneys... well, my heart rate starts to rise.

I enter autopilot, and start doing what I loathe the most - overtesting. It's what emergency physicians refer to as "moving the meat." It's a term I hate, but when there are multiple patients needing to be seen - any of whom could be dying - and the department is bedlam, it starts to make sense.

Chest pain? Check. How long? Describe it for me. Risk factors for cardiac disease. Labs, chest x-ray, pain control, next room. In and out the door in a couple minutes. Scribble on the chart, "typical chest pain story, patient appears well and in no acute distress, check labs. EKG nondiagnostic, will evaluate xray for pathology and admit for observation."

It becomes formulaic at this point. Patients with abdominal pain get "belly labs" and a CT. Headaches get compazine/benadryl/decadron and probably a CT & spinal tap. Traumas get "trauma labs" and a $15,000 full body CT scan to search for any hint of bleeding - it exposes them to approximately half the radiation experienced by survivors of Hiroshima.

My normally friendly bedside manner goes out the window. I'll usually introduce myself, "Hi, I'm Doctor Zac and I apologize for being brief. Unfortunately an SUV just overturned on the highway and they'll be arriving in 5 minutes, so I just wanted to pop in and see how you were doing."

I never yell, but I can be brusque. Before residency, I would have never imagined myself to be the type to say "I'm sorry, I don't have time for you right now," but it happens. At least I always say "I'm sorry" first.

I suppose it's part of being a feast-or-famine specialty. We don't have the luxury of scheduling our patients. It still leaves an unpleasant taste in my mouth when I don't feel like I can care for people the way they need to be cared for. Especially when it means spending thousands of dollars of their money that I know they don't have, and delivering enough radiation to possibly cause cancer down the road.

Tagged as: apathy, chaos, moving the meat, overcrowding, overtesting, radiation 6 Comments

24Jul/1121

A Tax For Cigarettes

I saw a cardiac patient today; 3 stents, COPD, peripheral vascular disease... the whole 9 yards. While asking him my standard social history questions (smoke, drink, do any street drugs?) he hung his head low.

"Yeah, my doc tells me I gotta quit, but I can't get down to less than a pack a day."

It's something I hear all the time. I've talked to smokers who are crack and heroin addicts - they say that the nicotine urge is worse than any other addiction they've fought.

For better or for worse, patients seem to focus on the lung cancer aspect of smoking. I suspect it's due to a particularly effective ad campaign in the past few decades, but the truth is, smoking is far worse with regards to other diseases. Tobacco, whether chewed, smoked, or snu'ed causes a huge variety of vascular diseases.

I figure it should be easy enough to calculate the cost of a pack of cigarettes. Ask a random sampling of ER patients how much they smoke per day (we measure tobacco use in pack-years, i.e. the number of packs per day they've smoked times the number of years). Get permission to access their healthcare records, and calculate the differential in healthcare costs between smokers and non-smokers.

Take that differential, divide it by pack, and add it as a healthcare tax. I support people's right to make bad choices; I also support their right to pay for those choices.

Your thoughts?

Tagged as: public health, smoking 21 Comments

21Jul/112

Smart Voices

While talking to a very amicable, pleasant schizophrenic man today:

Him: The voices in my head, they tell me all sorts of things.

Me: Like what?

Him: Don't eat raw bacon.

Me: ... smart voices!

Tagged as: overheard, schizophrenia 2 Comments

11Jul/112

But… why?

Lady, it's 4:17AM. Why are you bringing your child in for a "fever" of 99.2 degrees without any symptoms whatsoever? "Just to get him checked out" is not a good enough explanation.

Here are some possible reasons I came up with:

Me and my boyfriend were up partying all night with blow and ecstasy and we decided to keep the party going all up in this hospital.
I work at 5:30AM and this is the only time I could find to bring my kid in.
The kids were up partying all night with ketamine and poppers, so I figured I'd get them checked out since they were still awake.
We set our clocks ahead by three hours at my house so we're never late for anything.
Something is horribly wrong with my child and I noticed it when he woke up from sleep at 4AM.

Since you've made it clear that #5 is not the answer, I guess I'll go with #1. Also, ma'am, contrary to what you may think, being seen in the ER is not free. Giving our registration people a fake phone number isn't going to get you out of paying the bill.

Tagged as: cocaine, early morning, fevers, worried parents 2 Comments

10Jul/1111

Megacode

She rolled in to Resuscitation Bay One an ashen grey, the tired paramedic straddling the stretcher doing chest compressions. Sweat poured down his brow and arms. They had been at this for an hour en route to our hospital on dark, twisty back roads. She was just shy of 90 years old.

She died for the first time at home while washing the dishes; her husband heard a plate shatter and found her dead on the floor. He started CPR while calling 911 and valiantly kept doing chest compressions until the medics arrived. They jump-started her heart with a defibrillator, but she died for the second and third times on the way to us.

There is a hue about truly dead people - an aura, almost. Extremities pale and mottled, lips colorless. When she arrived the other physician and I shared a knowing glance. This would not end well for her. She was long gone already, but her wishes were to "have everything done". So, we started doing everything.

It is a peculiar feeling, cracking someone's ribs while doing CPR. The heart is simply a series of one-way valves; by doing chest compressions blood is forced out of the heart to the rest of the body. Unfortunately generating that much pressure is often too much for osteoporotic, elderly bones to handle. The result is a *snap* as ribs break from the force. It feels like torture.

Broken ribs are unbelievably sharp. Chest compressions generate inward force, and so the bones rip and tear the lungs, causing air to leak out. With nowhere to go, eventually the air pressure deflates the lungs. The solution is to "decompress" the pulmonary cavity with large bore needles stabbed directly though the chest wall.

As her heart began to fibrillate we began to shock it with 200 joules of electricity, over and over, in an attempt to regain a normal rhythm. Caustic medications were pushed through her IV's to try to stabilize and restart the heart muscle. None of it worked, of course, but she wanted everything done.

In ACLS training this is referred to as a Megacode - a code situation where every therapy and every algorithm is used. It's purely for training purposes; you never survive these extensive measures.

She briefly regained a pulse and then died for the fourth and final time, with a tube in her trachea and esophagus, every rib broken, a needle in each side of her chest, IVs in each arm, special intravascular devices to each groin, and a catheter up her urethra.

I wish I could bestow my entire medical knowledge on patients and families before they ask to have "everything done". They cannot possibly understand what they ask me to do to the ones they love.

Tagged as: coding, cpr, death & dying, futile care, heroic measures, shockable rhythm 11 Comments

8Jul/111

Bear With Me…

That's right folks, we're jumping hosting sites. In the meantime Agraphia might look a little different than what you're used to. Hopefully we come out the other side unscathed.

Tagged as: admin 1 Comment

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