Agraphia Medical Tragicomedy


Pulling The Trigger

One of our nurses just started nurse practitioner school and today was her first day seeing patients in her new role. She came back from her first patient's room and was completely paralyzed by fear.

"I think I want to check some bloodwork on him... but what if I'm wrong? What if he doesn't need it? What if the IV blows? Is it a waste of money? Oh my GOD I had no idea how much harder it is to pull the trigger when you're the one responsible! All the nurses are telling me I'm overreacting and he's fine, but what if I miss something? I've been a nurse for 10 years but I don't know what to do!"

She suddenly understood something that all practitioners realize during their first day - there is a huge difference between making a suggestion (should we check a CT?) and making a decision (we need to check a CT.) I even wrote a whole post back when I was an intern about a freakout I had about giving tylenol.

The weight of that responsibility rests with the physician, and it is both extremely stressful and extremely rewarding. After the fact, decisions are praised if correct, and second-guessed if wrong. It is easy to criticize both from the sidelines and through a retrospect-o-scope. The weight of those decisions - and the guilt when we chose incorrectly - are one of the main reasons we physicians earn our grey hairs.

For just this reason, I learned a long time ago to trust nurses when they are worried, but not to listen when they blow patients off. Just tonight I picked up on rib fractures in a drunk. "He's just an alcoholic," they said, "kick him out the door so he stops wasting everyone's time." He had shattered his entire left ribcage from a fall.

As an intern, I let a seasoned nurse sway me one shift and I didn't order a test I thought I needed. One of the best mentors I've ever had, who sadly passed away last year well before his time, caught the omission. We picked up what could have been a catastrophically disasterous illness.

When I beat myself up over the mistake, he stopped me. "Zac," he said, "all you have in this profession is your gut, your heart and your brain. Do what you think is right, every shift, every time, for every patient and you'll do right by them."

I've taken that to heart, and I to this day it's the best advice I've ever gotten. I passed it on to the NP student today.

"If you think he needs bloodwork, just pull the trigger and do what you think is right. Every shift, every patient."

Turns out, the bloodwork clinched the diagnosis. Having evaluated the guy myself I could have told her something was wrong, but I wanted her to learn to make the call. The glow of satisfaction on her face when the labwork came back abnormal was incredible.

RIP, John. Your passing has been an unbelieveable blow to our field. You are missed by your colleagues and all the young physicians who will never know what they have missed without your tutelage.

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The Radiologist Dilemma

The other day, I had a kid come in with a pretty obvious forearm fracture.  I took a look at the xray, sedated the kid, reduced the fracture, splinted it, called orthopedic surgery for followup, and discharged the kid in about 20 minutes.  An hour later, I got a call from our radiologist.

"Hey, man.  I was just looking through some films up here in the reading room.  You know you've got a forearm fracture in room 18?"  Politely, I thanked him and said I'd look into it.

In the past, radiologists were a prerequisite to the interpretation of films, in part because of how the images were processed.  Before the electronic era, xrays were put through a complicated chemical exposure and then a lengthy drying process in the radiology department.  If needed, a "wet read" could be obtained by having a radiologist look at the film prior to the full drying process - literally looking at a wet film.

The term "wet read" still persists, although now it implies a preliminary or stat read.  Since images are instantly available on the computer after being taken, often this is an unofficial read by an ER doc or another specialty. Sometimes it is the opinion of the on-call radiologist who is looking at an xray or CT scan outside of their subspecialty, which then gets looked at by a second radiologist the next day.

This means that often xrays don't get a definitive reading until well after the patient has left the ER.  This leaves us ER docs to read most of our own xrays and sometimes even interpret CT scans if things are moving slowly. There is an entire fellowship in emergency ultrasound, cutting out the radiologists entirely.

For the most part, if it's not something complicated, I'm pretty comfortable reading my own films.  I also have the benefit of directly correlating the images with the history and physical exam. Here's a paper from 12 years ago showing only a 0.1% discordance rate between ER docs and radiologists when the ER doc is confident of their interpretation.

Now, this gets into some significant medicolegal liability issues (and more than a few turf wars on both sides) that I don't have time to discuss here, but suffice it to say - medicare/medicaid and insurance companies are not super excited about paying two doctors to look at one xray.  One way or the other, I suspect change is coming.

I suspect that eventually radiology will turn into a centralized, 24/7 field. It's a growing concept called tele-medicine, comprising radiologists, pathologists, and other specialties whose intellects but not physical presence are needed in many locations at once.  With the exception of interventional radiologists who need to be on-site, all radiologic images will be reviewed by large groups not bound by hospital or timezone. I'm honestly surprised it hasn't happened already.  Think of it as the Netflix vs. Blockbuster of medicine.

I envision a huge group of radiologists, comprised of every radiologic subspecialty.  Need an xray of the knee read at 3:15 AM?  You'd better believe there's a trained musculoskeletal radiologist reading it within 5 minutes of it being performed.  Do things on a massive scale and the vicissitudes of any given hospital's patient volume gets washed out in the flood.  To some extent this already exists, but for the most part it's purely night coverage until the local radiologists put the official stamp on the report in the morning.

Radiologists aren't going anywhere - they are invaluable at picking apart small subtleties I will never see without their training and their high-end, high-contrast monitors in dark rooms.  The field as it exists now, though?  I suspect that will change a lot in the years to come.

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Playing With Fire

He looked pretty comfortable on the stretcher - unconcerned, even.

32 years old, already with bilateral toe amputations from massively uncontrolled diabetes.  He had already had bone infections, a condition known as osteomyelitis, and he had been through a few months worth of IV antibiotics through a PICC line.  Somehow he still managed to be completely noncompliant with every and all medical therapy suggested for him.

"Evening, sir, my name is Dr. Zac.  What brought you in tonight?"

"I think I got the bone infection again, and I want my Dilaudid," he said, casually, "I'm allergic to morphine and Vicodin, all I take is Percocet and Dilaudid now.  Also, I would like Phenergan and Benadryl with it."

I paused.  There are few things that bother me more than a patient requesting Dilaudid, Benadryl, and Phenergan in the very first sentence.  That particular cocktail of drugs is well known among ER physicians for being an incredibly potent high, and the immediate request for that triumvirate somehow belies a concern of illness from the patient. Most patients come in worried about what is causing the pain, and want an answer - the pain control comes second.

In this particular case, though, he was really quite sick.  He had a fever, his heart was racing at about 120 beats per minute, and his foot looked infected - and the infection was spreading up his leg.

Turns out he hadn't been bothering to check his blood sugars - routine for him, upon reviewing his chart - and his blood sugar was also around 350, which is great for hungry, thriving bacteria.

I started an IV on him, drew cultures of his blood, started potent IV antibiotics, and immediately called the admitting physician.  I begrudgingly gave him a small dose of Dilaudid - he had put our other pain medications on his "allergy" list, a common gambit among patients who want their physicians locked in to giving them the stronger medications only.

The nurse came to get me 30 minutes later.  "Room 5 says he's leaving.  He's got stuff to do at home."

I was floored, so I went and had a long talk with him.  I'm a firm believer that fear-based talks don't do anything for people and that positive reinforcement is more useful.

Still, I tried both.

"I can't force you to stay, and I know you don't like checking your sugars.  Listen, I'm not the diabetic, I never have been.  I have no idea how difficult it is to check sugars and dose insulin all day, every day.  What I do know is that from what I'm seeing here, you're probably about to lose your leg, just like you lost both toes.  I don't know, maybe the infection will even spread throughout your body this time and kill you."

"I can help you if you stay. I can get your sugars down, I can get antibiotics in you, we can try to figure out a way to make your diabetes control work for you before you become crippled."

"Tonight is one of those turning points in your life.  Stay, and we have a fighting shot at stopping this.  Go, and you'll always regret not staying, right here, right now, when you lose your leg."

Nothing I said stopped him from going.  He said he'd come back in the morning, but he never showed.  It's not often I feel like I've failed someone, but I feel like I failed him.  Then again, if I couldn't convince him to stay despite my best efforts?  Well.

I guess some people just like to play with fire.



A beat-up Corolla with a faded Papa John's tag rolled up to the ambulance bay of the ER.  A pockmarked teenager got out and knocked hesitantly on the ambulance bay doors.  With a raised eyebrow, the charge nurse let him in.

"Delivery for Jenny?" he said.

We looked around, a bit confused.  Jenny, our nurse wasn't working that day.

"Says here she's a patient in room 5," he added, helpfully.

Ah, Jenny.  Too bad for you, Hawaiian is my favorite.  You just became NPO.

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As I mentioned previously, I'm studying for the boards right now.  Just for fun, I pulled out my old study notes from Step I of the USMLE, all the way back in medical school.

It's really fascinating to look back at how far I've come.  My notes are covered in lists and lists of drugs, side effects, and mnemonics; stuff that once took massive amounts of mental energy to memorize. Now, much of it is either intimately familiar or gone completely.

What I find really interesting about these notes is that they don't have any weight to them.  Skimming through them now, my attention is drawn to specific diseases that occur more frequently than others, medicines that are safer and therefore more commonly used, and anatomic locations of significance.  7 years ago I went through and learned them all without much understanding of why.  Now it's all I care about.

Metformin, for example, is the most widely prescribed medication in the world for diabetes.  It shows up only once in my 15 pages of notes, listed in the middle of 6 other diabetic drugs, with the word "lactic" written cryptically next to it.  I did an entire lecture on metformin-induced lactic acidosis during my toxicology rotation last year... but for the boards, all I knew was that single word association.

That said, much of the information is simply gone.  I haven't thought twice about embryology since that test.  Sure, I know what drugs to avoid during pregancy, when to avoid teratogenic radiation, and what to do for premature labor, but the basic science behind the "why" has long been pushed out of the way for more clinically useful data.

Looking back through these pages is kind of like a stroll down memory lane - the study room in the medical school library, the grueling hours, the fast-food burritos scarfed down for lunch breaks.  I can't say I really miss it...

...but in a way?  I do.

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My board exam is coming up in a few weeks.  Back when I applied to medical school I never realized how much testing there was after you were accepted.  I figured that for the most part, you got into medical school, someone waved a wand, chanted some latin words, and you came out on the other end with a stethoscope.

Not true.  I've now been through 8 different national exams (MCAT, USMLE Step I, IICK, IICS, III, and 3 versions of the inservice).  Next up: the Board Certification exam.  This is the big one and determines whether or not I'm eligible to be a Fellow in the American College of Emergency Physicians.  Fancy!

So, in the meantime, it's back to studying for me... and I'm finding it oddly satisfying.  I rarely picked up a book in residency, mostly because I was so tired all the time.  Some of my classmates had strict schedules and managed to cruise through some of our major textbooks while working 80+ hours a week.  I didn't have that kind of stamina.

I'm not a very particular person, but when I study an almost autistic side of me comes out.  I need sheets of clean, white paper and ultra-fine point sharpies.  Lots of bullet points and arrows come into play.   I like to think it looks pretty artsy.

Part of the reason I enjoy this stuff is that it lets me put things into categories, especially now that I've been practicing for a while.  It takes the chaos of the ER and puts it into an orderly set of rules.  Below this level of white blood cells, these diseases become common in HIV patients.  See this phrase, start that treatment.  Cause and effect.

It also makes me realize - I'm not meant to do private practice forever.  I've been told I'm good at explaining things; I think it's because I have to organize them in my mind first before they make sense.   The real question is... when - and where - am I going to go teach?

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Dr. Zac’s Rule Of Twofers

This is a cross-post from The Hero Complex, where I was asked to write a guest post.  Also, thanks to ER Jedi for the inspiration... I've been meaning to write about this very topic for years!

When you get ready to examine a patient, there are a few clues you can use beforehand to determine how sick they are.  There are some quick ones, such as how many visits they've had in the past 30 days for the same back pain, or whether or not they have any vital sign abnormalities.  Sometimes you're in luck and labs or xrays have already been performed.

But all of these methods pale in comparison to Dr. Zac's Rule of Twofers.  Now, I don't mean to talk myself up, but this formula is genius.  Allow me to demonstrate:


Patented, Trademarked, and guaranteed 100% accurate by Dr. Zac

Where the total sickness of your patient is equal to a coefficient (δ) times the total possible sickness of any given patient divided by the number of patients in the room. Please note, there is a separate but directly related theorem when multiple people from one family check into different rooms in the ER.

You may ask yourself, "What exactly is δ, Dr. Zac?"  Quite simple.  It's the Coefficient of Chief Complaint, goes from 1-10, and it is used to scale the importance of certain chief complaints.  Usually it equals 1, but if the chief complaint is, say, "horrific car wreck on the interstate," it allows us to overpower the denominator.

A few examples:

  1. Mom checks in her four children at the same time, all who have "Fever x 1 Day" listed as a chief complaint.  Fever has a δ coefficient of 1.  Thus, the maximal sickness per patient is divided by four, leaving us with an essentially social visit.  Make your pleasantries, crack a joke or two, look in the kids' ears, no antibiotics necessary.
  2. Dad, drunk, lights the house on fire.  He and his 8 illegitimate children are brought in as well as his mistress.  "House Was On Fire," naturally, carries a δ of 10.  Thus, 10 divided by 10 patients gives us 1, leaving us with a maximal potential sick value equivalent to that of any other patient in the ER.
  3. A friend sitting in the room with your patient mentions offhandedly that she coughed once earlier today.  Unfortunately, all the sick in the room has already been used up by your patient, leaving the friend with a δ = 0.  This is a special case, also known as the "convenience coefficient" and occurs when someone is so far from being sick they couldn't even be bothered to check in at triage.

There you have it, folks.  Dr. Zac's Rule Of Twofers.  It's bulletproof.



It has been a slowly dawning realization for me - I don't love medicine.

It's not Emergency Medicine, either.  It's medicine as a whole.  I'll give you a few examples:

48 year old male, chronic back pain, wants narcotics.  Angry he's waited for 3 hours to be seen.  Even angrier that I'm not going to give him his fix.  Both of us walk away upset from our interaction.  I don't enjoy playing bad cop, but I do it about 10 times per day.

35 year old female, morbidly obese.  Smokes 2 packs a day, comes in because she "can't breathe right."  Lungs sound like ash.  I give her some breathing treatments and steroids, she gets a bit better.   Goes home to smoke more.

10 year old male, BMI of 40.8.  Mom is upset that his pediatrician wanted to start him on antihypertensives and comes to me - an emergency physician - for a second opinion.  I can't argue; his blood pressure is 160/95.  He's eating a cheeseburger.

85 year old female, completely demented at baseline, dropped off by nursing home completely unresponsive.  Third time this year.  Family nowhere to be found.  Despite my better judgement, I intubate her because I'm supposed to.  Feel guilty afterwards for not just letting her pass peacefully.

I know there are patients out there who really, truly need me.  They are few and far in between, however.  Modern medicine, for better or for worse, now treats first-world problems.   We "care" for nursing home patients because families can't be bothered.  We write prescriptions for vicodin because we can't bear to fight with 5 people in a row today about whether or not they need pain pills.  We prescribe antihypertensives and statins and diabetic medications for people who don't fill them and then go eat at McDonalds.

The truth of the matter is, I just don't feel like I make a difference any more.  My fellow emergency docs know how frustrating it is to go through a pelvic pain workup on an 18 year old girl, just to find out that she only came to get a pregnancy test.  The ER, you see, is cheaper than the dollar store.  Or the drunk who just needs a place to stay for the night and complains of chest pain to get a "free" bed.  Or the dialysis patient who smokes crack, forgets to dialyze for a week and comes in dying.

There has been a lot of discussion in our journals lately about physician burnout.  It's been labeled as an epidemic of sorts, one that is getting worse.  There are a lot of reasons why. Here are a few of mine.

1) There is constant pressure to never make a mistake.  Some of this is legal - screw up and you get sued.  I like to think most of it is humanitarian, though.  You don't want to miss something and have someone get sick and die.  It's very personal.  Your mistakes are your own.

2) Patients can be miserable.  Especially in my field.  For instance, I go through phases with drug seekers.  Sometimes I'm easily able to blow them off.  Other times it really bothers me. I never wanted to have to spend every minute of every day being suspicious about human motivation.  Now it's part of every workday for me.  For better or for worse I've developed an incredible sixth sense about when I'm being played.  It's not a skill I ever really wanted.

3) You can't help someone who won't help themselves.  I think this one is the worst.  The vast majority of what I take care of is the patient's own fault.  Smoke too much, get COPD - come to the ER when you can't breathe.  Eat too much, get diabetes - come to the ER when your sugars are too high.  Drink too much, get cirrhosis - come to the ER when you get a GI bleed.  And then get upset at me when the wait times are too long, or I can't get you back to normal.

In the end, the easiest insulation is to just care less.  That way you don't get burned when the oxygen-dependent COPD'er blows off his own face by smoking with oxygen tubing.  Or the full workup you just ordered on your chest pain patient ends up being a waste of thousands of dollars because he was just trying to scam you out of vicodin.  Or the family of the diabetic you're treating for high blood sugar brings her an Oreo Blizzard from DQ while she's hooked up to IV fluids.

I've spent the last 7 years really, really caring about what happens to my patients.  I still do, but it's wearing on me.  For every great save I make, there are eight more patients for whom I was a momentary speed bump in their fast lane to destruction.

It's tough trying to hold on to the good things I do.  A kid almost died after an inhalation injury a few days ago.  I intubated him and saved his life.  He's back at home now, normal, with his family.  At the beginning of residency, I would have been excited about that for weeks.  Truth of the matter is, I don't really get a rise out of it any more.  Just one more patient out of thousands.

And so, I'm looking for a reason to keep going.  One that spans beyond a need to pay off loans or make a paycheck or not to throw away 7 years of miserable training. I know things will get better.  For now, though, it feels like I'm a tiny brick in a massive dam that is trying to hold back the constant flood.  America is getting sicker.

I'm getting tired of fighting.


You Probably Should Quit Smoking

"Medic 5 calling ER.  We've got a patient who was... uh... smoking with his oxygen tank on.  It blew up in his face and now he's not breathing.  We'll be there in... uh... about 2 minutes.  He looks pretty bad."

Few things mobilize the ER staff quite as quickly as a bad accident.  So much of we see is routine chest pain, mild abdominal pain, and chronic migraines that a "real" emergency inevitably causes extra hands to materialize.  I immediately started getting set up for an advanced airway.  Burned face usually implies burned tongue, throat, and larynx - and although your face can accomodate a certain amount of swelling, swelling INSIDE the throat will close off an airway fast.  It's critically important to not only act fast, but before things get bad.

I was pleasantly surprised to find my training paid off.  This guy was the sickest person I've seen in about a week, but I knew exactly what to do.  Heart rate through the roof, blood pressure quickly circling the toilet, oxygen saturations less than 50%.  Calmly and quickly I intubated him - fast enough that the respiratory therapist, surprised, asked "already?" when I asked her to hook the patient up to the ventilator.  While intubating, I could see the ash trail down the bronchus, a telltale sign he was a smoker (alright, let's face it.  The guy needed to leave his oxygen cannula on at full blast to muster up enough breath to inhale his cigarettes.  That's olympic caliber dedication to tobacco right there).

That's when things went downhill.

The minute the paralytic wore off, he started squirming.  His blood pressure started rising.  110.  150.  210.  275.  The nurses started having trouble holding his arms down as he went to pull the breathing tube out.  Heart rate jumped into the 140's.

Knowing full well that too much sedative at one time could be a huge problem, I started carefully adding medications.  No response.  He kept trying to pull out my precious tube, the only thing keeping him alive at this point.  I gave him some more sedative, waited 5 minutes, and gave him more.  Still thrashing around, unconsciously reaching at the tube firmly lodged in his airway.  If I lost that, he was dead.

Suddenly, he crashed.   His blood pressure went from 275 to 75 in the blink of an eye.  Surely a mistake, I thought to myself.  I rechecked it, checked, and checked again.  It was real.  He was on the cusp of dying, and I could barely feel the pulse in his neck.

It's incredible how 4 years of medical school and 3 years of residency flash through your mind.  Over the next 15 minutes I started systematically checking for reasons why his blood pressure had dropped so rapidly.  Had the breathing tube been pushed in too far?  Pulled out?  Had his emphysema caused a rip in his lung, leading to a buildup of air?  Was our ventilator set wrong?  Did he have a sudden heart attack from the stress?  Had the sedatives all finally added up together?  Had his lungs filled with fluid from to the flames, suffering burns like his face?  The possibilities flew through my mind.

The nurses stood in silence while I pondered, carefully checking every tube, line, setting, and lab value.  A few threw out ideas.  I stood, thinking.

Finally having ruled everything out but over-sedation, I gave him a dose of medication to raise his blood pressure.  It worked like a charm, and I let myself relax a bit.  As he started to squirm again, one of the nurses asked if she should sedate him some more.  I gave her an icy glare.

It was only after he safely got on the chopper to the burn center that I realized how scary that situation really was.  I initially had no idea why his blood pressure dropped so rapidly, and I've never seen anything quite that dramatic before.  What's worse is that aside from burns to his face and his mouth, nothing else was wrong with him.  If he died?  I would have assumed it was something I did wrong.

Sure, if you really want to split hairs, he was a horrifically bad COPD patient with about 80 years of smoke and tar caked in his lungs, with countless other medical problems.  It's incredibly difficult to properly ventilate these people, and especially in the setting a huge fireball inhaled into his lungs, I suppose he was a setup for disaster.  Still and all, if he had died, I wouldn't have forgiven myself.  I sincerely hope all goes well for him at the burn center.  I've done what I can.

Can't prevent people from hurting themselves, though.  This field is exhausting sometimes.


Small Town

This new job is fascinating.  I'm working out in a rural county - about an hour away from the major metropolitan area where I live - and in only a month, the way I practice has changed.  Dramatically.

My residency was a pretty large hospital, and served as a massive referral hub for hundreds of miles around.  We were the catchment for millions of people, which meant that all of the sickest people came to us.  I was impeccably trained.  People were sick.

Out here, though?  Rough guess is that we serve 100,000 total people, and that might be pushing it.  Interestingly enough, since there's only one hospital in the area, we see the true flavor of what the community really suffers from.  It's not thousands of square miles of sickness condensed into one place.  Out here, there's no doctor shopping.   If you need to go to the ER, you come to us.

For the most part, the nurses, techs, and even some of the doctors are from around the community.  That means that many of the patients are neighbors or friends... or the town drunk.  We even have a family euphemistically referred to by the staff as "the shallowest gene pool in the county".  It's a very dramatic example of inbreeding, the likes of which I've quite honestly never experienced.

I'll give you an example.

Registration: "Ma'am, when's your birthday?"

Patient (after a moment of thought): "After Thanksgiving."

Registration: "...I see.  What year?"

Patient (lisping): "I have a birthday every year!"

She's in her 50's.  If the rumors from the rest of the family are true, she's dating her nephew.  As an aside, the above conversation is verbatim.  No embellishments here.  Can't make this shit up.

The "regular" ER visits are now a bit less... regular.  Gored by a bull.  Run over by a tractor.  Wants her vagina examined again by "the cute doctor who works at night" (not me, thankfully.  As an aside, the poor doc in question refuses do pelvic exams on this patient because she creeps the shit out of him).  It's a whole new world, and I am loving it.

Dear readers, I'm back.

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