One of my favorite things is when patients rip up a prescription - it's just such an unnecessary, childish action. Usually it goes something like this:
Patient: "I need purpleset tens for my back pain. My doctor is out of town."
Me: "That's Percocet, and the fact that you abbreviate the dose 10/325 as 'tens' makes me concerned that you're far too familiar with this medication. We're going to give you some Tylenol today."
Patient: "I can't take Tylenol."
Me: "You know there is Tylenol in Percocet, right? That's the 325. It stands for 325 milligrams of Tylenol."
Patient: "Its a different kind of Tylenol. You don't understand."
Me (sighing): "I know. These medical degrees, they hand them out like flyers these days, don't they? Doctors just don't understand medications like they used to."
I routinely write prescriptions for Motrin and Tylenol for patients. I'm not trying to be snarky or insulting - I truly want them to take those medications on a scheduled basis for their pain. They may not be prescription-only, but countless studies have shown that they are effective and are an integral part of therapy. I also write Sudafed prescriptions for sinusitis and otitis, and Prilosec prescriptions for heartburn. Both of those medications are over the counter, but patients may not know when and how to use them appropriately.
For this patient, though, there is one thing he wants from his ER visit - opiates. His body has gotten completely hooked on that sweet candy, and when he runs out and start jonesing badly enough... he comes to me.
What drug seekers want is multifactorial. I've sat down and talked to these guys occasionally and asked them what their gain is. They hate coming to the ER for the small 12 pill score they might get from us if lucky. What they really want is to find someone who is going to fund the habit; hopefully a doddering old primary care doc who is loose with his script pads. From him they can score 120 oxycontins with another 120 morphine sulfate tabs - doses that DWARF what we give from the ER. We're merely the safety net when their score doesn't come through.
And so, my little Tylenol script tends to make them upset. I've seen more of these ripped up, thrown on the ground, and stomped on in a pique of rage than I care to. One guy even accidentally ripped up a prescription for Vicodin along with the Motrin prescription I gave him. This will come as a shock, dear readers... but I did not reprint the script for Vicodin.
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:
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:
- 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.
- 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.
- 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.
This is a story that happened to the good Dr. O while I was on shift with her tonight. If female genital complaints gross you out, I suggest you stop reading now and go visit another website... although, it's pretty funny.
The patient's chief complaint was "vaginal discharge x 2 weeks", which - at minimum - requires a pelvic exam. Dr. O interviewed the patient, getting some more background information. Whitish discharge. Unprotected sex. New boyfriend. Run of the mill, most likely a sexually transmitted infection. The nurse comes in, they set up for the pelvic, and begin.
By her account, this was the most horrifically awful pelvic examination she has ever performed. Milky white fluid was leaking everywhere. On the sheets, on her scrubs, on the speculum. It was all she could take not to gag.
Impeccable, composed physician that she is, Dr. O obtained her samples, and then calmly told the patient that she was quite concerned about the amount of discharge. "This," she said, "is honestly the most fluid I have ever seen on a pelvic exam. We will empirically treat you with antibiotics for a suspected STI, and will call you with the results of the tests as soon as we have them."
The patient looked at her and said "Aw, that ain't no discharge. Me and my boyfriend just raw-dogged it right before we came to the ER. That's all cum."
A few weeks back I had to leave our med school tailgate to put in a shift at the urgent care. While I was truly saddened by my inability to contribute to the shotgunning of copious beers, alas, some of us are productive members of society. Then again, I'm of the mindset that shotgunning beers at tailgate is productive, but that's a debate for another time.
I had a pretty great shift, mostly because drunk college kids were brought in for various and sundry complaints†, and they were stoked to see the school colors under my scrubs. Halfway into the night, though, there was something... different. Cruising around the corner, I immediately noticed two things.
Firstly, my nostrils were assaulted with the pungent odor of vast, unimaginable quantities of shit; a horrific wall of feculent odor that knocked me backwards. This was shit to be reckoned with. This was shit that didn't take "no" for an answer.
Second, there was a very attractive sorority girl in school colors and butt shorts screaming blindly "I'm NOT as DRUNK as you THINK I am" at the nurse who was unsuccessfully trying to start an IV.
The incongruity of these two simultaneous events was difficult for me to comprehend, so I used my carefully honed powers of medical observation. "Ah, there's the problem" I thought to myself, "that lovely young lass has shat herself".
I mean, folks, I didn't realize you could even poop that much††. It was all over the poor guy drawing blood, the bed, the floor. It was splattered on the wall like a Jackson Pollock painting. It was a veritable cornucopia of fecal matter. It was Shitterhouse-Five.
That, my friends, is why I both love the ER and could never make it as a nurse. We love you so very much, you don't even know.
† If by "various and sundry" you mean "solely related to alcohol and the imbibing thereof". Pearl: if a piece of a broken beer bottle pierces through the insole of your Chucks, your antibiotics must cover Pseudomonas Aeruginosa.
†† let alone a girl who couldn't have weighed more than 90 pounds.
So in a week I start 4th year, and I'm debating whether or not to do Radiology first, or switch it out for ENT (ear/nose/throat surgery). Youtube is a fantastic resource for budding young surgeons, as you can watch whole surgeries from the comfort of the home. Bonus: you don't have to stand in the back of the OR looking bored!
Let me talk you through my thought process. As a quick warning, none of the links in this post are safe for children. Or adults. Or really anybody, including doctors. I'm not sure I can do ENT any more.
Zac (thinking): I wonder if I should look in to some sort of surgical field again? Honestly, I like procedures a lot. What about Urology? Nah, I don't really want to stick my fingers up dudes' butts all day long.
Another Med Student: Hey, man, look in to ENT! They do some really cool procedures.
Zac: Cool... lets just go ahead and YouTube some ENT stuff... lets see, this'll do. Endoscopic Dacrocystorhinostomy.
Hey, nice nose, man. They do this while the patient is awake? That's pretty cool, you can do it in-office. Neat-o, this is a pretty nifty, delicate procedure. Wait... wait, he's using a "chisel"? And the guy is awake? He's going to chisel through his nose while he's AWAKE? Oh, god, you can hear the bone breaking. Huh, that's kinda neat, though, he just removed all that bone and now there's a "sac" protruding. Wait, wait, wait... he's cutting open the sac. Oh, no - please no - now there's stuff draining EVERYWHERE... ugh, it looks like it's all going down the patient's throat. I think I'm going to vomit.
Zac (nauseated): OK, ok, I can do this. That was just one surgery. How about this one... Nasolabial Cyst Excision.
Hm, that's funny, that guy has really terrible teeth. Surgeon is getting ready to cut... nice incision, doc, strong wor- WHAT THE FUCK, WHAT THE FUCK IS THAT OH MY GOD ITS ALL DRAINING TOWARDS HIS THROAT!!!! THE IMAGE HAS SEARED ITSELF INTO MY BRAIN AND I WILL NEVER GET IT OUT... OH SWEET JESUS THAT MAN JUST SWALLOWED PUS EVERYWHEREOH GOD THE SURGEON IS MILKING THAT STUFF OUT LIKE ITS A COWS UDDER
A few days ago our office's nurse cornered me "Zac, I don't know what to do about the patient over in room 2. She was diagnosed with an ammonia over at the urgent care yesterday and was sent home... she just told me she's having trouble walking, has difficulty breathing, feels nauseated, and has a horrible headache. Dr. S is in with another patient so I figured I'd ask you if you think we need to get him in there right away."
Now, hyperammonemia is no laughing matter. Especially when it presents with gait problems, vomiting, and a headache you start to worry about all sorts of stuff, including alcohol withdrawal, drug overdoses, and liver diseases. Warning bells were going off in my head; I asked the nurse if the patient was a drinker; lo and behold, she was.
Rather than seeing my other patient, I waited outside the room for Dr. S so as not to miss him. I gave him the brief synopsis, and he dropped what he was doing immediately to walk over to room 2.
As we entered the room, he started smiling. The patient was sniffling a bit but looked just fine otherwise. She was 62 with a walker.
Dr. S: So they diagnosed you with a pneumonia at urgent care, huh?
Patient: Yep, that's what I told your nice nurse.