Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Monday, May 24, 2004
    The Treatment Is Worse Than the Disease

    Man sues guru over raw frog cure

    Friday, May 21, 2004
    The Code

    I was sitting in my office one day last week writing referrals, when I suddenly heard words you don't normally hear in a doctor's office: "Somebody get the oxygen. And where's the crash cart?"

    Driven by curiosity, I leapt up and headed down the hall toward a tight knot of ancillary staff clustered around the door to an exam room, their stares focused on an elderly woman slumping in her wheelchair. Actually, "slumping" is an understatement; she looked like she was trying to pour right out onto the floor. J, my partner, was trying to get her out of the chair with help from one of the nurses: "She isn't breathing," I overheard. I grabbed the phone and called 911 (I've only had to do this three or four times in the course of my eight years here, and it always makes me feel somewhat phony, like I'm an actor on ER).

    "What's the patient's age?" asked the operator.
    "Uh, she looks to be in her eighties." ("Ninety-four," prompted her relative, standing in the hallway looking freaked out.) "Strike that, she's ninety-four."
    "Does she have a pulse?"
    "No pulse." ("She has a pulse, she's just not breathing!" yelled J.)
    "Sorry, yes, she has a pulse but she's in respiratory arrest," I stammered.
    "And you're a health care provider?" (Was it paranoia, or did I hear a note of incredulity in her voice?)
    "Yes, but I'm not the patient's provider. Her provider is in there with her on the floor," I fired back.
    "Okay, fine, the paramedics will be there shortly."

    I hung up with relief, snagged a radiology tech student and assigned her to go downstairs to direct the paramedics to us when they arrived. Then I joined J on the floor. By this time the oxygen and crash cart were in the room. I uncoiled the nasal tubing for the oxygen and passed it to him, then grabbed her arm and felt for a pulse. The patient's eyes were open and staring at the ceiling - at first glance I was convinced she was dead - but the pulse was nice, regular and strong.

    "Can you find any Narcan?" asked J. The patient was on pain meds for a fracture, and his theory was that she might be narcotized and therefore not breathing. I fumbled around looking for the drug, then gave up long enough to grab the bag-and-mask mechanism off the cart and toss it to him so that he could ventilate her. Within seconds her previously open eyes started to blink and focus. By the time I found the Narcan and got it into the syringe, she was doing well enough that we didn't need to use it.

    I heaved myself up off the floor and listened to the distant siren. The patient's niece was sniffling into a Kleenex. I asked her gently, "Do you know if she was using more pain meds than usual?" The answer was no. She'd felt unwell, the family had brought her for evaluation and then she passed out. When elderly people in wheelchairs drop their pressure and pass out, it's usually bad news. The chair holds them upright and they can't get flat, which means the brain is being deprived of oxygen since it isn't being perfused with blood (that's why people faint in the first place. It's a safety mechanism to get blood to the brain when your pressure drops). If the person cannot be placed in a supine (horizontal) position, they may develop a watershed stroke due to decreased perfusion in the brain. In this case, she was densely unconscious to the point that she wasn't breathing. The good news is that if you can get them flat and ventilate, they'll wake up as soon as blood gets to the brain, as happened here.

    That's really the end of the story; the paramedics showed up, loaded the patient onto a stretcher and took her across the street to the hospital. We later found out that her sodium was low, but that still doesn't explain why she reacted the way she did. We got our reminder that day that it's much easier to manage emergencies in the hospital than it is in the outpatient setting, even with a crash cart and oxygen.

    Confound It, Ernie, Where Do You Find This Stuff?

    My milkshake bringeth all ye gentlefolk to the yard, and they're like,
    verily, it's better than thine...

    Oh and while we're on the subject of rap: "Hassle the Hoff" is coming out with his first album, produced by Ice-T. This oughta be the most exciting album since Pat Boone went heavy metal.

    Thursday, May 20, 2004
    Where Have You Been?

    Via Mental Office Girl, here's a map of the places I've visited:

    create your own visited country map

    Sunday, May 16, 2004

    Have you ever been in a library and seen one of those cool posters? The ones showing a celebrity with a book, and the caption "READ"? I've often wondered if they were for sale to the general public...

    Well, they are. The American Library Association sells them online. They've got everyone from Alec Baldwin to Shaquille O'Neal to Weird Al Yankovic (pictured with A Brief History of Time). Might be the perfect graduation gift for a friend's kid.

    Wednesday, May 12, 2004

    It's been two weeks of high drama here in Primary Care Land. (A place as wondrous as Disneyland, but much less fun.) I'll list the highlights briefly:

    - two elderly demented female patients dying of aspiration pneumonia. Slowly. I have been feverishly trying to convince the families concerned to withdraw aggressive care, so that they can die quickly. (Those are their only two choices at this point.)

    - a patient with hypereosinophilia, possible Loeffler's syndrome, and an elevated troponin. Her eosinophil count is over 25,000 and I have absolutely no idea what's going on. I have referred her to Rheumatology, Pulmonology, Cardiology and Hematology and am fielding their multiple requests for special studies as fast as I can.

    - a patient who wound up in the hospital with massive abscesses from shooting crystal meth, HIV positive, who's calling me up complaining that he's hungry and tired of being kept NPO (nothing by mouth) and the surgery isn't happening fast enough. From somewhere I dredge up some empathy and diplomacy and convince him please, please to stay in the hospital and be patient, it'll just be a few more hours.

    - I'm off to the Pri-Med conference in the morning so may not be posting much for the next few days (surprise, surprise). I will try to get back to a more regular blogging schedule ASAP - I feel guilty when I don't post!

    I leave you with a few links you might enjoy. First, Steve Almond is interviewed here about his book Candyfreak, which is indeed about his addiction to candy, any kind of candy, and his travels across the U.S. seeking same. This looks like a must-read. (via Bookslut.) Second, via Ernie, an adorable new anime character that trumps Hello Kitty anytime; lastly, via GruntDoc, say hello to my hero Doctor Id! (And look at all the other Scutmonkey Comics while you're there!)

    More later... I'll try to tell you about the wonders of the Pri-Med convention. Especially the free stuff you get...

    Why I Love The Internet #948

    Here on Amazon is a gem of a list from someone who reads to telemarketers (or claims that they do). Do click on this. It's funny and uplifting.

    Friday, May 07, 2004
    Today It's an 8

    Here's a handy program that will tell you the ultraviolet index in your area (if you live in the States, that is). With summer coming on this seems like a good idea to me.

    Tuesday, May 04, 2004
    What to Call Wal-Mart Wine... Other Than "Bitch Juice"

    Thanks to Jim of Snooze Button Dreams for this hilarious list.

    What Juice?

    Received the following email from V. down the hall:

    I just saw a patient who's just finishing a course of steroids for an MS flare. She's been getting 1 gram of Medrol daily for 5 days. She calls 'roids "bitch juice". I loved that turn of phrase. I've been rolling it around in my brain ever since. I had to share.


    The Kitchen Hand explains why it's never a good idea to handle chilies with your bare hands... especially if you wear contact lenses.


    Hi. Thanks for the slogans you submitted - I love 'em. I may entertain myself by sending them in to the Infection Control Committee.

    So the last couple of weeks I took some time off to spend with my family who came to town for a visit, then went to Phoenix the weekend before last to see our former rector being ordained as the new Bishop of Arizona. Our church put together a roadtrip, and a whole slew of us went. It was a beautiful ceremony. I was interested to see Frank Griswold himself presiding over the whole thing. I didn't get a chance to speak to him but met his wife briefly.

    I spent a lot of time in Phoenix shopping, rather productively, I might add. I usually get one or two good-karma shopping days a year when I can find everything I'm looking for - the rest of the time I usually don't have much luck- so I took full advantage. I got a lot of birthday presents taken care of (and Mother's Day, too!) The last day we were there, I went into Scottsdale with a friend to shop for a few things; as we drove into town we passed an ice cream place called The Sugar Bowl. Suddenly I thought: didn't Lileks write about this place?

    Yes, he did. We didn't go in, but I found it thrilling anyway: LILEKS SHOPPED HERE! In the Scottsdale shopping district we found a singing cowboy riding up and down the street. If his goal was to encourage purchases, he succeeded: I ducked into store after store just to get away from him.

    So now it's back to work. Last week was grueling, which is why I didn't post sooner; I started out all Zen and relaxed but that's worn off. More later.

    What Would We Do Without Spokeswomen?

    Hard to disagree with this phrase:

    "Operations should be carried out so that does not happen."