Pandorama Randomorama

Sweet, Sweet Chronic Back Pain

An extremely busy shift last night. Not necessarily by volume (because I actually saw relatively few patients) but certainly by acuity. Almost everyone was legitimately sick and required real, honest-to-gosh admissions for bona fide medical complaints. And three of them were admitted to the ICU, two of them intubated. In fact, the admissions were so strong that I was even spared the usual complaints from the admitting physicians, one of whom even said, “Wow, that sounds pretty bad…let me have his nurse so I can give some orders.”

So around eight o’clock as my shift was drawing to a close I was starting to feel a little worn-out when I picked up the next patient.

“What’s this guy here for,” I asked.

“Oh, he’s a regular,” said his nurse as I walked towards his room,”Chronic back pain looking for some narcotics.”

“Thank God.”

A Confession

I don’t want to work in a busy urban trauma center when I get done with residency. Our program gives us pretty good exposure to both this kind of department as well as the smaller, community type and I prefer the latter which has a mix of minor complaints, major medical complaints, some critical patients, and the occasional trauma. Just a personal preference. I can’t believe anyone will have the bad manners to castigate me in the comments section. Not that I don’t like the typical urban indigent and uninsured knife-and-gun-club patient but I can see how I’d like a little variety as well as the occasional uneventful day now and then. I find that three busy 12-hour shifts in a row sort of wear me out.

“Are you a good doctor?”

One of my readers asked me, by email, if I thought I was a good doctor to which I must reply that I believe myself to be an average to slightly-below-average Emergency Medicine resident. I am certainly not even close to the best resident you will encounter just as I am probably not the worst. I try hard, of course, and I have an excellent work ethic but I am not one of those residents who seems to know everything all the time. I try to keep up with my reading but it seems like none of it really sticks and the only way I can really learn something is if I see it a few times or really screw it up; for example how I learned that there is no need to bury the needle when looking for the internal jugular vein to place a central line. (Good lord, if you’re more than an inch or so in you’ve probably missed it.) Part of residency is to be criticised constantly. In good programs, and mine is an excellent program, this criticism is constructive and a legitimate method of teaching. Naturally it wears one out to be continuously under supervision but that’s why we have residency training and why any old Joe Blow just out of medical school is not qualified to be an Emergency Medicine Physician.

So, like I said, I’m working hard at it and graduation and eventual board certification will be an honor that I hope to have earned and for which I hope I am qualified.

With this in mind, I just want to remind attendings everywhere that if, on occasion, your resident asks you a question about a subject that technically he should know (assuming he remembers everything about the lecture you gave three months ago and everything he read in Tintinalli) rolling your eyes and looking at him as if he is worthless scum who will unfortunately soon be polluting the Emergency Medicine pond is not exactly going to encourage him to ask questions in the future.

Which may be your plan and I can certainly understand not wanting to answer a lot of questions.

But when the resident beats a retreat mumbling his heartfelt apologies and promising to “look it up,” please don’t call him back and pimp him on the same subject in front of the nurses and techs. People don’t believe me when I say this but in the Marines, an organization that I am fond of comparing to medical training, we were taught not only to never belittle our subordinates but to never criticise them publically. (Criticise in private, praise in public) If I didn’t know the answer to the question when I asked it I certainly didn’t learn it in the interval between the asking and the pimping and your frustration that I didn’t know it, as well as my rapid transition into the karmic solace of a humble “I don’t know” as I went into full subservience mode did nothing to dredge up information that just wasn’t there.

What can I say? I didn’t know. I do now.

For Fifty Bucks I Want You Naked, Damnit! Naked!

So there’s this guy with a horny parrot. To skip to the punch line and thus spare you the totally superfluous details of the joke, he pays fifty dollars for a female parrot and, after hearing her shrieking, rushes back into the room to find the horny parrot on top of the female pulling out her feathers and squawking, “For fifty bucks I want you naked, damnit! Naked!”

I learned a lesson a few months ago about exposing patients. You all know how it works. The patient is taken to a room for some horrific-sounding complaint and when you see them they are sitting in their bed fully clothed, socks and shoes on, or with maybe just their shirt off under the hospital gown. While I understand the reluctance of patients to disrobe in a curtained alcove in a busy Emergency Department, because a good physical exam is impossible to perform on a fully-clothed patient they need to strip at least to their boxers under the gown. It is particularly difficult, for example, to listen to heart and lung sounds through the kind of winter layering that is common up here in Yankee-land and it seems awkward reaching a stethoscope under somebody’s blouse. Sort of feels like groping.

I had a patient the other day with all the symptoms of Diabetic Ketoacidosis (DKA) and it was down this primose path that I was lead. He kept his shirt and pants on and there was nothing in the clothed physical exam to suggest anything else was amiss. He was a rather large fellow and as he was breathing pretty hard it would have obviously involved a major effort on his part to take off his clothes. When the laboratory studies started coming back my initial suspicions were confirmed and I sort of settled into the DKA autopilot mode, the only unusual thing about the patient being that he was a Type II diabetic (but insulin dependent, you understand) and they aren’t supposed to get DKA, at least not a commonly as Type I diabetics.

After a little while, his white count came back fairly elevated. It wasn’t incredibly elevated so the value wasn’t flagged for immediate attention and I didn’t notice it for an hour or so (not to mention that sometimes the lab is painfully slow). My attending directed me to a disrobed exam whereupon I saw extensive, well developed cellulitis (a skin infection) on both legs from about mid-thigh to just above the cuff of his pants. A couple of abcesses too, just for good measure. Diabetic keotacidosis can be precipitated by infections as well as quite a few other things so now the presentation was entirely clear and we started him on the appropriate antibiotics before calling his doctor for an admission.

“But Panda,” you say, “The patient didn’t tell you about the cellulitis, how could you have been expected to know?”

Well, look. When you weigh close to 500 pounds your daily activities are a little different than most of ours. It’s quite possible that my patient, otherwise a very pleasant man who answered all questions appropriately and cooperated for the exam and our treatments, had not had his pants off in several days. Therefore when I asked him if he had any skin rashes his answer of “no” was entirely truthful.

The point is that you need to get your patients stripped down for all but the most trivial of complaints. Imagine if this fellow had gone to the floor and his cellulitis had not been discovered until, despite clearing all of the markers for DKA, he continued to be dyspneic and hypotensive and somebody more intelligent than me slapped his head and said, “Good Golly, this patient is septic.” The idea is to start antibiotics and your Early Goal Directed Therapy…well…early. Not late.

For ten thousand bucks (or whatever his admission cost the taxpayer), I want him naked, damnit! Naked!

A Quarter of a Million

This blog is two years old and over the last fourteen months of it (when I started counting) I have had over 250,000 unique visits. I get some regular visitors and I have the accidently-dropped-by-after-looking-for-stuffed-panda-bears-on-Google-market absolutely sewn up. Whoever you are, I want to thank you for their continued interest in my humble blog. I hope you continue to read and your comments and criticisms are welcome.

Except, that is, for those of you who comment that my articles are too long. I know your lips get tired reading anything longer than a brief paragraph on your way to naked pictures of Britney Spears but maybe you could read until they cramped, mark the spot, and come back to continue later. This is just not that kind of blog. I think even my most rabid critics will agree that there are few medical blogs with as much content on them as mine.

26 thoughts on “Pandorama Randomorama

  1. First!

    That aside, I feel like that last paragraph was directed to me aside from the fact that I have only been tracking your blog for almost a year now. Thanks for all the great posts, and if anything – write more!

  2. Panda,

    I will certainly agree with you that you have more content than most other medical blogs. It’s the only reason that I bookmark you. What annoys me about many other popular blogs is that they are simply collection sites that feed off the success of other writers. If you were to peruse through the top 100 healthcare blogs, you’d see that almost all of them are meta sites. Thanks for all the laughs and witty comments over the past year.

    Half M.D.

  3. So, Panda, how does a med student like I am decide what specialty to pursue? I like the idea of EM and it pays well. It’s very competitive in the military and I’m working hard so I have it as an option.

    FP sounds good, too, though. I just hear about the relatively low pay and the migration of doctors out and wonder if it’s stupid to go down that path.

    You’ve been in both at least a little ways. What do you think would lead someone to think they were cut out for one or the other?


    (Primary care is dead or dying.  I’d stay out of it.  The reimbursement is just not there which is why Family Medicine, an otherwise very nice specialty, is so unpopular with American medical school graduates.  On the other hand I bet if you matched into it, with a little business savvy you could eschew the headaches and hassles of dealing with the government and insurance companies and open up a “concierge” practice where in exchange for access and longer apointments patients pay a reasonable rate.  People poo poo this but there is a great demand among the affluent and well-off elderly and near-elderly (of which there are many) for a doctor who will not only spend enough time with them during a visit but is also accessible.   Not everybody thinks they should have to pay for good access to a good doctor who knows them well but these people are eventually going to find themselves waiting to see me in gritty plastic chairs because they couldn’t get an appointment with their regular doctor who is going to retire soon anyway with no replacement.

    What do you really need to start a practice if you don’t need to worry about insurance, HIPPA, or the government?  An office, a cell phone, a nurse, and some basic medical equipment.  You can amortize the equipment, write it off or expense it, and maybe work a little urgent care to support yourself while you get it going and build up a panel of patients.  As long as you can refer to specialists and for studies and labs you are in business.  But making money seeing patients at forty bucks a throw for the insurance company or the gubmint’?  Forget about it.  That’s a lot of patients and most of your time is going to be spent wrangling the documentation so you can get paid, that is, not strictly for medical reasons.

    There is no law that says a doctor has to take insurance or even help patients file.  My dentist doesn’t.  You pay up front, they give me an invoice, and I work it out with my insurance company myself.  He seems to be doing all right and his entire administrative staff is one receptionist.

    Emergency Medicine is cool and it does pay well.  As to how long this will continue your guess is as good as mine. -PB)

  4. I have been reading and enjoying your blog for quite some time; this is my first comment. I couldn’t agree more with what Half M.D wrote. I love that your blog has lengthy, well-written, original content, on medical subjects – when I go to a medical themed blog that’s what I want to see. I don’t want to see pictures of someone’s vacation, recipes, You Tube videos or links to other articles or blogs. If I wanted to see those articles or blogs, I would…go to those sites.

    Thanks for taking the time from your busy schedule to keep up the blog. Looking forward to more.

  5. I’ve been reading the blog for a few months now and I just wanted to comment on how well written the posts are. They are thought provoking and informative. I understand you obviously a ton of time commitments so I appreciate the effort that goes into your writing.

  6. I know you were in the marines as a soldier and not as a doctor but do you have any insight into practicing medicine in the military? (either through acquaintances or any other experiences) I’m a midshipman looking into either applying to med school directly out of ROTC or a couple of years down the line just so you know who is asking.

    Also, your blog is amazing and one of the only independent blogs that I check on a regular basis. One of the things I really like about it is the fact that you take the time to write such extensive entries. (and reply to comments)

  7. FYI,

    Urban trauma centers get old real fast, which is why I don’t work at one. But don’t get *too* rosy a view of community ERs. Some are quite nice, cush places. But most are surprisingly busy, staffed thin on the physician side, and the community acuity can be higher than the inner city acuity, trauma notwithstanding. Moreso if your ER, like most, siphons off the simple stuff to PAs.

    Honestly, I am more tired after working an 8- or 10-hour shift in our community ERs than I was after a 12 in residency. There’s no let-up, and you never stop running. (yes, I *did* just get home from a wicked shift, now that you ask!) And often you are entirely on your own. Is there more variety? Yup. Is the pay better? Yup. Would I go back to a trauma center or academic center? Not on your life! So welcome to our side of the fence, if that’s where you come, but don’t expect it to be easy!



  8. Congrats on the milestone, your blog is excellent. I have turned all the ED physicians on to it at my hospital and it gives us something to talk about (I am in radiology) other than the usual squabbles that our depts face.

    Interested to hear that you consider yourself avg to below avg resident. Actually it is refreshing, I have a feeling that is because you are mature and honest with yourself.

    I can only second the disgust at the public dressing down residents are subjected to. What I want you to do next time in your best Pacino voice is respond “Who the hell you think you talking to? I’ve been around, you know. If I was the man I was 5 years ago, I’d take a *flamethrower* to this place.

    Best wishes

  9. Congrats on the blog traffic!

    I started reading about 6 months ago – about the same time I seriously started considering a career switch to medicine. Still considering. Still reading.

  10. That was good reading material.

    As a public service, perhaps you could put a hot-link to Britney’s pictures at the top of the page. Not that I would ever look at such things.

  11. Panda, great blog. I’ve been reading you since the beginning. You put out some fantastic content.

    I’m a former Marine currently plodding through third year and desperately trying to figure out what to do with my life. I hate that most med school curriculums are set up so that, if you have any interest in a specialty outside of the Holy Sextad (internal med, family, peds, surgery, psych, OB), you only have a few crazy months in which to find the best match.

    Having said that, I am slowly shedding the “it must be surgery or nothing” mentality and it seems that I keep coming back to EM. It sounds like a great specialty, and one that would seem to allow the possibility of having a fulfilling life *outside* of medicine. And dear Lord, I desperately want that. Italy for a month sounds just lovely right now…. Any thoughts?

    Thanks for all of your efforts, both here and SDN.

  12. Awesome blog. Ive only been reading for about 5 months and don;t intent to stop anytime soon. Great writing, good length and humor throughout.

    A quick note on primary care. My dad is a Primary care physician and I also intend to pursue it (along with surgery). Success in the field seems to hinge on having loyal and reliable staff. A good biller (track money and issue bills) a good nurse and a good receptionist. Quite frankly it requires a certain personality to do it well and be happy.

    Congrats on the milestone. Hopefully the first of many.

  13. Congratulations!

    Been reading regularly for quite a while, and I intend to keep coming back. Always a pleasure, Panda, we’re right there with you.

  14. Panda,

    I’ve been reading your Blog since I was a physiatry resident. Physiatry is about as far away from Emergency Medicine as you can get, but the core issues are the same! Residency sucks…

  15. Oskie,

    What exactly does a Physiatrist do? Is it physical manipulation? It’s been compared to sports medicine, but I’m not sure.

    Thanks for the info!

  16. Just a side note on concierge medicine. We just had a pretty prominent HIV specialist in our city go with this business model. He was booked solid, no problems, with patients wiling to go that route.

  17. Panda,

    You have told us a lot about working in the ER and it is very interesting. Tell me something, though, does your residency do a rotation with EMS in which residents ride along with paramedics on the ambulance or helicopter? If so, have you done such a rotation? If so, can you tell us a little about it?


    (EMS time is an ACGME requirement for Emergency Medicine programs and we are required to do 80 hours of EMS activities including teaching or riding with paramedics.  I have not done this rotation yet but at our program, it is exclusively in an observational role and we are not there to provide any guidance or medical help to the paramedics, for not the least of which reasons that our paramedics are very good at their jobs and there’s not to much we could add to what they already do.  Not to mention that we have no legal standing on their rig and are not their “medical direction.”  I plan on keeping my mouth shut and helping them lift heavy patients when asked but that’s going to be about it. -PB)

  18. My lips are tired.

    Perhaps I should engage in some resistance training for my maxillofacial muscles.

    Great read. Great writing. May heavenly panda muses continue to dance around in your head for many blogs to come. 🙂

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