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.”
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.