Category Archives: Medicine

Happy Doctor’s Day

A few days ago it was National Doctor’s Day.  Yup, that’s actually a day.  In honor of this clearly very important day I have a story to tell.  This story starts about a year ago.

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I had just tied the strings of the surgical mask, I secured one knot above my blonde pony tail and one, tied a little more loosely, at the nape of my neck.  I was standing in my blue scrubs at the head of the bed, I had taken off my white coat in preparation for a mess.  The laryngoscope was poised and ready in my left hand, my right hand was gloved and still empty.  I used it to rip the plastic eye protection part of my mask away from the part that covers my lower face.  Though I’ve been wearing masks like this for at least 9 years now, I still haven’t figured out how to keep it on my face for longer than two minutes without it fogging up and decreasing my visibility.  My glasses are protection enough.  The respiratory therapist was standing to my right, facing me at a ninety degree angle, he was at about the level of the patients right ear, ready to hand me the endotracheal tube when asked.

Just a few minutes prior a young patient with multiple gun shot wounds to the head and neck area happened upon my little, non-level-one-trauma-center ED.  Most of the people in that room had not seen a gun shot wound in years, if ever.  Having done a four year residency at the busiest trauma center in my region- when I was in training this was my bread and butter.  Penetrating trauma to the head and neck region, like a stabbing or gun shot wound, will make even your most seasoned emergency medicine physicians and/or trauma surgeons heart rate increase just a bit. In retrospect I wish I had been wearing my fitbit, my heart rate was up for sure  The head and neck region- think brain, face, trachea, mouth, carotid arteries, etc- it’s a high risk area.  And the A in our ABC mantra stands for airway.  If you can’t secure the airway because of trauma induced anatomical deformities, swelling, or blood- you are in for a really, really bad day.  Particularly if you are at a facility where the closest surgeon is at home and in bed.

Adrenaline and stress are the natural reaction.  And as the attending physician it’s my job to keep this at bay by being in charge.  It’s my job to project confidence, it’s my job to know what I am supposed to be doing, it’s my job to know what everyone else should be doing.  When you are running a trauma things move smoothly if the team knows that someone is in charge.  Every emergency medicine resident learns this- and the most important piece of this (I think) is communication.  I believe in calmly spoken, simple communication- so as I prep to intubate I said to the room (now filled with multiple nurses, respiratory therapists, techs, medical students, paramedic students, and a couple of voyeuristic police men)- “Is everyone ready? I need everyone on board. My first shot will be with the glidescope (video assisted laryngoscopy), I have the mac and bougie ready as back up, and if worse comes to worse” and said with an internal cringe and sphincter tightening, “the cric kit is just to my left.”

As an ED doc you are always aware of your surroundings and as I finish speaking I see a new figure enter the room, our new case manager.  Before being an ED case manager she worked as an ED nurse.  I am sure I am biased but in my opinion, ED nurses are the best of the best.  I see her make a spot for herself at the foot of the bed, intuitively she was looking to lend an extra hand.  She scanned the room to see how she could help and after she swept the room with her eyes the next words I heard from her were, “uh, aren’t we going to get a doctor in here?”

As these words registered somewhere in my brain I was already on the exhale of the deep breath I take before any intubation, something I learned in residency from my assistant program director.  As soon as that exhale is complete I am in game mode and my focus is on one thing.  I ended my exhale and made direct eye with my nurse, nodded, and she pushed the sedative.  “Etomidate in.”  I gave her a second look and another nod and with that the paralytic had been pushed. “Sux in.”  I watched for a few seconds- which always feels like a million seconds- and saw my patient’s muscles relax.

My right index finger and thumb scissor motioned his jaw open. I placed the laryngoscope in his mouth, I moved it around the tongue and ultimately caught a glimpse of the epiglottis, an epiglottis mostly obscured by blood.  In as measured a tone as I could muster- in a room that was now completely quiet but for the beeping of the medication and blood pumps- I stated, “I need suction”.  In my right hand I felt the plastic of the Yankauer suction tip.  Not moving my eyes from the screen I placed it in the mouth.  My goal was to remove enough blood in order to visualize the structures I’m supposed to.  With my left hand still firmly holding the laryngoscope in place- I managed to suction away enough blood and secretions- I saw vocal cords.  The surrounding structures were edematous and injured, this was not text book anatomy.  But I saw vocal cords!  Calmly I state, “I see cords.” My eyes have not left the screen, I will not lose my place in this mess of pink and red.  And as I held out my right hand the Yankauer was replaced with the endotracheal tube, stylet in place.  I placed the tube in the mouth, I moved it past the tongue, I saw it on the screen.  I slipped it through the cords as my anatomical landmarks again began to disappear and turn red.  My left hand removed and released the laryngoscope blade and I used it to join my right hand in grabbing the endotracheal tube to hold it in place, for dear life, as the respiratory therapist pulled out the metal stylet from the inside of the tube.  He attached the CO2 monitor- good color change- I took my first deep breath. I grabbed my stethoscope to listen to the boy’s chest, I listened on the left and then on the right, bilateral breath sounds. I took my second deep breath. Then I took a third deep breath. I was dripping with sweat but knew that at least for now we were out of the woods.

After this things moved fast.  The patient was appropriately sedated, blood was hanging, proper placement of the endotracheal tube confirmed, no pneumothorax, bedside ultrasound FAST exam was negative- there was no blood in the abdomen, pressure dressings were placed on the wounds, vitals were stable, the med flight critical care team was soon at the bedside, and then the patient was off to a level one trauma center with all appropriate consultants in house.

The police presence ultimately dissipated, the staff returned to their jobs, and I returned to my desk.  I looked at the tracking board and saw that there were many, (sigh) many patients waiting to be seen.  No time to dwell, time to go see that next chest pain.

Once we had all caught up a bit I was pulled aside by the case manager that had been in the room earlier.  I was taken aback because she, normally poised and stoic, seemed uncomfortable.  She was actually mortified and apologetic.  She thought that I was a physician’s assistant and she could not believe how ignorant she had been.  She respects our PAs.  But she couldn’t understand why, when seeing a young blonde woman at the head of the bed, she did not assume she was the attending physician.  Her apology was sincere and gracious.  And, in retrospect, what I realize is maybe worse is that I hadn’t thought twice about what she said in that room.  I am always mistaken for a nurse, a physician’s assistant, or a tech.  I am always mistaken as such even after introducing my self as Doctor.

Fast forward to the present day. As mentioned earlier, a few days ago it was National Doctor’s Day.  I was again pulled aside by this same case manager, she told me she had something to tell me.  Now we are good friends and supportive colleagues and I approached her with a different attitude entirely.  Thinking she wanted to update my on the rehab facility status of my 90 year old with a fall I asked, “What’s up?”  “I just want to be sure to tell you, happy Doctor’s Day, Dr. French Fry.  You continue to rise above the rest- you really do deserve recognition on this day.”

Her apology one year ago had an impact on me.  This was not an old man Vietnam vet who continues to call me “honey” (who’s verbiage I may be able to force myself to rationalize.) This was a fellow woman, a fellow woman working in the medical field, a fellow woman who faces similar discrimination as I do on a daily basis.  She helped me positively reflect on this experience is a few ways- 1) I appreciate how she forced the discussion thus making the issue important, 2) I realize sexism is sometimes so deep we don’t see it in ourselves, and 3) I realize sexism can be so deep and so prevalent that we all become desensitized- even those of us affected.  We don’t notice it.  By acknowledging this and forcing the difficult discussion this brave woman has pushed me to be braver.  It’ll be a slow road, but I am no longer going to let this sh!t slide.

Happy Doctor’s Day :).

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busybusybusy

Since I’m too busy (or lazy) to post, I suggest you read this:

Agraphia: a modest proposal

One of my favorite bloggers covering an issue I am forced to confront in one way or another every single day I spend in the hospital.

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mr. bossman

I met my patient when he was boarded and collared, on a stretcher in the hallway.  He is a hispanic man who was recently in a car accident who arrived with a relatively complicated facial laceration.  He speaks a tiny bit of English, I speak a tiny bit of Spanish.  He is a nice man, and somehow we  manage to create a rapport.

A while later he’s been moved into a room and I arrive back with the suture kit.  Now there is a dirt covered, young, white man in the room with him.  My patient’s employer introduces himself to me.  This man, no older than me, immediately (and with a lack of social graces) wants to know how long this will take.  I told him that realistically we have two more hours.  But for him, that just wouldn’t do.  Well, sir, your friend was in a car accident.  We’ve determined he doesn’t have any serious injuries but he has a pretty bad cut in a pretty bad place.  We need to do a slit lamp exam to rule out any corneal abrasions and then will need to sew him up.  By the looks of that cut the suturing alone could take over an hour.

Yeah but he still doesn’t understand why it will take two hours.  Two hours at minimun, I reminded him.  “Okay, but see,” (and he lowers his voice) “I’ve got a van outside full of five guys  outside,” (he glances over to my patient), “and there’s no AC.  Can you ask whoever is in charge if he can speed the process along?”

Um, really? You have a van outside with five men in it with no AC? Are they locked in? Aren’t they adults? Might they step outside for some fresh air? Must be a completely legal and humane operation you’ve got going on. And b.t.w., I am in charge of how long this process will take.

At this point another med student walks into the room, he’s checking to see if I need any more materials.  The boss looks at him.  Oh hey doc,  how long you think it’s going to take you to do this?

As I secure knot number two Mr. Bossman decides to confide in me about how he once sewed up his knee with no anasthetic.  Good work, buddy, you must be really tough.

Suture number three I ask my patient if he’s feeling anything.  “Feeling any pain? Need some more pain meds?” Mr. Bossman feels the need to translate for me, “Hey buddy, hurt-o?”

Listening to the conversation next door I advanced another suture through my patient’s lower eye-lid.  Mr. Bossman, who was hovering over my every move, was apparently eaves-dropping on the same conversation.

… and do you take any medications at home?

AT HOME? YES! OF COURSE I TAKE MEDS AT HOME.  AND I LIVE WITH MY STINKIN HUSBAND. TWO OF MY FIVE WORTHLESS KIDS, FIVE GRANDCHILDREN, TWO DOGS, AND ONE CAT.  AND A SON-IN-LAW, EFFING JERK.

… okay, I understand.  But can you tell me what medications you are on?

YOU THINK THAT’S YOUR BUSINESS? I CAN’T BREATH. WHO ARE YOU? YOU ARE A DOCTOR? YOU ARE FIVE YEARS OLD. I WANT TO GO TO A REAL HOSPITAL AND I WANT TO SEE A REAL DOCTOR.

I have a smile on my face because seriously, how can you not get a kick out of this stuff?  By the pattern of her speech I can tell this woman is having no real difficulty breathing and I know the resident in the room next to me is having the same thought process. I am curious to see how this conversation will play out and to see how he will manage to gracefully worm his way out of her room.  I sense my patient’s employer looking at me.  Apparently he thinks we’re good friends now.  “Wow, you must see all kinds of assholes in this place.”

I secure the last knot and  don’t bother to make eye contact. “You have no idea.”

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bad things

A colleague came up to me with a pained look on his face, “Something kind of bad just happened…”

I had NO idea where this was going.  Did you break up with your girlfriend? You missed your patient’s hypokalemia and she started having chest pain? You put a note in the wrong chart? A nurse yelled at you again?

“My stethoscope just fell into the toilet.”

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i don’t hate christmas, i’m just busy as shit

A few months ago when I was in my peds rotation and my roommate was on her surgery rotation I told her she was being a crank. She started to cry.

I am 6.5 weeks into my surgery rotation.  I feel shackled to the operating room and thoroughly sleep deprived.  This Sunday will be my first day away from the hospital in 14 days.

The other evening my roommate, who is now in her peds rotation, accused me of not liking Christmas.  What did I do? For no clear reason, I started to cry.

And then both of us, who are actually considering going into this ridiculous field, started cracking up.

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a joke

Yesterday a patient told me a joke:

What’s the difference between a surgeon and God?

God knows he is not a surgeon.

Funny only because it is so true.

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f-ed by the snake tip

Yesterday my patient said to me, “I got fucked by the snake tip.  It was waving a flag.” He then shifted his head toward me, looked directly into my eyes, and while grinning said, “Yeah that’s right, you know what I mean.  We got fucked by the snake tip. You know what I’m talking about, I know you do.  Right?” Still staring into my eyes, but now raising his voice and becoming agitated he continued, “Jesus came and I was going to gangsta parties. Like real gangsta.  And I came out alive and I know it’s because I am Jesus. I wasn’t treated like Mary did, but I got fucked by the snake tip.” 

In psychiatry there is something known as a defense mechanism.  Defense mechanisms can be mature, neurotic, or immature, they are ways that people deal with feelings of anxiety, pain, and internal conflict.  One of my personal favorites is suppression.  It’s classified as a mature defense mechanism, and is defined as conscious burrying of troubling thoughts so that you can continue to function.  Just push it out of your head an keep on truckin’. Acting out is an immature defense mechanism. Projection is transference of anger to a more acceptable recipient.  Intellectualization is when one can’t wrap his head around a painful thought or uncomfortable experience so he finds a rational way to process the info.  A classic example always given the text books is that of a man who finds out he has cancer.  This causes him to learn everything he can about the pathophysiology of the disease and instead of telling his son he has cancer he teaches his son about the aberrant cell cycle, P53, and the Rb gene. 

So, what do you do when your patient is searching your eyes, talking about being f-ed by a snake tip, and is making no sense whatsoever? Well, you nod your head, return the stare, remain expressionless, and intellectualize:

Psychosis has many, many causes.  In general the etiology can be considered primary (functional) or secondarySynapse_diag1 (organic). Schizophrenia, for example, is a primary/functional reason for the development of psychosis. A secondary cause can be due to things like a general medical condition or drug intoxication.  When psychosis is primary (like in schizophrenia) the neurochemical abnormalities have to do with an altered dopamine/acetylcholine ratio. There is a relative increase in the neurotransmitter dopamine, and antipsychotics work because they lower dopamine levels  (usually by antagonizing the D2 receptor).  Organic (secondary) psychosis, on the other hand, is often treated by anti-convulsants rather than anti-psychotics.  This is because this type of psychosis is thought to be ictal, that is, it is thought to be induced by seizure activity (ie. increased neuronal firing) within the brain.  Not only are anti-convulsants used alone, they can be used to augment the anti-psychotics because they are also thought to act on dopamine indirectly (through neurotransmitters like glutamate and GABA) which in turn enhances the antagonistic dopaminergic effects…. la la la.  

Sorry but if you’re gonna raise your voice and get all crazy on me my brain is going to move into science mode. Intellectualization at it’s best.

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