Sunday, November 30, 2008

The Gynecology Room

Everyone who has had the pleasure of working in emergency medicine has had their share of memorable patients. I actually have memorable patients in various categories: funny ones, stupid ones, ones I liked, and ones I hated. An old attending physician told me something that I have come to believe is true. He said, "If the patient pisses you off in the first 15 seconds of the interview, they have a personality disorder." I have found that if the patient makes you laugh in the first 15 seconds, the shift will go much faster.

The following are some patients I remember fondly from the dreaded gynecology room (colloquially called the "tuna pit" by the staff):

#1 (20-year-old Jerry Springer Show reject). I had to inform this eloquent young lady that her abdominal pain was due to her heretofore undiagnosed pregnancy to which she responded, "I can't be pregnant because my husband had a hysterectomy." Sigh...

#2 (27-year old morbidly-obese frequent flyer). After delaying the pelvic exam as long as I could (I was hoping I could push it off on my partner at shift change), I went to the gyn room with a nurse. I asked the patient, "What's the matter today Donna?" With a straight face she said, "It feels like Dr. Chong (the local Medicaid OB/GYN) put my IUD in with a pogo stick. I can feel it moving around in my pussy." Sigh...

#3 (Young married couple--not the sharpest knives in the drawer). I went to gynecology room where I found the wife reading the National Enquirer and the husband (a big burley blue collar kind of guy) reading BASSMASTERmagazine. I kindly asked, "What brings you to the ER today?" The young woman, ever so polite, said, "Doctor, I hate to bother you, but I ran out of my pills and can't get a hold of my doctor." I said, "What pills?" She produced a birth control package that was empty (we don't refill birth control pills, but I played along). The prescription was for a six month supply (21-day regimen) and was issued only 2-3 months earlier. I said, "You got a six-month supply. You know that you are supposed to stop taking the pills for a week after each pack for your period to start." She said, "Really?" I said, "Really." She pondered what I said for a minute and said, "I wondered why I ain't got my period in several months." Then, I realized that even this did not explain why she was out of her pills. I said, "How do you take your pills?" She replied, "My husband works nights so we take them before he goes to work." I paused to carefully assure I heard her right and said, "Did you say 'we'?" She replied matter-of-factly, "Yes. I take mine and he takes his." Evidently, both the husband and wife were taking oral contraceptives. I look at the man reading the BASSMASTER magazine to see if he is growing breasts. Can't tell for sure. Time to send in the nurse. Sigh...

#4 (Very prim and proper looking 50ish female with a quasi-Pentecostal look). I saw this patient walk in. She walked beside the nurse looking around the ER. She was plainly-dressed with a blue jeans skirt and a Pentecostal bun--no makeup or jewelry. Such patients were not uncommon in our ER and were usually quite pleasant. She was placed in a minor medicine room and I went to see her promptly with a young female nursing student in tow. I introduced myself and sat on the stool. She said, "Well doctor, I got a bad headache and it won't go away after two BC powders." I listened intently going through my list of differential diagnoses. I asked, "What were you doing when the headache started." Without a pause she replied, "Well doctor, my husband and I were f**king. After several minutes of it I was about to go 'boom-boom' and my head started hurting." I sat there for a few minutes literally speechless. For clarification I asked, "What do you mean by 'boom-boom'?" Again, without a pause she said, "You know I was about to come...go 'boom-boom'. Isn't that what you call it?" The young nursing student, all professional in her white dress and smock, was trying to keep from laughing so hard I literally thought she would piss her pants. I excused myself and walked to the ambulance dock where I laughed my ass off for at least 10 minutes. Sigh... (P.S. Mrs. Boom-Boom's CT was negative and her headache went away with some Imetrex).

You gotta' love medicine...

Saturday, November 22, 2008

A Picture is Worth a Thousand Words

Spinal immobilization over utilized in the United States? Never!

Nothing Says I Love You Like a Glock

I was in the local Bass Pro store (hey, they got great clothes!). As usual I spent some time looking at the guns and boats. I like both and wish I had more time for both. Interestingly, the gun counter was unusually busy. I think the uncertainty of hard economic times and a novice president is taking its toll. Several of the more popular guns were sold out. I watched a caring young man trying to select the perfect gun for his wife for Christmas. Certainly, nothing says I love you like a Glock.

But, the aura of modern day America is worrisome. It reminds me of the gas shortage of the 1970s and Black Monday in 1987. With the economy in the dumps and the stock market more labile than a fat diabetic's blood glucose level in a Krispy Kreme, the fear of the average Joe is real. People are stocking firewood and ammunition. Somali pirates have hijacked nearly 100 ships on the high seas. Las Vegas is so slow they are giving away rooms (and Chris Angel's MindFreak show at the Luxor is so bad it is stinking up the strip). Even American Airlines has some deeply discounted fares. Times they are a changing. But, are they changing for the better or for the worse?

Pondering this, I believe that many have lost confidence in America and are forgetting the American dream. The Drudge Report had a link that detailed the presumed demise of America as a world power. The recent elections demonstrated that we do not have a leader who can do for America what Lincoln, Roosevelt and Reagan did--lead us out of our despair. Until that leader comes, we must find solace in other things.

Well, I've put off seeing the Medicaid family of 4 with runny noses as long as I can. The nurse has put the charts in front of me 3 times now. It is amazing that an emergency department can look so busy it might be mistaken for a disaster, only to find that all of the patients are actully less sick than the staff working the department. It is hard to imagine the amount of money a small rhinovirus costs the welfare-paying public each Winter. Life sucks sometimes.

Round Up the Usual Suspects

In the classic epic Casablanca Captain Renault said, "Realizing the importance of the case, my men are rounding up twice the usual number of suspects." President-Elect Barak Obama must have taken this quote to heart. As a presidential candidate campaigning on the concept of change, it sure looks like the old Clinton White House. Soon, we will hear that Monica Lewinsky will be reappointed as "Special Asssistant to the President for Fellatio." Rham Emmanuel, Hillary Clinton, Bill Richardson, Tom Daschle, and Eric Holder are all Clinton insiders (although Daschle was in Congress--he still kowtowed to Bill and Hillary). Somewhere, inside of this, is the voice of Bill Clinton saying, "I'm still here. Where's that new intern with the hot little ass?"

"Change doesn't come from Washington. Change comes to Washington." (BARACK OBAMA, DNC speech, Aug. 28, 2008).

Horse Shit.

Thursday, November 20, 2008

American Legacy Businesses Need to Learn a Hard Lesson

I fly a lot. When I say I fly a lot, I mean 80,000-100,000 miles a year. Some years a great deal of it is international. Some years, like 2008, it is primarily domestic. Most of my flights are on American Airlines where I hold elite status. But, this year I have flown Continental and United a few times. Overall, all legacy United States airlines suck. The planes are old. The employees are angry. Bags are lost. Nobody answers the phone. It is a miserable experience.

Recently, I flew Richard Branson's Virgin America between LAS (Las Vegas) and SFO (San Francisco). What a wonderful change. The new Airbus was clean and looked like the inside of a Lexus. The seats were leather and each had satellite television and games. The flight attendants and pilots wore simple black shirts and pants. The pilots walked into the cabin and gave the introductory talk instead of using the speaker system. There were flowers in the lavatories. Even the required flight instructions were fun. The recording said, "If you are one of the 0.001% of the population who have never used a seat belt, please watch the following..." The trip was actually fun.

I have flown on quality airlines like Cathay PacificQantasAir Tahiti Nui and others and actually been pampered. But, to be treated like a human being and a paying customer on a domestic airline was truly a treat. Why can't American and the others adapt? All have suffered the ill effects of fuel costs. It probably comes down to the unions.

Yesterday, the news was about the bailout of the United States auto industry. Ford, General Motors (GM) and Chrysler all want billions of dollars in loans from the government. Interestingly, Toyota, Honda, Mercedes, and Nissan have not asked for anything. Then, an interesting graphic appeared on television. The average cost of health care insurance for employees accounted for approximately $1,600.00 of new car costs for GM and Ford. The same costs for American-made Toyotas is approximately $300.00. Is it the unions?

I was recently in Mexico and passed numerous US-owned factories (e.g., GM, Westinghouse). They are solely there because of labor costs. I feel everybody deserves a fair wage and unions have made life easier for most. But, have unions outlived their usefulness? Are they killing American business?

I own 4 cars (Lexus, Acura, Chevrolet and Nissan). The Lexus and Acura have never required anything but service. The Nissan has 128,000 miles and runs well. The Chevrolet has 30,000 miles and has been to the shop for warranty work 5 times. Several years ago I had a GM Chevrolet Tahoe. I kept hearing a noise and took the car to the dealer 4 times. Finally, they took ff the driver's door panel and found a golf ball. Evidently the factory workers were playing with the golf ball and lost it in my car. In Japan, an auto worker would commit Hari Kariover such an event. Here, they get a raise.

Perhaps the government should let nature take its course. I say we give GM, Ford and Chrysler a "do not resuscitate" order. In the overall scheme of things, Darwinian logic would say only the strong will survive. Likewise, let Northwest airlines and some of the legacy carriers go as well. It is time to think outside the box. If they are going to bailout the auto industry, then they should bailout health care as well. But, it is only wishful thinking...

Monday, November 17, 2008

It's a Sad Day When a Fart's Not Funny Any More

Recently, I was flying home on a two-hour American Airlines flight. A middle-aged woman dressed professionally in a gray pinstriped pants suit sat in the window seat to my left. We made the usual small talk about how tired we are of flying and how shitty American Airlines has become. Then, as the flight was preparing to leave, we did the Blackberry ritual of checking our emails and then prepared for the flight. After the plane had reached a comfortable cruising altitude, I heard a strange noise that seemingly came from the business woman. I thought to myself, “That was a fart.” I know a fart when I hear it for I have been on both the donor and recipient end of the fart spectrum. Unsure whether it was really a fart or some weird noise coming from the aging MD-80, I sniffed like a puppy looking for a dog treat. It was a fart for sure. I am not sure what this woman ate, but something crawled up inside of her and died. But, then I started to smile. The smile turned to a laugh and the laugh almost became uncontrollable. I looked at the woman who was sleeping soundly and she let another one rip. I was trying to cover my mouth to keep people from seeing me laugh and my nose to keep from smelling the weapons-grade gas this attractive woman was eliminating. With the second fart the old woman across the aisle scowled at me. I thought she was giving me the “what are you doing in first class with jeans and a t-shirt look.” Suddenly, I understood that she thought I farted (I know men enjoy and good fart here and there) so I quickly pointed at the sleeping woman and laughed. The old woman gave me an indignant look and went back to reading her Deepak Chopra book. I continued to laugh.

I am a physician. I understand the pathophysiology of flatulence. But, a fart is still a funny thing. Have we come to the point in society where a fart is not funny anymore? In Geoffrey Chaucer’s The Canterbury Tales (written in the fourteenth century) he details the story of a miller trying to trick another man by farting on his face. In high school, we used to have farting contests. In medical school I farted just as four of us were getting out of the car at a restaurant. When we returned later, the fart was still in the car and we had to open the windows and doors for 5 minutes before we got in (the fart later became one of the great legends of our medical school class). Everybody farts. Farts are funny (especially in a bath tub).

But, have we come to a point in our politically correct society where we can’t laugh at a fart? Will the PC police ban “whoopee cushions.” Farting can be an art form. I used to work with a friend who could fart the first 8-10 bars of the southern hymn “Dixie”. Racist, probably not as my friend was black. I am not sure I want to live in a country where a fart is no longer considered funny. How about you?

Wednesday, November 12, 2008

Immigration, Part II

I recently spent a week in central Mexico. Even though I was far removed from the United States/Mexico border, I clearly saw how important the United States is to Mexico. The U.S. elections almost overshadowed the deaths of several high-ranking Mexican federal officials in a plane crash. But, conversations with everyday Mexicans revealed how much they envy life in the United States.

Jorge was an affable young man. He preferred we speak in English because he doesn't get much chance to practice his English (which is quite good). Jorge had previously lived in Chicago and married a Mexican-American woman with whom he has a daughter. He left Chicago almost 9 months ago and returned to central Mexico because his mother was dying. However, when he attempted to return to the U.S., he was unsuccessful. He said, "President Bush doesn't want us in America and he has certainly made it very hard for us." Meanwhile, Jorge works as a valet parking attendant at an upscale hotel. He earns about 4,000 pesos a month (about US$360.00). Jorge said that he wants to stay in Mexico but the Mexican government won't allow his family to emigrate and he cannot return.

Rico is a gas station attendant at a Pemex station along the autopisto. Despite my best Spanish, he recognized the American accent and asked where I was from. After some small talk, Rico told me that he lived in San Diego for many years. He had been deported more than 6 times (he thinks) and now cannot return because he is "in the migra computer." Unlike Jorge, I did not have a good feeling about Rico. But, he went on to say, "The Americans and President Bush have made it very hard to cross. The coyotes (human traffickers) will charge you US$1,000 to take you across. But, they will leave you in the mountains in the desert without food or water. It is very dangerous." He went on to say that he had to wait 10 years before he could cross again (there is a rumor in Mexico that U.S. ICE files are purged of names after 10 years--not sure whether that is true or not).

But, I can say, after several conversations with Mexicans of different social groups, the Bush policies on immigration are working. They may not be perfect and people still cross, but the numbers are down and the word is out that America is very difficult to now enter. Also, the lack of jobs for Mexicans in the United States are down due to the economic downturn and that is widely known. Thus, like him or hate him, Bush has made a difference in immigration and that relates directly to our national security. For that, I am thankful.

Wednesday, November 5, 2008

Antidepressant Advertising a Major Source of Depression

I do not think it is a good idea for the pharmaceutical industry to advertise directly to the public. Would you trust the advice of the big pharmaceutical companies in regard to medications they manufacture? As an analogy, would you continue to see a doctor who only orders the drugs advertised on the pen with which he writes the prescription? How many times have we heard a patient ask for Viagra or Cialis after seeing an ad on television. We reply, "Oh, do you have erectile dysfunction?" The patient answers, "Gosh no doc. I can get it up OK. I just want an erection like I used to have when I was 16." Or, there is the patient too stupid to even understand the message in the television ads. The mother looks me in the eye and asks, "Do you think my child should get that there vaccination called Gardasil?" I think for a moment and decide to give a simple answer. I say, "No." She goes on, "Well on TV they say it prevents many types of cancer. I don't want my child to get cancer." I take off my glasses and look the mother in the eye and say, "Until your son grows a uterus, his chances of cervical cancer are quite low and I really don't think he needs Gardasil." Missing my humor (alright, frank sarcasm) she says, "Thank goodness. That is one less thing to worry about." I sigh and wish I had gotten a business degree instead.

One of the biggest issues I have, at present, is the advertising for antidepressants. Hell, the advertisements depress me and I am usually as happy as a clam. Last night I saw an ad for Cymbalta. The ad was dark and the music sad. The people were virtually catatonic. Before I knew it I was in the kitchen looking at knives and trying to determine which was sharpest and would be the least painful when I cut my own wrists. Later, I saw an ad for Abilify. It was equally depressing. What is most disconcerting is the fact that I have never heard of Abilify. Thus, the patients may be more informed than me. But, I am just an emergency doc and don't prescribe antidepressants and rarely diagnose depression.

Is it me or is depression the diagnosis de jour? Feel bad, here, take a pill. I think the problem of depression is related to modern television. Today the people watch too much television and the programs on television are as depressing as the antidepressant ads (except House and Boston Legal). When I was a kid I watched the Three StoogesTom and JerryFelix the Cat and similar epics. We never got depressed (besides, we rode our bikes so much we slept like rocks). I think the major reason we have so much depression is because of the 24 hour media and the fact that too few children now grow up seeing the exploits of Curly Howard. Instead of writing a prescription for some SSRI, just tell the patient to go to Wal-Mart and buy Three Stooges DVDs and watch them for one hour before retiring for the night. That is a much safer, less expensive, greener, and more appropriate treatment. To quote the great philosopher Curly, "I'm a victim of circumstance!"

Monday, November 3, 2008

Mentally Ill?

When I was much younger, I was interested in all things weird. Once, near our town, there were several sightings of a "goat monster." So, for several weeks, the adventure de jour was to go in search of the "goat monster." As we drove to the area where the monster was seen, we started trying to scare our friends. When we got to the area, we became convinced we heard sounds and saw evidence of the monster. It was fun.

Now, to 2008. Not long ago I was flipping through the channels and came across a "marathon" of a show calledHaunting Evidence. Two people, featured on the show, are "forensic paranormal investigators." These people traveled to Colorado and stomped around the house where Jon Benet Ramsey was killed. In another show, they went to Aruba and investigated the death of Natalee Holloway. The segments are always shot at night and these people, the investigators, seem to be on the cusp of overt mental illness. It is interesting, yet sad to watch--like a train wreck.

Bullshit, masquerading as science, is entertaining. But, this is nothing but entertainment--much like Sylvia Brown and John Edwards (the psychic, not the North Carolina shyster). Unfortunately, desperate people will do desperate things in times of grief. And, these people are profiting off the loss of others.

But, I have a few questions:

1. Why does ghost hunting and paranormal crap happen only at night? Well, it goes back to our fear of the darkness. Available light camera shots and muffled speech are part and parcel of the show.

2. Why is it faces are all that are often seen? The identification of faces is an evolutionary remnant. In days of ole, face recognition often meant the difference between life and death. Thus, we humans tend to see faces on the moon, on trees, and in other situations. A whole flock of people came to worship the image of Jesus on a flour tortilla. Could heaven be nothing more than a good burrito?

3. Why are snakes often seen? Seeing snakes is an evolutionary remnant as well. Snakes can kill. Even puppies know to stay away from snakes. Our mind, as a defense, will look for patterns that appear to be a snake (e.g., a piece of rope, a belt on the floor) and we will immediately, and subconsciously, stop in our steps. It is in the primitive brain.

Back to the television show. These two researchers go through great emotional displays as they retrace the last steps of deceased persons and then come up with "scientific" conclusions about the deaths. Much of what they find can be explained by pure chance, coincidence, or just the excitement of the hunt. Their emotional displays and behavior certainly make you wonder about their mental health. How different are they from those who wear tin foil hats or get cryptic messages from their televisions? How different are they from those who let religosity impair their activities of daily living? Certainly, each to their own. But, I was just somewhat saddened to see these people paraded on television when their issues seem to be deeper. Most of us have outgrown the search for monsters and ghosts--but, we need our television and we have to watch an occasional train wreck to see how lucky most of us really are. James Randi has done a great job of debunking these myths and actually has amillion dollar challenge for anybody if they can prove the paranormal. Despite being available for years, the challenge is untouched.