Wednesday, December 31, 2008

Perhaps It Is a Training Issue...


Friday, December 26, 2008

Potato Salad

The middle-aged woman seated in the eye room was moving nervously in her seat. Her right eye was quite injected and teary. I went in and introduced myself and asked her what happened. She replied, “I think I got something in my eye.” I asked, “When did it happen?” She answered, “I’m not sure, but it was several days ago.” I did a general external eye exam. I noticed that the woman had very pale, white skin. As I looked further I noted a few bruises on her face and arms. I made a mental note of these as they are often an indicator of domestic abuse.

I placed the slit lamp and had the tech darken the room. Upon magnification I saw that her conjunctiva was injected and swollen. There were several denuded areas on the cornea and these readily took up fluorescein and lit up under the blue light. I moved the slit lamp aside and said, “You have several nasty abrasions on your cornea. These need to be treated.”

I looked her in the eye and said, “I’m concerned about the bruises on your face and arms as well as the eye injury. Is there something you need to tell me?” The woman looked a little perplexed and shifted her weight in the seat. She said, “I’m not sure what you mean doctor?” I answered, “Well, these injuries often occur as a result of domestic abuse. Are you in an abusive relationship?” She answered, “Oh gosh no doctor. I’m not in a relationship at all.” I confronted her more directly and said, “State law requires me to report cases of suspected domestic abuse. It is for your own protection.” She carefully considered what I had told her and replied, “Potato salad.” I said, “Pardon me?” Again, she said, “Its potato salad.” I thought to myself that this woman was in a level of denial that I have never seen before. I asked, “How can potato salad cause these bruises?” She answered, “I like potato salad.” I answered, “I like potato salad too, but I am not sure what this has to do with this.” She answered, “You don’t understand. I really like potato salad.” I said, “Yes, me too—with mayonnaise—but you have to stopt beating around the bush.”

The woman stared at me for a bit and started to move around more anxiously in her chair. She said, “I really like potato salad.” I stared at her waiting for her to elaborate. Finally, she spoke, “I know it is kind of weird, but potato salad makes me frisky.” “Frisky?” I questioned? She said, “You know…frisky…horny.” Incredulously I asked, “Potato salad makes you horny?” She said, “I know that sounds weird, but yes, it makes me horny.” I asked, “Are the nurses playing a joke on me?” She got a serious look on her face and said, “No. It’s true. I guess it is some kind of a fetish.” I sat there totally perplexed. Finally, I said, “OK. So potato salad is your fetish. That doesn’t explain the bruising and the eye injury.” She sighed deeply and said, “I like to have the potato salad thrown at me.” I looked up from the chart and said, “What?”

It seems that Ms. Papa’s last marriage was somewhat kinky. Evidently she and her ex-husband liked to have sex in the kitchen and somehow potato salad got into the picture. The patient went on to say that when she gets comfortable with a man she gets out the potato salad. She takes a large sheet of plastic and tacks it to the wall and strips down. She then gets a tub of potato salad out of the refrigerator and has her current beau “chunk the potato salad” at her while she stands in the middle of the plastic sheet. The harder the potato salad is thrown and the more it hurts, the hornier she gets. Then, once she has been adequately exposed to potato salad, it’s off to the bedroom where, evidently, the encounter with the potato salad continues. Thus, the bruises and the corneal abrasions were due to high-velocity potato salad striking her during the throes of passion. I looked her in the eye for a minute and pondered what I had just heard. I said, “OK. I don’t really need to know more (although that little devil on my shoulder wanted to know the intricate details). I’m going to give you a prescription for eye drops and some pain medicine. Be sure to follow-up with the ophthalmologist in 48 hours.” I watched her walk out. She looked so normal I thought—almost frumpy. Since then I have never looked at potato salad and not thought of her.

Wednesday, December 24, 2008

Merry Christmas

All the streets are filled with laughter and light,
And the music of the season.
And the merchants' windows are all bright,
With the faces of the children.
And the families hurrying to their homes,
As the sky darkens and freezes.
They'll be gathering around the hearths and tables,
Giving thanks for all God's graces.
And the birth of the rebel Jesus.

Well they call him by the Prince of Peace,
And they call him by the savior.
And they pray to him upon the seas,
And in every bold endeavor.
As they fill his churches with their pride and gold,
And their faith in him increases.
But they've turned the nature that I worship in.
From a temple to a robber's den.
In the words of the rebel Jesus.

We guard our world with locks and guns,
And we guard our fine possessions.
And once a year when Christmas comes,
We give to our relations.
And perhaps we give a little to the poor,
If the generosity should seize us.
But if any one of us should interfere,
In the business of why they are poor.
They get the same as the rebel Jesus.

But please forgive me if I seem,
To take the tone of judgment.
For I've no wish to come between,
This day and your enjoyment.
In this life of hardship and of earthly toil,
We have need for anything that frees us.
So I bid you pleasure,
And I bid you cheer,
From a heathen and a pagan,
On the side of the rebel Jesus. 

The Rebel Jesus by Jackson Brown

Wednesday, December 17, 2008

On the Bastardization of Language

All countries will have variations in language. We typically call proper English “the Queen’s English” or we will call proper Spanish “Castilian Spanish” (although Latin American Spanish is certainly recognized in its own right). But, no nation like the United States has butchered language like we do. The United States is quickly becoming a Tower of Babel. But, in the United States, instead of correcting the problem, we romanticize it by giving it cutesy names like “Spanglish” or “Ebonics.” Children who attempt to enter the workforce using Spanglish or Ebonics are doomed to fail (or spend a career at McDonalds).

Language bastardization is a major problem—not as bad as the economy—but still a major problem. I can’t count the number of times I have heard a young Latina mother tell me, “Well, I was going to take him a bath.” Many African American patients use so much slang that I have a hard time understanding what they are saying. Noted minority figures who have risen above the fray; such as Collin Powel, Barak Obama, Condolezza Rice, Bill Cosby, and Henry Cisneros; have done so with mastery of the language. Bill Cosby was on the money when he told the NAACP, “I can't even talk the way these people talk. 'Why you ain't, where you is.' ... I blamed the kid until I heard the mother talk. Then I heard the father talk. This is all in the house.” I have a good surgeon friend who is Nigerian by birth (although educated in the United States). He is appalled at the language skills of African Americans in the United States (especially some of the chosen names). Who would trust a doctor who said, "Well, I is going to give you a prescription”? Who would trust a doctor who said, “Here drink these pills three times a day.” (Spanish does not distinguish between “take” and “drink” so the verb tomar is used for both).

I laughed once while watching a show about the islands off the coast of Scotland. The people who were interviewed had such a Scottish accent that they were very difficult to understand. So, the editors used English subtitles to translate the “English” being spoken by the Scots (which was actually only a thick accent). I have occasionally watched a show on A&E called the “First 48 Hours” that details real life murder investigations. The show is well done and contemporaneously details two murder investigations in two cities. Recently, two things struck me. The victims and suspects are almost always black or latino (this may be because they often shoot the segments in Memphis, Dallas, Miami, Detroit, and Phoenix). Certainly, the crime rate is higher in some minority communities. The other thing that struck me is that when they have African American people on camera, they almost always have to use subtitles. The English is so bad or the accent is so thick that they are hard to understand. Why has this evolved? This is the standard “chicken or the egg” argument. Did the language contribute to the poverty or did the poverty contribute to the language.

Believe me, I am not a racist (but, I will never buy another Dell computer because I will never attempt to get service help from a call center in India from a person named “Bill” with a very thick Indian accent). But, modern society depends on language. If you don’t have the language skills, you’ll never make it. I have chosen to speak two languages (with help from my mother and family). I think speaking more than one language is desired, but an option. Romanticizing the bastardization of language helps no one. So, the schools should not allow this crap to continue. Bilingual education is fine to help the young Spanish-speaking child transition to English. But, after a year or two, all need to speak English. The same holds true for so-called “ghetto-speak” or Ebonics. I would not move to Mexico and try and speak English to the locals. Yet, millions of people mover here and try and maintain Spanish as the language of choice. We Americans are just too gracious sometimes.

Monday, December 15, 2008

A Liberal Treatise From a Staunch Conservative

I’m no tree hugger. I hunt and I fish (not as often as I would like). But, I have my limits. I will not hunt anything I won’t eat or won’t be eaten by somebody. I have found that ardent hunters and fishermen are dedicated conservationists. Ducks Unlimited has done more to protect waterfowl than any liberal environmental movement. That said, I don’t think marine mammals have any significant food value. I would never consider eating a dolphin (porpoise) or a whale. In fact, just recently I was at a meeting on the southwest coast of Maui and spent hours watching humpback whales (and their calves) frolic in the Pacific. They were spectacular. Every time one of these leviathans hit the surface, a tour boat would approach. Finally, a group of jet skiers chased them off (these jet skiers could face large fines for approaching whales under Hawai’i wildlife laws). Life and let live I have always said.

The night after watching the whales off the Maui coast I caught a show about an activist environmental group called the Sea Shepherds. This was a group that broke from the Greenpeace people because the Sea Shepherds wanted to be more aggressive in stopping whaling and other animal abuses. I always thought the Greenpeace people were a little kooky. I have encountered them in Australia and they can be fairly militant. The Sea Shepherd people operate a boat called the “Steve Irwin” named after the Australian crocodile hunter who succumbed to a massive ray after the animal plunged the tip of his serrated tail into Steve’s heart. The Sea Shepherd boat had the usually suspects—twenty-first century hippies, vegans, and remittance men. Interestingly, everybody was from a first world country (there would be something ironic about an Ethiopian or Nigerian on the boat preventing the harvesting of food. Of course, if there were Nigerians on board nobody could access the internet because of the outgoing email scams). But, I digress.

I actually thought whaling was illegal with the exception of some Canadian and Alaskan aboriginals who hunt whales specifically for sustenance and actually respect the species. Thus, I have read quite a bit about whaling over the last few days. Whaling may be restricted in most waters, but the Southern Ocean appears to be a different story. The Japanese, who will eat anything that comes from the sea, still have an active whaling program. I read where the Japanese do not see any difference between pelagic mammals and fish--they all should be on the dinner plate. They harvest about 1,000 whales a year—primarily minke and finback whales. This year they are hunting the humpbacks as well—an endangered species. There are treaties in place that prevent whaling. The Japanese take advantage of a loophole in the treaties. The loophole allows whales taken for research to be subsequently butchered and sold. Thus, the Japanese take upwards of 1,000 whales a year for “tissue samples” and to monitor calving patterns and diet (supposedly). Every Japanese sailing vessel has the word “research” on the side. In one camera snap on the Animal Planet channel show they showed several Japanese fishermen butchering a whale while an idiot in a hard hat holds up a sign (in English) that says they are “taking tissue samples.” Horse shit!

If a people are dying and whale meat will save them, I’ll be the first son-of-a-bitch on the water looking for these critters. But, Japan has plenty of food. In fact, the demand for whale meat in Japan has fallen to a point where it is almost negligible. In fact, Japan has tons of whale meat from prior hunts in frozen storage. In order to support the archaic whaling industry, the Japanese government is trying to get schools to include whale meat in their school lunches. Why not serve Nemo as Sushi?

I have been to Japan several times. It is a curious, yet beautiful country. I cannot understand their adherence to traditions that result in whaling or the harvesting of shark fins (I like to catch and eat small black tip sharks—they are great. But, the Japanese cut the dorsal fin off the shark and throw it back in the sea where it dies immediately or becomes vulnerable to predation). I just can’t understand the Japanese way of thinking. I also can’t understand why Japanese women can’t walk in high-heel shoes—their gait is a continuous near fall. I am not sure I have a point here—just a concern.

By the way—the day I was watching the whales in Maui was Sunday, December 7, 2008. Seems as though the Japanese have struck again.

A Sad Case

Patient R. X., a 30-year-old white male surgical House Officer was admitted to the University Medical Center Emergency Room with depressed sensorium and focal seizure activity. The onset of symptoms occurred suddenly when the patient, present at a medical fraternity party, observed an inebriated female lab technician dancing naked on the piano. Those individuals present stated that the patient manifested an acute loss of reality contact, staring and fixed conjugate gaze, drooling and smacking of the lips, and pseudochoreiform movements of the fingers.

When first seen in the Emergency Room his blood pressure was 200/150, his pulse 160 and bounding, and he exhibited Kussmaul's Breathing (1). He was noted to have considerable proptosis (36/36 over 102).

The oculocephalic reflex was exaggerated. The tongue was protruding and deviated to the right. Auscultation over the precordium revealed an obscene murmur. There was rigidity of the abdominal musculature. The cremasteric reflexes were hyperactive, resulting in a gubernacular hernia on the left. The remainder of the physical examination was censored.

His past medical history was remarkable in that the patient had experienced several petit mal seizures when watching young women in mini-skirts. Reportedly he once suffered a grand mal seizure while on a beaver-shooting expedition in Focal Point, West Virginia.

Seizure activity was ameliorated by cooling 3 liters of saline to 5 degrees Centigrade and pouring it directly on the umbilicus.

He was admitted for observation and further diagnostic studies. Routine lab studies revealed a mild increase in Serum Porcelain (28.2 mg/L -normal 0 to 18) and a Horni titer of 1 :256. There was a ten-fold increase in delta-4-androstenedione as measured by immunoflourescent assay utilizing the seminal fluid from the Lithuanian Hairy-Necked Jackal (Lupus heavihungus horribilis).

Electroencephalography revealed paroxysmal three-per second spike and dome activity in the right temperoparietal leads when exposed to Playboy centerfolds. Brain scan utilizing labeled Acnesium240 (Acne244) demonstrated uptake only in the central facies. Cerebral angiography revealed a superior displacement of 3 capillaries of the right lenticulostriate system. Magnetic resonance imaging revealed impingement on the anterior horn of the right lateral ventricle.

Symptoms did not improve and on the 52nd hospital day, having been cancelled 38 consecutive times by the Anesthesia Department, he was taken to the operating room where a right temperoparietal craniotomy was performed. A cystic 4 x 6 centimeter mass was discovered adjacent to the amygdala in the Corpus Hornii. This was removed intact. Radioassay of the specimen with Low-Activity-Radio-Detection-Assay-Scintillating-Substance (LARD/ASS) revealed a weight-wet tissue Testosterone level 1,400 times normal. Tissue blocks were referred to the AFIP where microscopic exam revealed palisades of well-differentiated oxyphilic cells resembling abnormal Leydig cells. AFIP pathological diagnosis was "Functioning Ectopic Intracranial Testicular Adenoma." Histological diagnosis at this institution was "Normal Gallbladder."

The postoperative course was complicated by optic constipation leading to irreversible blindness. The patient was left with severe deterioration of intellectual function and was presented to the Department of Vocational Rehabilitation for disposition. As a result of extensive testing which revealed severe, generalized impairment of cerebral function he was given a scholarship to Law School, from which he graduated summa cum loudly. He is now gainfully employed as legal counsel for the Tip-Top Grill (2) where he spends his days reading the Kama Sutra in Braille and seeking olfactory ecstasy among the bar seats.
1- Seymour Kussmaul. a local "breather" well known to the Telephone Company and the County Pervert Patrol.
2- A local establishment frequented by randy ER nurses and tenured faculty.

Sunday, December 14, 2008

Can Somebody ExplainThis To Me?

I'm no economist (I know, supply and demand). But, I'm no Forrest Gump either. Today, in my town, I found unleaded gasoline for $1.25 a gallon (don't forget the 9/10--the fraction used in gas pricing is more nonsense I have never understood). How can we go from what some naysayers were calling the "end of western civilization" when gas passed $4.00 a gallon to the current price which is almost $3.00 a gallon less in just a few months? I didn't understand why oil approached $140.00 a barrel (and don't give me the Gulf of Mexico hurricane crap). I don't understand why it is now significantly cheaper. Bush was blamed for the high gas prices several months ago. Will the Democrats give him credit for the current price? I doubt it. The credit will go to Lord Obama (unless the Governor of Illinois is caught selling oil futures). What about all the people who sold their gas guzzlers and now driving Cooper Minis and Toyota Prius hybrids. When gas was high, the difference in what it cost to fill the tank of my car was almost 30% higher than theirs. Now, the difference is minimal. I wave at them when I pass them on the roads as their car groans while trying to get up a simple rise in the road. Perhaps they need some Viagra in the car's gas tank.

Saturday, December 13, 2008

A Reasonable Living Will

To my family physician, my lawyer, my friends, and all others to whom it may concern: 

I, _____________________, being of sound and disposing mind and memory, do hereby make, publish and declare this to be my LIVING WILL. If the time comes when I can no longer take part in decisions of my own future, let this statement stand as an expression of my wishes and directions while I am still of sound mind.

If I suddenly begin to take an unexplained turn for the worse, before any drastic or irreversible decisions are made, it is my desire that someone first check to make sure my attending physician is not Dr. Jack Kevorkian.

Should my attending medical personnel determine that an organ transplant is necessary, it is my expressed wish that, if at all possible, the baboon be of the same faith as me.

If a kind soul takes it upon themself to read aloud to me, it is my fervent wish, as it was during my non-incapacitated life, that they skip directly to the dirty parts of the book, and then read those passages over and over and over again.

It is my expressed want that no family member, friend or acquaintance shall enter my hospital room bearing one of those tacky "Get Well Soon" helium balloons. Likewise, any get well card sporting Garfield the Cat shall immediately be returned to its sender.

I wish my TV set off whenever "Oprah" or “The View” are on.

If at all possible, I prefer "Depends" over "Serenity."

I would prefer that my visitors leave their small children home if all the kids are going to do is stare at me and play with my toes.

When it comes time to change my Foley catheter, I would prefer a nurse with untreated Parkinson’s disease perform the procedure while singing "Barnacle Bill the Sailor" to me.

At no time, even on the occasion of my birthday, do I desire to have a party hat placed on my head.

While I am not morally or ethically opposed to so-called “life sustaining equipment," I am vehemently opposed to the concept of hooking up such machinery to "The Clapper."

I agree to sponge baths only if given by a member of the opposite sex. Several members of the opposite sex at once is certainly acceptable and, in fact, preferred. Ditto for any "therapeutic Jacuzzis" that may be prescribed.

Please kill anybody trying to enroll me in Wii-Hab or similar nonsense.

It is my strong desire that in any and all elections that may take place, my absentee ballot be marked for the individual running opposite Barney Frank.

In the unfortunate event that the time comes to donate my vital organs, it is my wish that in all donations, a receipt be obtained for tax purposes. Also, do not give my organs to anybody associated with the IRS or the United States Postal Service—let those bastards die a slow and painful death.

No Jello or Ensure. Margaritas with Patron Tequila (preferably the Grand Platinum variety) will be acceptable.

When it comes time for me to give up the ghost, make sure the embalmer leaves a smile on my face.

This statement is made after careful consideration and is in accordance with my strong convictions and beliefs I want the wishes and directions here expressed carried out to the extent permitted by law. 

IN WITNESS WHEREOF, I have hereunto set my hand and seal to this my LIVING WILL on this the ___ day of _______________, 20_______


Wednesday, December 3, 2008

The Gynecology Room (Redux)

In the house of medicine, we often give obstetrician/gynecologists a hard time. After all, it is the only medical specialty soley based upon a totally normal human event. We give them colloquial names such as “vaginicologists” or “spreaders of old wives’ tails.” Regardless, we in the emergency department usually despise the gynecology room. But, they provide memorable patients.

While a resident I was moonlighting at a fairly rural emergency department. A young Mexican woman came in complaining of contractions. I assessed her and sent her to the OB floor. During the night, a small dusting of snow paralyzed the town (people in my area start buying milk and break anytime snow is in the forecast). At 6:00 AM, 1 hour before my shift was about to end, I was called to assess Maria on the OB ward. The on-call obstetrician could not (reportedly) make it to town because of 2 millimeters of snow that supposedly made local roads impassable. I was literally beat. I had not slept in 36 hours and was not excited about delivering a rug rat. But, being the professional I am, I scrubbed and gowned up. Maria was a 19-year old Gravida 2, Para 1 (second pregnancy). I checked her and she was 10 cm dilated, 100% effaced and the head was at a +2 station. We were going to rock and roll. I sat on the stool and, in Spanish, talked her through the second stage of pregnancy. I readily delivered the baby girl, clamped and cut the cord and handed the baby off to the nurse. I took the curved Kelly clamps and wrapped the maternal segment of the umbilical cord several times around the clamps and waited for the placenta to separate. While I waited, I was so tired I dosed off while seated at Maria’s perineum. Suddenly, I was awakened by the sound of the placenta hitting the hard tile floor taking my clamps with it. This was a sound unlike any I had heard in my life. It scared the shit out of me. Suddenly, Maria started crying, “Mi hija. Mi hija. (My daughter. My daughter)." I realized that the mother thought I dropped her newborn baby. I reacted, although exhausted, by grabbing the placenta and picking it up to show the mother that I dropped the placenta—not the baby. I forgot that most people have never seen a placenta (it looks something like the alien larvae from the movie “Alien”). She took a look at the placenta and started screaming and saying Catholic prayers. I thought, “What the hell is going on with her.” Then, it hit me. She thought the placenta was her baby and that it was some sort of demon or alien. She began to scream and cry. Finally, I got the nurse to bring the baby to her side. For the life of me, I could not remember the Spanish word for placenta (it turned out it was a cognate—same word in English—just pronounced with Spanish vowels). Finally, I explained the situation and I think she understood. She was happy to see her baby girl was OK although she kept looking me with a look that would thaw a snowball.

Another memorable vaginicology patient was a 30-year-old female in the tuna pit. She had a “discharge.” Finally, I went into the room. The patient was pleasant enough, yet a few sandwiches short of a picnic. The nurse and I explained the procedure. I stuck my gloved finger into the vagina and struck a firm object. “That’s weird,” I thought to myself. I got the speculum and carefully inserted it. There was something solid in the vagina and it smelled like a morgue somewhere on the equator. The nurse handed me a pair of ring forceps and I removed a clump of pus that appeared to have some shape. I realized that it was a contraceptive sponge (these were popular contraceptive devices in the 1990s, except they led to some horrible pelvic infections). Then, I pulled another one out, and then another, and finally a fourth one. I looked up at the patient and said, “I see you are using the contraceptive sponge.” She said, “Yes, my boyfriend won’t wear a rubber.” I said, “You know you’re supposed to take them out when you are through with your sexual encounter.” She looked at me totally perplexed and said, “I thought they dissolved.” What amazed me even more is that she somehow managed to have sex with 4 contraceptive sponges in place.

Finally, one of the most memorable patients in the gyn room was a patient named Monique. She was a very pleasant black female who presented with a vaginal discharge. No big deal. This was the third patient with the same complaint during the shift. Monique was a big woman—in excess of 200 pounds. The young nurse (the young nurses are low on the totem pole and draw the tuna pit). The nurse put Monique up in stirrups. I explained to her what I was doing. My technique is to carefully insert a gloved finger into the vagina and put pressure on the posterior vaginal wall. Then, I tell the patient I will be inserting the speculum. I then turn the speculum sideways and insert it and then rotate to the upright position, spread the speculum and look for the cervix. At this point Monique started to move around and moan. I thought I had pinched her with the speculum. I released the speculum and reopened it. I was not pinching the vaginal mucosa. Monique started to move around more and moan. Her moans got louder. I looked and saw her vaginal muscles start to contract rhythmically and she pushed the speculum out into my lap. Immediately Monique apologized, “I’m so sorry doctor.” I still didn’t have a clue as to what was going on—-but the nurse did and started to smile. I asked Monique, “What happened? Did I hurt you?” Monique couldn’t speak. The nurse said, “Can’t you tell she had an orgasm?” I said, “What? Are you kidding me?” I looked and Monique was still twitching. I was perplexed. This had never happened before (at least in a medical examination room). Monique was very embarrassed (and apparently quite sensitive). I didn’t know what to do. I just sat there. Then, I had the urge to offer her a cigarette. In fact, I wanted a cigarette and I never smoked a day in my life. I was obviously the source of much teasing for months thereafter.