Working In The Fishbowl by Dr. Jeanmonod

Posted on February 25th, 2010 by uberlumen.
Categories: Interviews, Vital Signs of Healing, medicine.

Working in the Fishbowl

[Ann Emerg Med. 2010;55:125-126.]

“I have a confession to make.”

This is my favorite part of the history. It’s also the part I understand the least. It typically occurs after I’ve asked questions I wouldn’t ask my mother. After I’ve inquired about the medical history, perused her potential illicit drug use, plumbed the depths of the sexual history, examined all the parts the patient wouldn’t show strangers on the beach or even a spouse in the bedroom. This is the part where I find out the secret nugget of information in whose context everything that has happened up to this point needs to be placed. This is where it will all fall into place and make sense. It’s the moment when I believe the patient knows I want to help and is showing some trust. I don’t understand it because the confession so often seems less intimate, less personal, less critical than everything else I’ve said, heard, and done in the room. But it’s my favorite part, because it has a sense of sanctity to it, a mark of the physician-patient covenant. It doesn’t happen every time, but I like it when it does.

I sit back down on the lid of a trashcan, so she knows I’m not in a rush. I’m superficially familiar with the studies about sitting when you’re talking to patients and I’m a fan of both sitting and evidence-based medicine, although I’m not sure if any studies address where you sit. I avoid the biohazard bin as a sign of respect for what might be in there (I am also a fan of signs of respect), but the trashcan is the perfect height. It also has a big lid, so I feel less unstable on it than on a stool, which is really only good for pelvics and procedures.

“Tell me what’s on your mind.”

By way of background, this woman does not see doctors. Period. She hasn’t seen a doctor since the birth of her last child 30 years ago. I am aware that I feel a little honored that she has chosen to see me, because I know this isn’t easy for her, and she wouldn’t be here if she didn’t think she needed to be. As a corollary to this, she is not insured and has no money. She is about the age of my mother, and I wonder if maybe she’s thinking all the things my mother thinks of my appearance. I try to sit up straighter and arrange myself more ladylike on my trashcan. I cover my dozen earrings with my hair.

She is here for a rash. It’s on her left buttock and has been spreading for a couple of days. She’s starting to feel unwell, with chills and fatigue. It looks to me like cellulitis, and she doesn’t seem ill enough to warrant admission. This makes her happy. I was about to write her some prescriptions, but she has stopped me from leaving, and now I am perched waiting for her confession.

“I take fish antibiotics.”

Fish antibiotics. I turn this over in my mind, trying to look at it from all angles. Is this actually a psychiatry patient? Does she think she’s a fish? Is she saying she can only take fish antibiotics? Maybe asking me to prescribe fish antibiotics? Do you need a prescription from a fish doctor to get fish antibiotics? Is she familiar with the common metaphor that the ED is a fishbowl? Is she making fun of me and my job? Is this the kind of day I’m going to have? Is my next patient going to take reptile antibiotics? Will he think he’s a dinosaur? Suddenly, my rapport with my patient teeters vertiginously on the edge of the chasm of my judging her.

“I’m sorry. What do you mean?” I can hear my tone has changed, and hope she doesn’t hear it.

“I’ve been taking fish antibiotics. You know, from a pet store. I thought you should know, because I’ve been taking fish amoxicillin for 2 days. I’ve done it for years, but this time, I’m not getting better.”

Suddenly, I understand. Aquarium drugs. The loophole of the United States prescription antibiotic system. I remember treating my own home aquarium with an antifungal tablet, and how many choices there were for antimicrobials, no prescription necessary. So she’s been on amoxicillin of some formulation or other, intended for a goldfish. I am no longer irritated or judgmental. This woman is resourceful. She has no insurance. She has no doctor. She has needed drugs over the course of 30 years and has researched what she thought she needed and treated herself to good effect up until now. She has never been to the ED before. She likely would have made a better choice for herself if she had had more information on community-acquired MRSA, and then she wouldn’t have presented for care this time, either. I wish patients didn’t do this, and I wish it wasn’t an option for them, but in the same situation, it’s something I can see myself doing. In some ways, it is what I do for myself. I decide what I think I need and prescribe it.

“Um, ok. Thanks for telling me. That’s really helpful information to have. Do you mind if I ask you how you dose it?”

“I take one tablet. I figure I’m about the size of a 10-gallon tank.”

I quickly do the math. 80 pounds. Not even close.

I write up a prescription for doxycycline and some generic discharge instructions. I add in, “It would be a good idea for you to see a primary care doctor, as this is safer than you trying to figure out what infection you have and buying antibiotics intended for an aquarium. If you do buy antibiotics for an aquarium, remember you are the size of a 20-gallon tank.” I hope this will help her make a more informed decision next time.

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Chess With God by Dr. Veysman

Posted on February 3rd, 2010 by uberlumen.
Categories: Interviews, Value, Vital Signs of Healing, medicine.

This is a GREAT glimpse into the world of an ER doctor:

Chess With God

Boris D. Veysman, MD

[Ann Emerg Med. 2010;55:123-124.]

Give me a bad position, I will defend it. Openings, endgames, complicated positions, dull draws, I love them and I will do my very best.—Hein Donner, Chess player, 1950

Not only does God play dice, but… he sometimes throws them where they cannot be seen.—Stephen Hawking

Amidst a busy shift when patients pile in, seasoned nurses start to grumble, and my blood sugar and bladder volume are most discordant, I overhear a fourth-year medical student share wisdom with a third-year newbie. “ER’s got a good schedule if you like doing overpaid triage.” I smile, enjoying the involuntary adrenaline boost from sublimated anger, before refocusing on the labs of the 80-year-old woman with digoxin toxicity and acute renal failure, presenting with runs of unstable tachycardia, prolonged QT interval, hyperkalemia, hypocalcemia, and a filthy cough suggesting preseptic pneumonia.

The next 20 seconds is a synaptic typhoon. Could elevated lactate mean not sepsis but mesenteric ischemia? A benign exam would not rule it out, and she is too sick to complain of abdominal pain. Tachycardia and hypoxia suggest pulmonary embolism (PE), given her edematous legs and recently stopped Coumadin when she had a GI bleed. This also increases the risk of mesenteric clot. Yet the contrast timing is different for CT angiograms of chest and abdomen, and I will have to choose which to optimize. Both studies are perilous because of the dye load, given acute renal failure, but failure to make either diagnosis would be fatal in a patient this sick. Meanwhile, empiric anticoagulation risks another massive GI bleed. Dialysis and transfusion may be necessary damage control to be considered concurrently with the diagnostic studies. Furthermore, calcium gluconate is contraindicated in digoxin toxicity because of mostly hypothetic cardiac tetany but would probably help with the blood pressure. Calcium would also treat hyperkalemia and hypocalcemia (strangely equal at 6.5), which both contribute to cardiac toxicity. If the heart gives out, it’s my fault either way, and I find that liberating. Digibind for the hyperkalemic digoxin toxicity, but that will worsen the heart failure. Definitely fluids for hypotension and sepsis but absolutely no fluids because of pulmonary edema and renal failure.

“Dr. V, she’s 80/50,” the nurse reports. Time’s up. Make a move….

We may choose emergency medicine for different reasons, but we fall in love all over again when after a few years of practice we begin to understand its magic. For me, it’s the intensity of thought when time is short and stakes are high in a battle against the worthiest of opponents. There are many hard cases that challenge the depth of our ability and ingenuity. We believe that God plays fair and you often get a shot at winning, regardless of how dismal the malady. A broad differential and rapid and often imperfect diagnostics are often the only way to find in time what’s lethal and irreversible. And before the diagnostics are back, preemptive strikes of empiric therapy based on calculated risks and hunches may earn you a guerrilla victory.

There are no simple cases. Not at this level. There are simple doctors unwilling to try harder to optimize efficiency, cost, and outcomes, to do it with less radiation exposure, fewer side effects, and higher real and perceived quality. Every ankle and ear doesn’t need radiographs and antibiotics, but some do, and most need thoughtful pain management and anticipatory guidance, with the entire encounter limited to only a few seconds by more pressing cases. Every patient, sick or well, is a chance to be our best, to recognize when our best is not enough, and to get help before it’s too late. If it were easy, I wouldn’t want to do it.

When consultants who see the patient the next day whine about “shotgun workups,” “excessively broad antibiotics,” and “inconsistent management,” emergency physicians laugh nostalgically and think, “that was a good save.” However lacking in elegance the evaluation may appear to the hammer who sees the world as a nail, he should have spoken when he was somehow unavailable at 2 am on a Saturday. We are emergency specialists and we step up to the board, for anyone, at any time, and with a unique skill set.

We know that you don’t always get second chances playing against God. Specialists wishing to “see the patient in the morning,” surgeons who interrupt with “what did the CT scan show?” and primaries requesting to “wait for the blood cultures before treating” are occasionally right, but more often they fail to feel our sense of urgency and appear not invested in the battle. Seasoned ER docs are not desperate for approval, camaraderie, or admiration; often we can even write a rain check on respect. When squaring off against our adversary 30 times a shift, self-respect is earned and goes a long way toward self-esteem. But we deserve alliance, for others to be on our side in caring for the patient. This means trusting our instincts. This means respect for our expertise in ambiguity and patients who don’t read the textbook.

The metal doors burst open and the paramedics roll in a man who looks grayer than the sheet. “All we know is he’s got a kidney pancreas transplant with a pacemaker and he’s been depressed lately. We found him unresponsive next to some pills. Good vital signs in the truck but now I can’t feel the pulse.” The third-year med student stares blankly at the paramedic, while the fourth-year looks close to passing out. The nurses run to the gurney to transfer the lifeless body onto the stretcher, begin working on access, connecting leads. I stand up slowly and take a deep breath. The board is set; the next move is mine.

Welcome back, old friend. You open well. Let’s play….

Chess With God

Article Outline

• Copyright

[Ann Emerg Med. 2010;55:123-124.]

Give me a bad position, I will defend it. Openings, endgames, complicated positions, dull draws, I love them and I will do my very best.

—Hein Donner, Chess player, 1950

Not only does God play dice, but… he sometimes throws them where they cannot be seen.

—Stephen Hawking