A Review of Showtime’s Nurse Jackie

June 15, 2009
She Does What we Only Wish We Could Do to Some of our Patients

She Does What we Only Wish We Could Do to Some Patients

I recently watched the pilot episode of Showtime’s new show, “Nurse Jackie”, with the night crew. Jackie, played by Edie Falco, snorts crushed vicodin, steals money to give to the poor, forges an organ donor’s card, has sex on the job with the pharmacist who supplies her with the vicodin and flushes an arrogant jerk’s ear down the toilet after some choice words – and that’s just in the first episode.

In many ways – sex and drama aside – Nurse Jackie is the quintessential “take-no-crap” ER nurse that has served as an experienced den mother of sorts to so many young doctors and nurses still finding their way in the medical field. I still work with , and learn from, nurses like that, who continue to enlighten me with their experience, wisdom and knowledge. And no, I didn’t grab their boob or have sex with them in the supply room.   

On one hand, I fear that people will actually believe that nurses behave this way and treat them with even less respect.  I guess we will just have to leave it to shows like ER and Hawthorne to teach people to respect and admire the amazing efforts that nurses make to brighten, save and enrich so many lives on a daily basis in hospitals and clinics throughout the world. It is a noble profession that is too often the unsung hero. But back to the show …

Although it does present a flawed character portrayal of nurses, it is kinda fun to see someone act out what we all sometimes wish we could do with at least some of our patients. She has a distorted sense of ethics that leads her to do what will in the end be the most benefit to society in her opinion, and other times just gives people what we all know they really deserve. Except maybe her poor husband, but maybe the reasons for that will play out later.

From a doc’s perspective, I thought the whole Heimlich scene was coldly amusing. I get a similar feeling when responding to “Is there a doctor on the plane?”, because you really are never on vacation as a medical professional. It is a blessing, and sometimes it can be a drag, but no doubt it is wonderful to always be able to impact people’s lives – although not always in such dramatic fashion.

The nurses who watched it with me – male and female – enjoyed the show and were looking forward to future episodes. It presents an entertaining contrast to shows like ER and Grey’s where political correctness sets a border around the characters. So many of us in medicine hold back what we really think of some of the pathetic excuses for humanity that we see on such a regular basis from the the drug seekers, the self-righteous and those who feel they have the “right” to put us down, the domestic abusers who beat on their spouses, all the way down to child abusers and those who have children when they have no intention of doing anything remotely resembling parenting or loving, etc. It might just provide an outlet for those of us who bite our tongue and “do the right thing” even when it would feel so good to tell these people what we really think.

What I really want to know though is why the pharmacist has a bedroom in the hospital?

Add to Technorati Favorites


The Radiologist Examined a Patient!

May 30, 2009

Those of us in the medical field know the radiologists – the doctors who read xrays, CT’s, etc. – usually sit in their dark room all day and read films, often times with CYA statements at the end of their official report that say something like, “_____ cannot be excluded, and so a [another imaging study inserted here] would be recommended …”.  The type of person who typically goes into radiology is a person who doesn’t much like dealing with other people, and so they only “see” patients when, and if, they have to do a procedure, or if they pass them in the hall. It is rare that I even have the chance to discuss my clinical exam with a radiologist since they don’t usually seem to care about our seemingly worthless thoughts.

But in my hospital, I have the great honor (doesn’t always feel that way) of working with some of the smartest doctors in the world when they moonlight here away from their Ivory Tower. Their hospital is internationally recognized as one of the best medical centers in the world. Among this distinguished group are the radiologists that will moonlight here on weekends. I have to say that some of them have their nose so stuck up in the sky that we only look like ants to them, and that is how they speak to us. But something cool about medicine is that experience almost always trumps medical training. There are many nurses I would rather have treat me that some of doctors I have had the horror to meet.

So, last week I came into work and my first patient was a poor old woman who was run over accidentally by her husband with a farm tractor. I called to request a CT of the chest, concerned about flail chest and significant thoracic injury. The Ivory Tower radiologist balked at my request and stated with great annoyance (how dare I interrupt his computer game) that he would read it, but that he thought it was totally unnecessary. He felt a simple x-ray should provide adequate information. I responded by saying innocently that I was unaware that x-rays would show vessel damage since after all there are some big pipes running through the chest (aorta, IVC, subclavians and oh, that darned thing that keeps beating).

He made getting the CT a chore as well (some sort of punishment I suppose) by having the techs refuse to do it until I checked her kidney function. It was a trauma! Why should I wait for kidney function? But they insisted.

He humbly called me back an hour into this poor woman’s ER course to tell me, “Man, this lady’s really messed up!” I asked if that was his medical diagnosis.  The “official” report was that she had broken 10 ribs on one side, had a collapsed right lung, and bilateral lung bruising. Nah, we didn’t need that CT now did we? I resisted the urge to rub it in and focused on taking care of the patient instead.

But every now and again, we do get an exceptional resident from the Ivory Tower. This weekend, I have the true honor to work with one such radiologist. Professional and personable, so much so that I am almost convinced that he is not a radiologist by training. Maybe he’s like that guy from Catch Me If You Can? He doesn’t call us to give us reports, but comes in to see us in person on almost every case in order to discuss the case and provide his report. This not only makes him courteous, but way smarter than the other radiologists because getting the clinical backdrop is a very good way to not miss something important. When you understand in detail why the test was ordered , it helps you zoom in on the area of concern with a different perspective.

But then he did the unthinkable. Our stellar resident actually went and examined the patient! I don’t think that in all my years of medicine I have ever witnessed such an event. I thought radiologists had lost the art of examining patients by the time they finished their internship, but this guy proved us wrong. Kudos to you my friend and maybe you will be an inspiration for the others in your field to come back down to earth.


You Don’t Need to Come to the ER at 3am for “Strep Throat”

May 15, 2009

Among the more frustrating ER visits that you will never see on your favorite TV medical drama of choice is that of the 3am visit for possible “Strep Throat”. The sad reality though, is that this is something that we as a medical community have contributed to in a potentially large way. Some people are afraid of Strep because of the supposed connection to Rheumatic fever, while others are just uninformed (putting it nicely) and think that getting that holy prescription for Amoxicillin will make their discomfort go away in a space of hours (which it doesn’t). I guess I should be glad that most of them don’t come in trying to get Percocet to kill the pain (which doesn’t work well in this case either).

Regarding the whole strep and rheumatic fever issue though, I came across an article a few months back that addresses this issue. I will reproduce it at the end of the post for whoever would like to read it, but since it is medical speak to a degree, I thought it might be thoughtful to at least summarize it for those who don’t have the time or medical background to read it.

Basically, the article states that our current understanding that untreated Strep results in Rheumatic fever comes from only one large study that appears to be an anomaly. Two more recent and rigorous medical studies show that there is actually a relatively low risk of Rheumatic fever connected to Strep, and that the number of cases of serious side effects from our overly generous use of antibiotics far outweigh the risks of the limited number of cases of Rheumatic fever in this matter. It recommends against use of antibiotics in this case, but I wonder if the damage is already done? Trying to explain this to the average soccer mom would more likely result in a complaint than a “Oh thank you Doctor for looking out for our best interests!”.

In today’s internet society, too many people come to the doctor looking to get an order filled as opposed to getting an evaluation and medical advice. We keep saying that it is Burger King and we are not here to fill your order, but that message seems to have been missed by Hospital Administration and the general public.

For those who may be interested, here is the article:

Add to Technorati Favorites

Antibiotics for Strep Do More Harm Than Good
By David H. Newman, MD

Military and civilian medicine have always been intertwined, but nothing compares to the strange tale of Warren Air Force base in the 1940’s. Perched on the high plains outside of Cheyenne, Wyoming, the combat training center was, mysteriously, a bacterial cauldron. For more than a decade virulent strains of group A streptococcus caused unprecedented rates of pharyngitis among the trainees, and history’s worst epidemic of rheumatic fever.

A small cadré of military researchers at the base seized the moment, executing a provocative series of trials that tested the potential of antibiotics to prevent post-streptococcal rheumatic fever. Roughly 2% of the trainees given placebo in their studies developed rheumatic fever, while under 1% of trainees given antibiotics experienced the disease. For every 50-60 trainees treated with antibiotics, the researchers had successfully prevented one case of rheumatic fever. It was a small, but decisive victory.

Prior to the epidemic at Warren Air Force base there was little interest in ‘strep throat’. During the twenties and thirties in the Unites States, sore throat care focused on diphtheria, “the strangling angel.” The characteristic ‘bull neck’ and the dreaded grey pseudomembrane led to a gruesome, asphyxiating death for thousands of children each year. Comparatively, strep throat was a minor nuisance that often received little more attention than the common cold. But by the 1940s vaccination programs had nearly eradicated diphtheria, and antibiotics were becoming widely available. When the Air Force studies were reported in the early 1950s, they resonated. Rheumatic heart disease was common among adults, making its prevention seem immediate and intuitively important, and antibiotics for a bacterial infection made good sense. Identifying and treating ‘strep throat’ quickly became a staple of medical education, and little has changed.

The problem, of course, is that one can only prevent rheumatic fever where it may plausibly occur. Outside of Warren Air Force base in the 1940s, is rheumatic fever a plausible risk? Apparently not. There have been only two other cases of rheumatic fever ever reported in a pharyngitis study, both in 1961. In fact, despite large, contemporary studies tracking tens of thousands of strep throats in the general community, many of whom received placebos or no treatment, there hasn’t been a case of rheumatic fever reported in a study for nearly fifty years. When the incidence dropped to less than one per million in the general population in 1994, the Centers for Disease Control and Prevention stopped tracking rheumatic fever entirely.

At Warren Air Force base only 50-60 recruits were treated to prevent one case. Today, preventing one case would likely require antibiotic treatment for hundreds of thousands of strep throats, making it a mathematical certainty that antibiotics will do more harm than good. For each case of rheumatic fever prevented in modern practice, a few dozen patients either die or suffer near-fatal anaphylaxis, toxic epidermal necrolysis, colitis, or other antibiotic reactions, and many thousands more suffer diarrhea, rashes, and yeast infections.

Fortunately, rheumatic fever has been declining for a century, starting well before the introduction of antibiotics. While strep throat is no less common today, ‘rheumatogenic’ strains have dwindled, leading epidemiologists to conclude that antibiotics have little or nothing to do with rheumatic fever’s disappearance. Changes in hygiene, nutrition, population crowding, access to care, and changes in the bacterium are all felt to be important factors, which explains why the disease is now typically seen most in third world settings.

There are, arguably, other reasons to consider antibiotics for pharyngitis, but the evidence does not rise to support them. The Cochrane group estimates a 16-hour reduction in symptoms with antibiotics, but ibuprofen, acetaminophen, or a single dose of corticosteroids is as good or better, with fewer side effects. And while peritonsillar abscess may be minimally reduced by antibiotics, abscesses typically present primarily rather than after strep throat, and in most cases are easily treated. No studies have shown that antibiotics reduce the transmission of strep or reduce other complications.

The administration of antibiotics for strep throat, endorsed universally by practice guidelines and professional societies, is based exclusively on data from the world’s most concentrated epidemic of rheumatic fever. Using this to guide modern therapy is like administering antibiotics to prevent bubonic plague.

The essence of evidence is its ability to point us toward truth, and we must first understand what truth we seek. We do not ask whether antibiotics may be useful during a military epidemic of rheumatic fever. We ask a different question. We ask if antibiotics are beneficial for every day strep throat. Those who have written our guidelines and crafted our recommendations have, unfortunately, failed us. The strange tale of Warren Air Force base is a lesson in evidence: The only way to get an answer right is to pay attention to the question.

David H. Newman is the author of
Hippocrates Shadow (Scribner $26)

Add to Technorati Favorites


House MD: Good Ratings, Bad for Medicine

May 12, 2009

house_md_pillsAs TV season starts to wind down to the season finales, I can’t help but express my frustration at some of these medical dramas on television. I remember how fun it was as a medical student to watch the show “ER”, but how the relationship factor eventually made me lose interest. Unfortunately for some, in the real ER’s of the world, partner swapping is not a reality (at least not publicly).

Sure some relationships may develop between some of the staff from time to time, but I hesitate to say that it is no more often that what happens in any other workplace. And when it does happen, those involved usually like to keep it very private. Discussing what you and Nurse Janie did last night over CPR just hasn’t ever happened in my experience. But this issue is far from being the most publicly dangerous idea promoted by these shows. That goes hands down to the idea that ER doctors can do anything.

Watching ER, there were episodes when the ER doctors did c-sections in the back of a grimy ambulance after a gruesome car accident – and amazingly everyone survived! Happy endings all around. Unfortunately, the only C-sections we might ever get involved in are the emergency ones where mom is pretty much a goner and you’re worried about saving baby. There are no fine bikini cut incisions. Its blood and guts, and the baby’s chances are not very good either. Unfortunately, we also don’t take out your appendix or cure cancer.

Watching House MD though, things have been taken to an even higher level of unrealism. The docs on that show are not only walking encyclopedias of rare diseases, but they are also genetic specialists, nurses (all specialties), pharmacists, x-ray techs (who do CT and MRI), respiratory therapists, phlebotomists, social workers, abuse counselors, chaplains and private detectives. I personally have never gone through a patient’s trash or through their drawers to look for “clues”.

And House himself, as funny as he can sometimes be, would have been hauled off to jail a long time ago and lost his license for his interest in pornography and narcotic pain medication addiction. Just try imagining the guy from the Percocet video posted a few days ago being your doctor – not the kind of person we would generally associate with mega-book smarts if you know what I mean.

Yes, I know you are probably thinking, “dude chill out! It’s just a TV show”. So why does this matter? It matters because there are a lot of people out there who have a big problem between fiction and reality. They actually believe that we can do all these things and are very disappointed when we tell them we cannot.

I cannot even begin to count the number of times a patient has shown up in the Emergency Room saying, “I have been to my doctor and so many specialists and they can’t figure it out, so I decided to come here.” Then I have to explain to them how, unlike “House MD” or “ER”, I am more akin to “Scrubs”. I am pretty good with the common stuff especially if it has recently started (acute conditions). Once you get into chronic diseases (ones that have been there for a long time) or rarer conditions, then as much as I would like to stroke my ego, I am pretty lost.

I wish I could possess vast amounts of knowledge in several specialties. But I figure that since the people that go into those specialties have to spend several years honing their knowledge in that corner of medicine, it would be quite arrogant of me to assume that I can do their job so easily. I certainly get annoyed enough when someone training in dermatology or rehab medicine thinks they can step in and do my job, so I don’t want to be hypocritcal and do the same. These people have the training and specialized knowledge that don’t and they should be consulted. At least in “Scrubs” they usually use consultants and there are no “jack of all trades” doctors.

And in case you’re wondering, we also don’t have “quickies” in the medication or supply room.

Add to Technorati Favorites


Hydroxycut and Fad Diets

May 6, 2009

little_girls_smallA sad day in dieting occurred late last week with the pulling of Hydroxycut – the famed dieting pill (as seen on TV). The FDA is now warning consumers to immediately stop using Hydroxycut.  Apparently, Hydroxycut has been  associated with a number of serious liver injuries ranging from jaundice and elevated liver enzymes, an indicator of potential liver injury, to liver damage requiring liver transplant. One death due to liver failure has been reported to the FDA. Other health problems reported include seizures, cardiovascular disorders, and rhabdomyolysis, a disorder of muscle cell destruction that can lead to kidney failure.

Of course, news like this thins out the competitive field a little bit. True there are still pills out there on the market that promise that you can eat all the Twinkies, Hardee’s thick burgers and Oreo milk shakes that your heart desires without a nanosecond’s worth of exercise. For example, there’s always Alli – the non-prescription strength version of Xenical – which promotes weight loss by decreasing absorption of fat by the intestines, thereby reducing the number of calories you absorb. It also gives you diarrhea and nasty farts that leave skid marks in your underwear. And that’s on a low fat diet. Try that Hardee’s heart attack burger while on Alli and you my friend will understand the true meaning of pain while you spend the next 2 hours on the crapper.

By the way, did you know that the name of the man who popularized the toilet was Thomas Crapper? The guy who actually invented it was Sir John Harrington, hence the usage of “going to use the John”.  Ah, but I digress.

Losing weight is easy and it is hard.  To lose weight you need to eat less calories than you burn – easy in concept, hard in practice. One can also increase their activity level and decrease the amount of calories they consume and they will lose weight.But that won’t keep people from trying to find the magic lazy bullet which allows them to do nothing, eat anything and still have a beach bod. So let’s take a look at some popular, and not so popular, fad diets.

The Tapeworm Diet – Someone actually thought it would be good to eat one of these disease causing parasites. Hey, they’ll just eat all the excess food right? Wrong. Just like any pregnant woman will tell you, parasites eat what they want first and then you get the left-overs. So tapeworms get first dibs on your vitamins, nutrients and minerals. That’s why people with tapeworms usually develop ascites (big round pot-belly). I think I’ll pass thank you.

The Lemonade Diet – Popularized by Beyonce Knowles before filming Dream Girls, this disaster was originally called The Master Cleanser Diet by its creator, Stanley Burroughs in the early 40’s. Stan was a therapist once charged with second-degree murder after a patient died from one of his treatments. The diet eliminates toxins and “congestion” that have built up in the body, and because it doesn’t provide a complete source of nutrition, it is actually consider fasting more than a diet. Beyonce did lose 22lbs in 14 days on this diet, and the diet generally seems to have had good results with others who dare to try it either in Hollywood or elsewhere. Side-effects include lethargy, depression, dizziness, nausea, trouble concentrating, headaches and the one other one … oh yeah, death.  Use at your own risk.

The Paleolithic/Caveman/Stone Age Diet – The hunter-gatherer diet was introduced to modern times in the mid 70’s by a GI doc named Walter Voegtlin, with many variations since. Basically, if you can hunt it or collect it from a plant or tree, you can eat it. That means no dairy and no grains though. Hence the diet is essentially made up of  lean meat, fresh fish, vegetables, nuts, berries and fruits. No sugary calorie bombs or processed, preserved, cancer-causing excuses for food to fatten you up. Good for rapid weight loss in a healthy way but somewhat difficult in practice since you miss out on dairy and grains.

The ABS Diet – Newer kid on the block, created by David Zinczenko, the editor for Men’s Health. For many years most athletes and bodybuilders have applied the same basic fundamentals of the ABS diet to their dietary programs. These principles include eating often (5-6 times per day), a focus on building muscle, eating lean proteins, and striving to eat whole unrefined carbs.The Abs diet is made up of 12 ‘power foods’. One meal per week is designated as a ‘cheat’ meal – where you eat anything you want. The power foods are Almonds (and other nuts), Beans, Spinach (and green veggies), Dairy (fat-free or low-fat milk, yogurt, cheese), Instant Oatmeal (unsweetened and unflavored), Eggs, Turkey (and lean meats), Peanut Butter, Olive oil, Whole grain breads and cereals, Extra-protein whey powder and Raspberries (and other berries). It is a lifetime dieting plan with excellent results and a practical approach.

If none of these seem up your alley, here is one that I think we can all agree on every now again:

The Stress Diet:

This diet is designed to help you cope with the stress that builds up during the day. Breakfast

  • 1/2 grapefruit
  • 1 slice whole wheat toast – dry
  • 8 oz skim milk

Lunch

  • 4 oz lean broiled chicken breast
  • 1 cup steamed spinach
  • 1 cup herb tea
  • 1 small cookie

Afternoon Snack

  • Rest of the cookies in the package
  • 2 pints of  ice creamof your choice
  • 1 jar hot fudge sauce nuts, cherries, whipped cream

Dinner

  • 2 loaves garlic bread with cheese large sausage, mushroom and cheese pizza
  • 1 Liter of your favorite soda pop or cola
  • 1 bag of nachos with tub of hot cheese and salsa sauce

Late Evening News
Entire frozen cheesecake eaten directly from freezer

Add to Technorati Favorites


No, We Don’t Need to Land in Scotland!

May 2, 2009
Fish or chicken? Should've had the pasta.

Fish or chicken? Should've had the pasta.

As I had mentioned before, I am on vacation for the next couple of weeks. I thought I would be getting away from the stupidity of swine flu (now called H1N1 flu to protect pork sales), but it looks like I landed right in the middle of stoopid yesterday.

I’m on an international flight and heading towards Europe. Mid-way through the flight I see a crowd gather near one of the galleys and then a frantic sounding flight attendant gets on the mic and calls for one of her associates. I figured it was likely a medical emergency of some sort and followed the hurried attendant.

At the galley, I find a young man laying on the floor breathing O2 through a mask with two disoriented looking passengers fiddling with him. I tell them that I am an ER doc and they tell me that they are paramedics from Europe. The story is that this guy got up to go to the bathroom and became presyncopal (almost fainted) and called for help. I ask the scared looking flight attendant for the medical kit so I can assess this guy.

Now of course, everyone is worried about one thing – SWINE FLU. I can read their scared minds … “Oh no! We’re all gonna get swine flu and die horrible deaths!”. But when I assess the patient, after pushing the very eager, overly wound up paramedics away, my first question is, “How much have you had to drink?” Previous experience with airline medical emergencies has taught me that, just like on the ground, alcohol factors into a lot of emergencies.

After establishing the fact that he didn’t have half a cart of Jack Daniels, my next set of questions focuses on flu symptoms (fever, nausea/vomiting, body aches, fatigue, cough, runny nose, etc.). He was only nauseated, likely from the near fainting. No medical history, on no medications.  Then I hear one of the paramedics talking with the flight attendant about an emergency landing in Scotland and I get really peeved.

Dealing with the totally awesome EMS personnel in the States, I get used to them understanding chain of command and knowing when to defer. I imagine that many EMS personnel in Europe are also the same, so not sure what was up with these jackers. I tell the flight purser that I am the medical doctor in charge and that an emergency landing is not necessary at this point in time and that everyone should chill. Too many cooks in the kitchen.

Getting back to the sick person, I observe another flight attendant trying to put the leads from the automatic defibrillator (AED) on the patient – one on the stomach and the other near the right shoulder. It was like doing a code on the floor – total cluster. I was totally expecting to see the “paramedics” preparing to inject this poor guy with some epinephrine or something.

So, what was the sick guy’s story? He was majorly sleep deprived (typical for many people preparing for international travel), been staying awake on lots of caffeine and probably not having enough fluids to replace all the ones he was urinating out. Add to that, the chicken meal he ate on board.

The AED shows a very temporary sinus bradycardia (slow heart beat) at about 40. While I was checking his blood pressure, it went back up to normal between 65-72. I think it was because he was overhearing the “paramedics” from Hell discussing totally inappropriate interventions. His blood pressure turned out to be 110/70. My team of boners tried to get a blood sugar and failed. But by this time, the guy was saying he was feeling better and wanting to sit up. His “fight or flight” response was probably in high gear overhearing the things being said.

Catastrophe averted for the moment. I told the sick guy to contact me directly if he started to feel woozy again and to avoid the “paramedics” at all costs. The flight attendants were thankful for the man’s quick recovery and for services provided.

In the last hour of the flight though, I was heading up near the sick guy’s seat and see his wife standing and looking concerned. He was feeling woozy again and luckily I arrived at the right time (read – before Beavis and Butthead). I had him lie down and put his feet up. Checked his pulse and it was regular at about 65. He was very nauseated again. To avert another medical emergency landing, I went to the head purser and told her that the guy was stable and not to be worried. I would stay with him until we landed and inform her of any changes.

Within minutes, the guy was feeling and looking back to normal – a good sign that he was likely dehydrated and getting vasovagal. A few nice passengers near-by offered to move so that he could lay down across four seats. Beavis and Butthead arrived soon enough with an O2 tank (incorrectly set-up). Once again, they by-passed me to tell the captain to land ASAP. I think one of them was trying to impress one of the attendants or something.

Just before we landed, sick guy vomited up his chicken. I was sitting right in front of him and immediately after I asked him if after vomiting he felt better or worse. Although it’s not so evidence-based, I have found over the years that with food-borne illnesses (commonly called “food poisoning”) that people generally feel better immediately after vomiting – likely because of the reduced toxin load in their stomach. On the other hand, vomiting from flu syndromes usually results in a person feeling even worse and more fatigued. Maybe it was the chicken after all?

We arrived to our destination after a hurried landing and had to wait on board until this country’s EMS came on board to load up the patient and take him to the airport medical facility. I gave report to the ER doctor that accompanied the team and gave my new friend (sick guy) some farewell advice and a good-bye. My advice was get some IV fluids and some rest. After he was gone, I had to reassure several passengers that there was no flu threat and that they should all be ok.

That is, unless they had the chicken. Glad I ate the pasta.


Laying on of the Finger

April 29, 2009

healing_fingerPart of my mission with this blog is to help those outside of the medical realm to understand how much BS we often have to sift through in order to get to the bottom of things. Case in point, I get word that EMS is bringing in a potential “neurological injury”.

Let me tell you, neurology and nerve injuries are not on anyone’s list of favorite things to deal with in medicine. They’re confusing, complicated and then you have to deal with neurosurgeons – the medical equivalent of getting sodomized with a baseball bat. So, needless to say, I was worried.

Finally the patient rolls in, appropriately strapped to a spine board and in cervical precautions. He looks scared and worse yet, he’s not moving. He’s a young person, maybe in his mid 20’s, which makes it a recipe for true disaster. So, I carefully start getting the story.

Turns out that John and his girlfriend were having some fun at home and started chasing each other around the dinner table. But then suddenly John hits something and crashes to the ground, unable to feel anything below his waist. His girlfriend starts to panic and calls 911.

My first instinct was to get on the phone with neurosurgery, and get this guy into the right hands ASAP.  But the image of a baseball bat makes me think that I should at least do a thorough neurological exam on this guy first. I start with his cranial nerves, which seem normal above his waistline. Beyond that though, he has no pain response, no movement and no sensation whatsoever in his legs. I’m starting to sweat.

Last on the list though is to check rectal tone. When someone is truly paralyzed below the waist, they almost always lose their muscle tone in their anus and rectum, as well as losing control of their ability to control their bladder. Put simply, they urinate and defecate on themselves. Yet John’s tighty whity’s are Clorox clean. Hmmm? Maybe he was lucky enough to preserve this area I’m thinking. But, like it or not, I have to do the rectal exam.

As I start pulling his underwear down, for the first time it seems, John starts to look anxious. “What … what are you doing??!!”, he blurts out.

I explain, “I have to do a rectal exam … basically involves me putting my finger in your ass to check your muscle tone. It will help me to understand your degree of paralysis.” I have the nurse put the lubricant on my finger and just as my cool, gloved finger touches his anus, something miraculous happens.

John’s butt cheeks clench so tight, and his previously “paralyzed” legs snap shut and come off the backboard with truly impressive force.

So all was well in the ER. I wasn’t going to get sodomized by neurosurgery after all, John had a “miraculous” recovery and I temporarily became known around the ER as “Jesus”.

What had happened? I will never know for sure, but I’m pretty sure John was alright before EMS even arrived to his house. How far could this ruse have gone? Who knows? Why was he faking it? The promise of a disability check, for sympathy, thought it would be a good joke – your guess is as good as mine, but he wasn’t the first and he unfortunately won’t be the last person trying to pull the wool over our eyes for some alterior motive.