Nude Psychiatry

April 28, 2009
Shirt and shorts required.

Shirt and shorts required.

I had this patient come in for a fall this weekend – seems like everyone was falling for some reason. He was in his sixties and had recently lost his job as a marital counselor because the foundation he worked for lost 1.5 million dollars in the Bernie Madoff scandal. Till that point, he had been sober for eight years, but the news was too much for him. So he went to the bar and got hammered.

Came home totally stinking drunk, and freshly unemployed to boot, so his wife said she had enough of him and told him to get out. So the marriage counselor was having marriage problems and not approaching them in the way that he probably advised others to do (at least I hope not).

Since this poor soul had fallen while drunk, the nurse asked him to get into a gown so that I could check him for injuries from the fall. I walk in and find a pleasant gentleman sitting on one of the chairs in the room. As we get into the physical exam, he tells me about some bruises and abrasions he suffered from the fall and proceeds to lift up the gown to show me his abdomen.

He didn’t tell me though that under that gown, he was totally naked. Just naked and casually sitting on a chair reading a magazine. Personally, I don’t prefer that any of my skin touches anything in an ER patient room.  But he, on the other hand, didn’t seem to mind plopping his naked genitals (i.e., free-birding) right down on that cloth lined (read absorbent) chair that others before him had bled, vomited, urinated and God knows what else on before. Either that or he really trusts generic hospital brand Lysol.

This reminded me of a patient we had a few months back in our psych room. She was about 50 and depressed. One of my colleagues went in to see her and being that it is the psych room, it is monitored on CC TV. As he was interviewing her, I noticed from my peripheral vision that she was successively taking off her clothes. Right down until she was totally naked and just sitting there answering his questions. It was a most unusual site to behold.

I mentioned this encounter to one of my other colleagues who is a serious triathlete. He told me that this was nothing compared to the guy that visually tortured him for months when he used to go swimming at the YMCA. This guy used to strip down to nothing but his socks and shoes and spend a good half hour riding the air-dyne (fan bike) in full view of all to behold. Not a nice image.

So, all-in-all, not sure if these are just nudists who happened to need to come in to the ER or what? But there is no doubt that we sometimes get to see way more of our patients than we ever intended to – and in most of these cases, have to live with the nightmares.


Swine Flu: Epidemic on Our Hands?

April 26, 2009
Duct Tape. Save Yourselves! The End is Near!

Duct Tape. Save Yourselves! The End is Near!

I’m almost glad that I will be having some time off in the coming days because with all of the insanity regarding the swine flu racing through Mexico City, and now in certain parts of the US. News reports thus far have done what they have become exceedingly good at in recent years – scaring people. Remember duct taping your windows in case of a nuclear strike? Probably about as effective as hiding under your desk (what they officially taught the last generation to do in case of a nuclear strike). So what do I expect will happen?

Starting soon – in a city near you – ER’s will start getting loads of visits from people suspecting they have swine flu (had our first one already today). What are the symptoms you might ask? Same as any other kind of flu – fever, cough, fatigue, body aches, nausea/vomiting, lack of appetite, etc.  Pretty vague right? But there must be a way to get tested right?

Yes, there is a test. Whew, you must be thinking! But, the test needs to be done at a public health lab. So, in other words, it might take a while to get results. But there must be something I can do right?

Sure, if you notice these vague symptoms and get to your doctor within 48 hours of the onset of your symptoms, then you can get antivirals. “What are antivirals?”, you may ask. They are very expensive medications produced in very limited quantities that have totally variable rates of success. What does that mean? It means good luck.  Beyond that, only two out of the four available class of antivirals “seem to be effective” per the CDC. So what happens then if you get to your pharmacy and they’re out of Tamiflu or Relenza (the two that “seem” to work)? If you can’t get it within the first 48 hours then its not worth taking. But you’re not dead yet.

The CDC recommends routine precautions to prevent the spread of infectious diseases: “wash your hands often, cover your nose and mouth when you cough or sneeze, avoid close contact with sick people. If you are sick, stay at home and limit contact with others”.  So, I’m following their advice and staying away from sick people by not working until this fear campaign takes a rest.

The thing that really bothers me though is scaring people over something when there aren’t reasonable options for reassurance.  The last thing I want to see is a run on ER’s and people who are minimally ill, but maximally worried, depleting whatever supplies of antiviral are available (even if doesn’t work so effictively) so that later waves of possibly sicker people will not be able to get treatment.

I also hate seeing people get worried over something which in many cases is no different than getting Influenza. Influenze kills lots of people every year – approximately 36,000 deaths and more than 200,000 hospitalizations are directly associated with influenza every year in America according to the Journal of the American Medical Association. I’m not sure about you, but I don’t change my lifestyle or schedule because of Influenza. Do we really need to change our lives because of the Swine Flu?


Internet Date Goes Horribly Wrong

April 23, 2009

You're hot An interesting thing happened last weekend. My own Romeo and Juliette … from Hell that is.  We had two patients come in from a car accident by EMS. Here is their story; a story that deserves a movie deal, or at least a Saturday Night Live skit.

John and Peggy.

John, a portly 275lb, unemployed alcoholic was looking for love. But unfortunately, love wasn’t look back in his direction. So he tried the internet. Peggy, an equally portly 255lb, gainfully employed assistant manager was having trouble finding the right man and also thought to try her luck on the internet. It was a match made in heaven, or at least in Heaven-Hill.

Their love on-line seemed to blossom, until they could hold themselves back no longer and just had to meet. John unfortunately had a suspended license (damn DUI’s), so Peggy would have to go and pick him up. They decided to go someplace exotic, someplace intriguing, a place where they could look deep into each other’s eyes and hear one another’s sweet words. They decided to go to a bar.

At the bar, they drank and drank. Maybe they imagined that the alcohol would make them appear more enticing (ahh, the famed beer goggle).

They hoped for the arrows of Cupid to pierce deeply into their hearts, but instead they discovered that the alcohol only brought on the spear of Ares (Roman god of war). Their arguments led them to decide that maybe it was best to go home. But Peggy was nice enough to at least drive the drunk and stupid John home.  John, alcohol having removed his ever so thin veil of “niceness”, told Peggy she needed to take a certain route to get him home.

Peggy, on the other hand, thought that John’s liquor was talking instead of his “brain”, and she decided to take another road to get him back to his hometown. I guess her route would have eventually gotten him home if they had driven long enough in such a great circle, but we will never know the answer to that intriguing question. Why?

Because poor John became so angry at his dear Peggy on their way home, that he decided to grab the steering wheel at 50 mph and spin it around. He apparently thought that this would be a good idea and help put her on the “right road” as he tells it. Unfortunately for our dear couple, the car rolled and landed in a ditch awaiting the fine men and women of EMS.

Upon arriving, EMS immediately recognized that they were in the middle of a love nest and decided to transport our  Romeo and Juliette together in the same ambulance. Although it sounded to everyone else like they were arguing and blaming each other, as well as calling each other @$%&*# and the ever-endearing ?*&$%#!, I’m sure that this was just John and Peggy’s own special love code. We on the other hand in the ED had to give them separate rooms. That didn’t stop them from yelling at each other across the hall though. Oh no, love like that just can’t be stopped.

They were both drunk – John weighing in at an alcohol level of .31 and Peggy (the driver) coming in a close second with a .20. State Police was present to give them citations by which they could immortalize their first date. Who knows, maybe they may even consider tying the knot when they show up for their court date. Although some may see Peggy losing her license for drinking and driving as a tragedy, my sentimental side sees it as an opportunity for them to take long, romantic walks along the highway together.

At the end of it all, it turns out that even though John was chomping at the bit to leave and get out of his spine precautions, the poor soul had suffered a broken neck. Yep, a good old C2 fracture. It would be a wonderful reminder of his first date with Peggy. Peggy would only end up with a few scrapes and bruises to remind her of their first meeting though. Ahh, a first date to remember. Just hope I’m not around for their next one!

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* Note – a case like this illustrates the great importance of radiographically clearing a C-spine when you are dealing with an intoxicated patient. Don’t be misled by their lack of pain and get a good radiographic exam.


On Death and Dying: The Grieving Tray

April 22, 2009

 

I think that all doctors would agree that of all of the moments we get trained for, the one that can be the most difficult is when telling a family member that their loved one has passed away. It’s hard to find the right words, especially when speaking to someone that, in many cases, you have known for less than a few hours at best.

 

Not so long ago though, I had accepted an assignment at a new hospital and was still getting my bearings. I had become used to the culture of the South where usually I made sure my back was covered before I informed families of bad news as they were known to sometimes attack me in their misguided grief (they usually apologized later). This though was a different part of the US.

 

Enter Mr. W from the nursing home. This patient was 66 years old and had suffered through many medical problems in his life. He was a double above the knee amputee who was coming because of lethargy and abdominal pain. When I went in to see the patient, he looked ashen and was very lethargic. His abdomen was very distended and had the distinctive tin sound of a bowel obstruction when I listened. So, I ordered blood tests and an x-ray. He didn’t last long in x-ray as when they tried to lay him down he groaned and started retching. So, the x-ray staff brought him back and requested we maybe put a tube in his belly (NG) to prevent him from barfing all over the place when he got flat.

 

“Reasonable enough”, I thought, so I asked the nurse who was taking care of this patient to come with me and we would get this done together and hopefully soon because he wasn’t looking so good. The nurse passed the tube as I tried to coach the patient and when it was hooked up to suction, suddenly the patient stopped moving and his color paled a little bit. I almost wondered if we had passed it into his lungs, but it sounded like it was in the right place. We stood there for a moment considering whether the old timer had just taken his last breath. It was an interesting moment in my career – no urgency, no fear on my part for some reason.

 

Then I said to the nurse, “Hey, if this guy’s not a DNR (do not resuscitate) then we should probably call a code.” Some of you may be thinking, “Wow, that’s kind of a nonchalant attitude isn’t it”, and I wouldn’t blame you because it really did seem as if time was passing a little slow. We went out and were told that he did in fact have a medical directive and so we had done the right thing. That’s when things began to get interesting …

 

A call was promptly put out to family. A message was left for his wife, but we did succeed in getting a hold of his son. We told him that he should probably come to the hospital immediately as his father was very sick and may not survive. His answer?

 

Well, there’ll be no love lost there I tell ya.” And then he hung up. Hmmm.

 

I then asked the nurses where they usually have the doctor tell the family the bad news. They said that there was indeed a family room and they would go ahead and getting the grieving tray ready. “Grieving tray?”, I asked. The grieving tray was a special at this kind hospital – loaded with cookies, fruits, pie, tea and soft drinks – to help grieving families with their overwhelming emotions. I thought that was nice, but then one of the nurses told me, “Yeah, they usually never touch it, so then we get it after they’re gone and can snack on it.” Ahhh, the ever practical mind of the ER staff.

 

So, I got busy with some other patients and about 45 minutes later, I’m called out to the nurse’s station to meet with the deceased man’s wife. I ask the nurses where I can go (assuming they understood that I meant I wanted to go to the family room) and they told me to go to the end of the ER in the last room. As I’m walking with the woman, I’m at a loss of what to say and just trying to get her to where we can sit down so that I can break the news to her. I get to the last room and pull open the curtain only to find the dead man lying there! Doh!

 

The woman pushes past me to go to his side – still not knowing if he’s dead. Meanwhile, I’m desperately thinking what to say to her and how to handle this awkward situation (and how much I wanted to strangle the nurse who sent me down here!). As the woman stands – oddly enough at a distance – by the bed, she asks in a confused voice,

 

Is he dead?”

 

Damn it! Have to think fast …

 

Yes ma’am, actually your husband did pass away just before you arrived. I’m sorry that you had to learn this way, but we did try everything we possibly could …”

 

She didn’t seem to be listening though. I was thinking that maybe I should get her a chair or something. Was she going to pass out? Suddenly, the single most amazing thing I have ever seen in a dead patient’s room happened next.

 

The woman leaned over her husband’s face, looked at him directly and then asked out loud,

 

I wonder if he’s in Hell right now.”

 

Overwhelmed with relief that she wasn’t pissed at the lack of a proper introduction, and at the same time by my disbelief at what I had just witnessed, I blurted out anything I could to keep from laughing. “Ma’am, there seemed to have been some confusion over his medical directive. Did he in fact have one?”

 

The disbelief continued in her next statement.

 

You know, I have no idea. But if you woulda asked me, I woulda told ya to let the bastard die.”

 

Ok, what do you say to that? Before things got any stranger, I excused myself and told her that I would give her some time alone and that if she wanted anything to drink that the grieving tray was there for her – although in her case, I guess it may have been more appropriately called a party platter. As I stepped out, I silently wondered if she was going to slap him, spit on him or even worse, get out a knife and carve her initials into his chest.

 

Turns out, after some further research, that this man had been a wife-beater and a terrible father to his children. He had lived a life of hurting everyone in his family which explained the interesting reaction of his whole family to his death. For me though, it is a case I will never forget,

 

And by the way, the cookies were good.

 

 


My Brain Feels Numb

April 19, 2009

It’s 1:30am and I’m 15+ hrs into my Saturday shift (now Sunday) that was supposed to end 3+ hrs ago. My brain has started to have that numb, tingly feeling that I imagine precedes fainting or a narcoleptic sleep attack. If I put my head down now it will not come back up for a while I know, so I press on. Why? Because it’s a Saturday night and the hospital couldn’t get one of the attendings to work because there is a motorcycling event in town this weekend that usually brings in its fair share of casualties. So admin in their infinite wisdom filled the shift with a physiatrist or rehab medicine doctor. This is his first shift to top it all off as well.

So I know I will be here for a while. The moonlighting doc is a nice man, very capable and talented in his field I am certain, but ER medicine is not rehab medicine. I don’t blame him, because he was probably told that it would be an easy night and that he might even catch an hour or two of sleep. The wonderful lies and pipe dreams that admin types like to tell to lure people out. So, because I don’t want this poor guy to get sued and because I love my night nursing staff too much than to leave them in this mess, I will keep dragging myself around the ER until sleep overtakes me or things stabilize out to a safe point.

But I find it interesting in such circumstances how my brain begins to feel. Almost like someone injected it with lidocaine if that has ever happened. Coffee won’t help, Red Bull would probably give me a stroke at this point and I’ve already had so much sugar that I feel like a kid with a stomach ache from eating so much Halloween candy. I think I need a good code to get my second wind.


The Tabias Heal Advice Column

April 17, 2009

HelpOne of my initial hopes when starting this blog was to be able to provide a source of help and advice to those in need. Since we do live in a medico-legal minefield, I cannot do so without first having an agreement or disclaimer between myself and those who would like to ask questions or seek advice. You can find this lengthy disclaimer at the end of this post. But to make it simple, if you do write seeking advice (hopefully of a medical nature – not sure I can be as helpful with your car problems, Italian recipes, computer glitches or the fine art of Oragami), then I will answer you as a friend answers another friend and no more.

Since you will be writing to Tabias Heal, which is not my real name but instead a pen name or nom de plume (that just sounded cool – sorry), you of course understand that the advice does not take the place of asking your own doctor or seeking medical help at your hospital, local witch-doctor, exorcist, etc.

I hope though that this will in time become a searchable forum where we can try to help solve the world’s problems together one case at a time. Beneficial questions will be turned into blog posts for all to benefit from in the future. My contact info is at the bottom after the oh-so-fun disclaimer!

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Disclaimer (writing to me assumes that you have completely agreed to all aspects of this arrangement, yada yada yada … I will try my best to translate as much of this legal babble below for your convenience):

This advice column (the “Service”) is an online information and communications service provided by a totally awesome yet fictional character named Dr. Tabias Heal (“Provider”) subject to your agreement with all of the terms and conditions offered below. Please read this Agreement carefully before accessing or using the Service. By accessing or using the Service, you agree to be bound by all of the terms and conditions below, which are intended to be fully effective and binding upon the Provider and users. The Provider may modify this Agreement at any time, and such modifications shall be effective immediately upon posting the modified Agreement. You agree to review the Agreement periodically to be aware of such modifications and your accessing or using the Service constitutes your acceptance of the Agreement as it appears at the time of your access or use.[This means you need to frequently visit my blog 🙂]

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ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH PROVIDER (IN THE CASE YOUR PHYSICIAN IS A TOTAL GOOF) PRIOR TO STARTING ANY NEW TREATMENT OR WITH ANY QUESTIONS YOU MAY HAVE REGARDING A MEDICAL CONDITION, MEDICAL QUESTION, NEW EXERCISE REGIMEN, NEW DIET, STOCK PURCHASES OR ANYTHING ELSE THAT MIGHT EVEN REMOTELY AFFECT YOUR HEALTH. NOTHING CONTAINED IN THE SERVICE IS INTENDED TO BE FOR MEDICAL DIAGNOSIS OR TREATMENT OR TO SUBSTITUTE FOR YOUR RELATIONSHIP WITH YOUR MEDICAL CARE PROVIDER (EVEN IF HE ISN’T SO SMART).

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Healthy Snacking at Work

April 16, 2009
Call the Fire Dept for my mouth

Call 911! My tongue is on fire!

Scrubs aren’t just comfortable work clothes, but they help us hide that extra 10, 15, 20 lbs that we usually gain at work. Why? One of things that we have all noticed working in a chaotic and stressful Emergency Department, is how hard it can be to get enough time to eat.

As a result, we “graze” all day long and even worse on night shift as we look to calories, especially sugars, to keep us awake. Just about every ED I have worked at has the bottomless snack zone where all the wonderful, well-meaning doctors, nurses, secretaries, EMS personell, etc. bring us goodies and treats to help us get through the day. Had a tough patient? Here, these cookies will make you forget all about them. Who needs Percocet when you have such home-made delights?

When I noticed my own weight getting me to the tight stage on my large scrubs, I realized I had better do something about it before those 2X scrubs were looking inviting. Here are a few tips that I have picked up along the way that might help turn our snack zone into a healthy grazing area, and help us keep the weight off:

Dried Figs:  A delicious dehydrated fruit that’s high in fiber – you might get a little gassy, but hey, we’re all friends right?  “Figs will give you slow-burning energy to see you through a workout,” says Cynthia Sass, M.P.H., R.D., a spokeswoman for the American Dietetic Association. They also pack a lot of potassium, to help repair muscle.

Sunflower Seeds: With their shell, they keep our tongues busy with something other than high sugar candies. Also high in protein, at 5 grams per half cup, which helps us feel more full.

Shredded, unsweetened Coconut:  Also from the experts over at Men’s Health, although high in fat, more than 50% of its saturated-fat content is lauric acid. The American Journal of Clinical Nutrition reports that even though lauric acid raises LDL (bad) cholesterol, it boosts HDL (good) cholesterol even more. Overall, this means it decreases your risk of cardiovascular disease. Filling and won’t cause a spike in your blood sugar (followed by the dreaded crash and craving for more sugar).

Beef Jerky: High in protein, tasty and doesn’t affect your insulin. Avoid brands high in sodium content though by going with more organic, preservative-free options. Also, try to get ones that come from grass-fed battle, as studies show that, unlike grain-fed products, grass-fed beef contains the same healthy omega-3 fats found in fish.

ApplesApples have no fat, cholesterol or sodium, and contain small amounts of potassium, which may promote heart health, help maintain healthy blood pressure and a healthy weight. If you cut them and sprinkle some cinnamon on them, they taste even better and you get the added benefits of cinnamon!

Quick bowl of Cheerios and Light Milk:  Not enough time for a meal and need a quick energy burst that will satisfy the growling in your stomach? try this easy snack that has only 150 calories (skim ilk included), no cholesterol, 3grams of protein and loads of other good things. Fiber One brand cereals are lower in calories, but if you had the dried figs, you might need to use a space suit to contain your fumes.

Almonds: A personal favorite of mine. A health gold-mine that acts as a natural appetite suppressant, reduces bad cholesterol, regulates blood glucose and even has phyochemicals, that help prevent some types of cancer. All that and they taste great, especially now in flavors like Wasabi, Jalapeno and Vanilla!

What works for you? Let me know. I’m always on the lookout for a tasty and healthy way to keep my taste-buds busy and my stomach from overpowering me. Later, we will also look at food syou should avoid at all costs while at work, or anywhere else for that matter!