Friday, May 29, 2009

Why Are You Here If You're Not Going to Listen?

I'm really not sure why people come to the ER sometimes. They aren't going to listen to what we say. Stop smoking to help my COPD/shortness of breath/asthma/habit of getting pneumonia? No thank you. Quit drugs so I'm not found wandering in Walgreens in my boxers mumbling about how Barack Obama is the Antichrist come to get us all? I don't think that's what's wrong with me. Lose weight so my knees don't hurt? Well that can't be the cause of it!
One of the attendings told me a story about when he was a resident. A 300lb lady came in complaining of chronic back pain. And not just complaining. She spent most of their time talking together saying, "Well WHY do you think this happened to me? Why has God put this affliction on me? Why? WHY does my back hurt? What can I do?"

Now, how I would have handled that question is why I probably shouldn't work with the public. This doctor tried a little tact. "Well ma'am, as we age and start to gain a little weight..." "ARE YOU CALLING ME FAT?" Welp, there goes that. He tried to tell her he wasn't calling her fat per say (which she was--and how she didn't know it I have no idea), but she was done with him. She left with a harrumph! and wrote a letter to the hospital. When he explained himself to his ER director, the director said, "Well, you have a chance to respond." So he did. To the tune of "I didn't call you fat, but now that the cat's out of the bag, you're OBESE! And that's probably why your back hurts!"

Yesterday we had a gentleman in his 60's transferred here from another hospital. He went there complaining of odd chest pain. When I went in to see him, I saw a ruddy, solid looking guy in a hospital gown and cowboy boots already fussing and complaining about all the things we'd done to him, how he shouldn't have come in, how he was fine now and the pain didn't feel like a heart attack. Here's the funny thing: he had a scar along the entire length of his sternum. What was that from? Oh, just his quadruple bypass a few years ago. Yeah, you're not having a heart attack sir. I tried to explain how this probably wouldn't feel the same because his surgery cut through nerves and altered his pain sensation. We tried to explain how the fact that he did manual labor everyday doesn't replace a stress test, especially because his chest started to hurt while he was doing said manual labor...you don't have to have a medical education to put that together. We tried to talk to him about how we only wanted him to stay one night so they could check his enzymes and have him see a cardiologist.

But it was no use. Two hours later we got called to his room because he was ripping out his IV lines and preparing to leave Against Medical Advice. I can't think of any other word to describe what I felt when I looked at him stubbornly refuting everything we tried to tell him except revulsion. "Well what's all this bullshit! I don't see why I have to be here! I've already sat here for an hour and a half! (btw you have to wait to take serial cardiac enzyme assays-we weren't just holding him) I don't think anything's wrong with me! I'm just gonna go back to work." I wanted to light into him for being so stupid. I resented every word out of his mouth. My attending pulled out every reason and logical explanation for why we wanted him to stay. He seemed like he was going to agree, then he just said, "Well, I think I'm just going to go. I'll take my chances." I wanted to say, "fine, get the hell out of my ER, you old fool. Next time it's gonna kill you."

You might say, "Al, it's his choice, why are you so mad?" If he were to leave and never come back, that's one thing. But what "take my chances" really means is "I'll go back to my habits, do the same thing, and then when this happens again I'll either get scared and come back or I'll be dead before I have a chance to get here." People come into the ER scared to death and desperate for help, but they leave exactly the same person they were before. Talking to people about changing the very things that are killing them is a frustrating effort in futility most of the time. The Mom-Dad-daughter combo in room 11 who each have their own oxygen tanks will probably still populate the smoking section of Denny's. The woman with a wall of mesh surgically placed in her stomach will still work at her heavy-lifting job, smoke, and weigh too much. My attending says it means job security, but I think it means a lot of emergency medicine is hand-holding and stabilizing for people who are intent on eventually killing themselves.

Saturday, May 23, 2009

When I coughed, my bottom exploded!

More tales from a male doc:

One day a lady is nearly two hours late for her clinic appointment. She had driven a long way, so my attending decided to squeeze her in the schedule.

The first thing you ask a patient is, "Why are you here?" (It's called the Chief Complaint on every form we have to fill out later).

"I coughed at work and something popped down there." What? You coughed and your butt exploded. Hmm....what in the name of episiotomy is the differential diagnosis for that?

Welp, time to take a look. I think maybe there was a little more history of swelling or discomfort, but in the end you're going to have to check it out anyway so you might as well get to it. Plus I'm sure his curiosity was running rampant by this point.

When he gets a look, a wrinkly discolored mass is pushing out where her perineum (there are a few other names for it, go to Urban Dictionary and poke around a bit.) used to be. It was a shock. Imagine going in thinking you'd see just normal skin and you see this.

To make a long story interesting, she had vulvar cancer. This cancer had been growing for a while, probably helping itself to her tissue, making a bulge and hurting and making look very ungracefull when she sat down. Then one day, she coughed, and her old episiotomy scar just gave up. KER-PLOP!

Ladies, please go to the doctor before this happens to you.

Thursday, May 21, 2009

Cancer stinks. Literally

I keep getting comments about a previous link I posted. I will give warnings, but come on! The first sentence of that blog was "What's the most disgusting thing you've ever seen?" In the future I will try to find more representations rather than real images, you bunch of pansies. My Sesame Street reference apparently got the point across without grossing my dad out.

My attending told a few great stories from his experiences in clinic. Apparently, if you're a male OB/Gyn, you're a little hard up for steady business.

HA! I just realized how funny that last sentence was.

In all seriousness, while 50% of the urology resident population is now female (and guys don't seem to have a problem with it yet), many male OB/Gyns have two flavors of patients: Multiparous (had babies) patients who are new to town and no longer care who's poking around down there, and train wrecks who need to be seen right now and can't wait for an appointment at the highly sought after female OB/Gyn. I think all-female practices who advertise really chafe his chaps. It all makes for a fewer patients, but more drama as far as I can tell. Examples:

One lady came in completely incontinent of urine. Dribbled like an pervert at Hooters. I think this had been going on for months. Yes, months. And she wasn't old enough for that. Now I'll admit I thought about wearing a Depends during surgery just so I wouldn't be the first to break scrub, but she wears them all the time!

Obviously this lady needed a pelvic exam. You leave the room, the patient undresses, you come back and they have a sheet covering all sorts of possibilities. You never know what you're going to find when you get in under there. I just hope I remember to mouth breathe and keep a poker face. WhOOooaaHH!


Open Wide!

When he walked back in after the patient undressed, he said he could smell cancer. Yes, it smells. Like acrid, rotting flesh apparently. So he takes a look with the speculum, he said he could see all the way up into her bladder. Some flavor of cancer had eaten through her apparatus and destroyed her urethra. As soon as some urine got in her bladder, out it went.

This lady didn't go see a doctor because of fear, or lack of funds, or flat out denial. Now her bladder dumps into her vagina. And that's probably not the biggest problem she has.

Tuesday, May 19, 2009

A Wild Day in Resident's Clinic

Around here, the resident's clinic is obviously the stepchild of the OB clinic. The attendings take all the insured, usually married, intentionally pregnant patients for themselves. Which leaves a wild and varied patient population for the residents...like the teenager who came in with her 1 month old wearing a black tank top that read, "Make Sex Not War." I can see you live your philosophy. Good for you kid. Since that worked out so well for you, what are your plans for the future?

In the attending clinic, they have cool little doppler machines that calculate the heartrate for you. In the resident's clinic, you have to bring a watch and count. I have a clock on my cell phone and pager, so of course I never have a watch.

Yesterday I worked with a resident in clinic. Our patients ranged in ages from 17 to 31. I always feel a little past my ovarian expiration date when I see the majority of our patients are several years younger than me. Sometimes the teenagers are mature, sometimes they come in with their little attitudes. Lucky for them, I'm with a resident and can't say, "I'd like to see your 'tude when your kid doesn't give a crap if the world goes your way or not." She wanted an ultrasound and apparently Mom came all the way from East Jesus Out of State to see it. Curious...not sure where mom was when the kid got pregnant...

It also cracked me up that this one did NOT want a male doctor to work on her. For modesty I guess. You're not fooling anybody kid. I know how babies are made.

When I put the machine on her to listen to the heart rate, she started crying. So did Mom and Grandma. The boyfriend just kind of stood there looking around. I'm not sure if they were crying for happiness or despair. My resident just said, "Now it's real, huh?" Which could be taken either way I think--nicely put.

Another wanted us to sign her short term disability papers because she couldn't work. She's not really disabled, her current assignment is just uncomfortable. Varicose veins? Wear support stockings. Have you been wearing them? No? Why? You have a prescription, they are covered under Medicaid. The one pharmacy you tried said no? You can try another. Yes, really. Your veins are just superficial. You are going to be fine. I don't know what to tell her; it's not like we can mind meld the ability to problem-solve. And it gets old spoon feeding people who don't really want to work in the first place.

A third needed signatures for her immigration papers. This was her second baby in a year and I'm pretty sure was married to someone over twice her age--though he was nowhere to be found. She was actually the most pulled together of all of them; she had all her paperwork and a checklist of questions to ask.

I don't know how doctors deal with all the paperwork thrown at them. Each patient expects the doctor to have all their paperwork, know exactly what to do to get them what they want, and oh yeah, be willing to spend their precious time doing it all for them. I feel like a social worker sometimes.

Sunday, May 17, 2009

An addendum

I have gotten a few comments about the link in my previous blog. It is not made for sensitive eyes. Here is better representation without the gore. Image courtesy of science-facts.com

Tuesday, May 12, 2009

HPV-At your cervix

While we were in the car tonight, my sister said, "Al, what's the grossest thing you've seen on OB?" "In strictly Labor and Delivery or in all of vagina-land?" I asked. "All of it" my sisters said in unison.

I only had to think for a minute, then "CONDYLOMA! Easily the most disturbing thing I've ever seen."

Now, condyloma is another name for the little fleshy genital warts one gets with certain strains of HPV (6 and 11). But these were no mere warts. They were huge! I said, HUGE! When they get really big, condyloma look like big fleshy, warty, bumpy, friable sheets of gross hanging off all the architecture down there. This particular patient I'm thinking of had condyloma the width of half my hand strung all around there like crepe paper at a junior high dance.

"How could anyone let it get that BIG?" one sister asked. That is a very good question. I don't know how this woman sat down. Unfortunately, she probably had them for a while, then she got pregnant. Pregnancy is something of an immunocompromised state, seeing as you wouldn't want Mom to mount a constant underlying attack on her own child. Nope, that's better saved until later in the kid's life, like when she wants grandkids but unfortunately the kid decided to go to school during the best years of her ovaries.

Anyhoo, when the defenses are down, the condyloma can get a little out of hand. Or a $@%-ton out of hand for this woman. After pregnancy, the warts decrease in size, but usually the woman wants them gone yesterday. So we go back to the OR after a couple months of letting them die down.

"You have to go to the OR?" Yes, we do if they're big enough. And boy-howdy were these big enough. We use electrocautery (BZZZzzzzZZ!) and a laser to finish them off. But not before we take pictures. Woof. Here's a representative pic I found on the internet. It's a little sensitive, and copywritten, so I'm just sending you to their site.

Btw the Gardasil vaccine prevents serotypes 6 and 11.

Sunday, May 3, 2009

God has a sense of humor.

After I posted that, actually as I hit the "Post" button, a nurse came in saying, "42 is dilated to 5 cm!"

That woman had come in maybe one or two hours early without any hint of labor. And she was nulliparous, meaning this was her first baby. That usually takes a while. "Crap," I thought, "now I'm never going to bed. We still didn't expect her to have the baby for hours, but if she managed to expand her cervix to 5 cm that quickly, who knew what other tricks she had up her....sleeve.

Forty five minutes later she was dilated to 8 1/2. Now that is just ridiculous. The nurse told her, "When you have babies, you mean business!" "I guess?!" She wailed.

Just as we were finished delivering and were sewing her back up (ugh), a sound comes over the room's intercom: "We got a lady in labor coming in an ambulance!" Uh oh. If someone comes to the hospital in an ambulance they're either an overexcited idiot or they're about to pop. (Btw we told the first lady that if she ever feels a contraction again, call an ambulance) She hit the floor just as we were done in that room. I didn't even have time to put on my sterile gloves, we were short on nurses so I helped coach her and count her pushing with her.

Just after THAT lady delivered a nurse ran in the room, "Some lady just drove herself in and she's dilated to nine cm!"

We left the second mess to the nurses and took off for the next room. This lady had also had three babies-this was not going to take long. Did I mention none of these women got epidurals? They went too fast for the anesthesiologist to get there. AAAUUUUUUGGGGHHHHH!!!

As this lady was screaming that she couldn't (and I didn't blame her for saying it), we quickly tried to get in our sterile stuff before the kid came out. We were all ready, she was pushing hard, tension was building, the head kept sticking farther and farther out....then POP! This kid came flying out like a pop fly at a Cardinals game. They say you "catch" the baby, but really that's what happened. I was just glad the intern caught the slippery thing! The grandma pointed at me and said, "You should have SEEN the look on your face!" Well yeah, that was fear of brain damage and a lawsuit. I tried to find a picture that would do the moment justice, this is the best one to describe it.


In the span of about an hour and a half, ending at 6:54 am (my shift ended at 7am), we delivered three babies. It was the wildest night I've ever had in the hospital.

Saturday, May 2, 2009

I'm going to give you something to cry about.

The next pregnant lady who comes in to triage complaining of nothing except being pregnant is going to get spat on. I could have been sleeping hours ago.

Friday, May 1, 2009

Just when you thought I'd gone to bed...

Though the posts ended at 2:30, my night certainly did not. I just couldn't get to a computer to blog.

2:48: I had taken a twenty-minute nap when my pager went off. At least I didn't sleep through it like I did on surgery. I didn't bother answering it, I just went downstairs to Labor and Delivery just in time to put on a gown and gloves while another alien was pushed out into the world. I definitely felt woozy.

3:07: Baby borned, still exciting, still gross. Dad was very very pale, even though he kept his ball cap low so he wouldn't see his wife's lady parts split, he accidentally saw and nearly passed out.

3:48: Finally done sewing and cleaning things up. I am in no mood to mess with the placenta. G-ross.

4:00: This is just F@#$%ING AWFUL!

4:15: Unit Clerk is giving back massages around the swamp. No Gracias, Unit Clerk. Keep your roving hands to yourself, I don't want to catch Ignorant.

4:30: I throw in towel and just ask if anything else is going on. Then I go back up to the fifth floor, down the dark long hallway that gets scarier the later it gets and collapse in the call bed.

5:55: BAAAAHHH my alarm is going off. I have to get up, round on patients, write a couple notes, and try to keep my mouth shut.

7:00: No luck. When the team talks about a lady who says she got Trichomonas because her boyfriend used an old tongue ring that had made the rounds to pierce his...ahem, I'm not sure I buy it. "That's like saying you caught gonorrhea from a tractor. Can that even happen?" I blurted out.

7:15: The attending on call talks about another woman with condyloma all-ovah. "We tried to get the medical student to do cervical checks, but she refused." "You're dang right, I'm just the medical student. I'm not going to go in there and get nubbins all over my hand for my trouble. Oh God, just let me go to bed."

8:14: Finally home!

More ramblings

The unit clerk came in fussing about someone not doing a chart right. "Blah blah blah She sucks!" to which I belligerently replied "You suck." Oh no. That was something I should have said inside my head.

This is the same unit clerk who last night said we should bomb Mexico and can't eat bacon anymore b/c of swine flu. Then we should bomb Africa he said. "Yeah, because that worked really well in the Middle East." I responded. So I didn't figure I would bother to explain myself tonight.

Can't. Focus. Any. More.

I think I'm supposed to be doing something useful...

But I just can't bring myself to do it.

Some nurse is telling a disgusting story. And instead of appreciating it, I want to throw up the scalloped potatoes the night chef so kindly gave to me.

Maybe staying up late just makes me want to vomit in general.

Night Shift Blog

I am sitting at a computer while on Labor and Delivery Night Float, so I thought it was a great time to give my dear readers a glance into my mind at night. Mind you, this is day two on night float, I barely sleep during the day, and I lose my mind at night.

I was standing up in a room about an hour ago and realized I was sliding sideways on the wall, I suppose at the beginning of passing out. But I caught myself. I don't think anyone saw.

There was a room service menu for the moms out in the hallway. It's title was "At Your Service". I put a piece of tape over the last word so it read "At Your Cervix", but later realized that was probably the sleep deprivation saying what a good idea it was, so I took it off.

I saw my first vaginal delivery tonight. I felt like crying and throwing up. I can't even watch A Baby Story on TLC without crying, so the real experience was much more emotional. I had to pull it together before I hyperventilated and snotted on myself.

Babies are Nas-Tay when they come out. We have a hippie couple on the floor who don't want their baby cleaned AT ALL when it gets borned. I'm pretty sure they're a. stupid and b. ignorant of what a baby looks like when it gets squeezed out of a va-jay-jay.

If you haven't seen it yourself, it looks whitish-purple and is completely covered with cheesy-looking white crap. By it I mean the baby. I suppose that's insensitive.

What the hell is with natural childbirth anyway? My mom did it three times, but she's German, so I don't think those standards apply to me.

Placentas are possibly the most disgusting thing I've ever seen, not counting the time I threw up putting that Foley catheter in. And it's my job to handle them. You're supposed to measure and what-not, but as the intern said, "Either they're going to get destroyed or go to pathology, so why would you ever take the thing out of its bucket?" Nobody's watching, so I just do a little guestimate work with the tape measure to make sure it's not outrageous abnormal. Also, they smell like bait.

Sorry, that was gross.

Toot-te-la-fruit,
Your Pal Al