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Author Archives: WhiteCoat

Redefining the Pain Scale

The smiley faces just don’t seem to cut it any more. The Wong Baker pain scale was originally created for children. Now it is used by medical providers to precisely gauge pain in adults all over the United States because of the concept pushed on medical providers that “Pain is the Fifth Vital Sign.” Although this phrase was originally created by the Department of Veterans Affairs, The Joint Commission adopted it and ran with it, rolling out Pain Management Standards declaring in 2000 that “the pain management paradigm is about to shift,” that pain control was a “patient rights issue” and that providers would be required to measure pain on a 1-10 scale. See JAMA article here. PDF here. Skeptical Scalpel weighed in on the “Pain as a Fifth Vital Sign” issue in 2013. Of course now that the US is in the throes of an opiate epidemic because of the Joint Commission’s actions, the Joint Commission walked back its demands, stating that it only required providers to measure pain, not to use drugs and that it didn’t require the patient’s pain scale to reach “zero.” Then it put out a propaganda bulletin (.pdf) describing “Myths About The Joint Commission pain standards” … but that’s fodder for another post. So when I get to the whole pain rating thing and someone says his or her pain is a “10” while simultaneously munching on Cheetos and playing Flappy Bird on his or her TracFone, I have cause for concern. Either the patient is dissociated from reality, has some ulterior motive for overestimating his or her pain, or the patient doesn’t understand the pain scale. No matter how many times you shove the smiley faces in front of the patient’s smiley face, the patient just doesn’t get it. So sometimes I call them out. “Consider ’10’ as pain that is so bad that you are rolling around on the floor in agony and asking for someone to put you out of your misery.” [flap flap flap] “Oh, yeah,” [crunch chew chew chew] “it’s definitely a TEN” “Oh, but my unfortunate patient in distress, you’re not rolling around on the floor.” [Looking up from the screen momentarily] “OK, then it’s a 9 and a half” Brilliant. If only everyone could be so mathematically adept. There have been many memorable attempts to describe the pain scale. Brian Regan described his experiences trying to outmoan the patient in the next room, then discusses how he decided to describe his pain scale to the nurse. If you’re at work, don’t drink coffee while watching. If you’re at home, pop a beer and fire up the link. It’s worth 8 minutes of your time. Then there’s xkcd’s take on the pain scale – which piggybacks off of Brian Regan’s stand up routine. How would you rate your pain if 10 is the worst pain you could imagine … ? Allie from Hyperbole and a Half did an admirable job of it when she took her boyfriend to the hospital for vomiting Crasins and needing to be checked for Ebola. You really need to read that post for some good chuckles. So then I happened to come across an Improved Pain Scale picture on Reddit that does a reasonably good job at describing pain. View post on imgur.com Personally, I still like the Hyperbole and a Half scale better, but this Reddit one isn’t bad. And before someone out there tries to call me out for all of the links being in the Reddit post, the only one that I hadn’t seen before was the xkcd scale. I’ve passed around the links ...

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Time To Retire Revisited

Remember the doc from “Time to Retire“? Had a few amusing stories from patients about some of the statements he made while working in the emergency department. Since that post, I became friends with one of the people working in his emergency department. I keep trying to get that person to start a blog … to no avail. Here are a couple of more stories from reported patient encounters. A sick kid comes in. I started an IV. Kid is in and out of consciousness. Doc says “let’s tube him.” The mom is freaking out. I grab the resuscitation bag and hand the doc the Broselow tape. He gives me a blank stare and yells at me. “What the hell is this?” Mom and dad look at him then give me a look of terror. Doc says he’s never heard of a Broselow tape. Fortunately, the rest of the visit went smoothly and the kid was transferred to the peds hospital across town fairly shortly afterwards. I see a patient and then mention to the doc, “Hey just wanted to know that the guy in Room 2 has a glass eye on the left.” Doc says “He isn’t here for a problem with his eye.” I say “I know, I just didn’t want you to look bad by putting ‘PERRLA‘ in your dictation when one eye doesn’t work.” Doc says “What the f*** is the matter with you? I’m not even looking at his eyes. The guy is here for a problem with his leg. Stop worrying about my dictations. ” After the patient was discharged, I look at the dictation. What shows up? You guessed it: PERRLA.

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Antibiotic Apocalypse

The beginning of the antibiotic apocalypse may be nigh. Woman dies from the ultimate superbug – carbapenem-resistant Enterobacteriaceae (CRE) with New Delhi metallo-beta-lactamase (NDM). The bacterium is resistant to 26 different antibiotics. There were no antibiotics left to treat the infection – it was resistant to everything. Word on the street was that she was taking a Z-Pack for her cold before she got sick. Kidding about the Z-Pak thing, but this is no laughing matter. I thought it before and I still think it now – antibiotics should be treated like Norco and other controlled substances. Tracked. Patients who take too many of them should require special paperwork before they can fill prescriptions. All these unnecessary prescriptions for coughs and colds are just making the bugs stronger. We’re doing this to ourselves. Then again, scientists just announced that they have discovered a molecule that reverses antibiotic resistance in multiple strains of bacteria at once. The bad news is that some jerkoff investor will probably purchase the patent, jack the price for the molecule to about $17,000 per dose and will make sure that the molecule won’t be covered under Obamacare or any other insurance plans. The molecule is called a peptide-conjugated phosphorodiamidate morpholino oligomer or PPMO and works to disable the NDM-1 found in the most resistant bacteria. Powerful weapon to beat resistant organisms, but if we don’t change our prescribing habits and demands for antibiotics, it’s only a matter of time before the bugs learn how to beat the PPMO in this high-stakes game of cat and mouse. Is a post-antibiotic world approaching? This NY Times article again notes how the number of effective antibiotics in our arsenals is diminishing and that there isn’t much of an incentive for pharmaceutical companies to produce new antibiotics. The article states that Medicare has moved to require hospitals and nursing homes to adopt plans to prevent the spread of drug-resistant infections and to assure the proper use of antibiotics However, note that under the “Hospital Compare” program – created by the same government that wants to “assure the proper use of antibiotics” – hospitals are deemed substandard if they don’t throw strong antibiotics at every pneumonia within six hours of a patient’s presentation to the emergency department. Have those policies decreased pneumonia deaths since they were initiated? According to CDC data (.pdf file), deaths from influenza and pneumonia decreased from 18.4 per 100,000 population in 2006 to 15.1 per 100,000 population in 2014 – an 18% decrease (see page 37). During that same timeframe, the rate of death from all causes decreased from 791 per 100,000 to 724 per 100,000 – a 9% decrease (see page 35). I picked the cutoff date of 2006 because the Hospital Compare website started comparing hospitals in 2005. There are multiple confounding variables such as inability to separate influenza (viral-related and unaffected by antibiotics) from bacterial pneumonia that would be affected by antibiotics, the fact that pneumonia is a subjective diagnosis in many cases (was it pneumonia, CHF, or chronic interstitial changes?), that many deaths have more than one cause, and that financial incentives may make it more likely that pneumonias are underreported (readmissions for same diseases may not be paid by Medicare). Draw your own conclusions. A somewhat dated article, but one that shows the potential seriousness of a world in which we don’t have readily available effective antibiotics. In Venezuela, the imploding/imploded economy has made antibiotics largely unavailable and turned simple injuries such as a scraped knee into major health threats. One more infection-related article for the day. If you want to be ahead of the curve at medical dinner parties, learn ...

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The Aspirin Technique to Stop Pregnancy

I’m going to preface this post by saying that it isn’t for the faint of heart. You’ve been warned. We’ve all seen them. After a while they become emotionally frustrating. Some patients would rather spend several hours waiting in an emergency department waiting room rather than going to the Dollar Store and buying a test to see if they’re pregnant. No, the hospital tests aren’t more accurate. For all I know the hospitals get them from the same supplier as the Dollar Store. You don’t need to recheck … oh nevermind. Just get five of them. You know that no matter what the test says, if you think you may be pregnant, you’re going to check it over and over again to make sure one way or another. Just buy a handful and be done with it. I’m happy when people are excited about being pregnant, but it gets frustrating when people don’t want to be pregnant and at the same time don’t take any precautions to try to prevent themselves from getting pregnant. Which leads me to my little story… One of said potentially pregnant patients came in for her usual pregnancy test. Her name popping up on the board caused a few people to shake their heads. “C’mon. She was just here like six weeks ago.” “She needs to get a prescription for some birth control.””Or she can just use the aspirin technique.” Suddenly there was a gasp from behind the nurses’ station. One of the older secretaries was coming in for her shift. She was walking behind everyone and had apparently heard the tail end of the conversation. She stood there shocked. This was a four-pack-a-day smoker with a raspy voice who took pride in making others blush with her “colorful” language. Most of the time her breakroom talk could make a truck driver lean back and raise his eyebrows. Yet this time, it was her increasingly reddening face that formed a stark contrast to her white hospital jacket. “What? You know? The aspirin technique? Put an aspirin between your knees and keep it there while you’re having sex to keep from getting pregnant?” She heaved a sigh of relief and smirked. “Oh Hells bells. I thought you said the a**hole technique. Then I’m standing here thinking that you’re all a bunch of sick sons of bitches.” Which made everyone crack up. As she was walking away, she added “Although either way would probably work just as well. Baaaahahaha.” And with that comment the staff decided to skip lunch that afternoon. Got us again. Remember, I *did* warn you … ———————– This and all posts about patients may be fictional, may be my experiences, may be submitted by readers for publication here, or may be any combination of the above. Factual statements may or may not be accurate. If you would like to have a patient story published on Dr.WhiteCoat.com, please e-mail me.

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Random Thoughts – Dragonisms, “They,” and Lemonbreasts

Dragon NaturallySpeaking is both good and bad for medical charting. On one hand it gives you real-time chart entries without having to spend an inordinate amount of typing. On the other hand, it is an imperfect science, leading to voice recognition errors I’ve dubbed “#Dragonisms”. A couple of the latest are as follows A guy was beaten up at a bar. He has injury to both feet when the assailant stomped on both of his feet. I dictate “no injury to patient’s knees.” Dragon spits out “no injury to patient’s niece.” True (at least I think). Wouldn’t it be ironic if the patient’s niece was involved in the bar fight. I dictate that a patient with abdominal pain has a history of “ovarian cysts.” Dragon somehow comes up with the patient having a history of “a brain systole.” Maybe a new way of describing seizures? *** We’re getting lots of referrals for emergency department evaluations from “They” lately. It used to be the evil “Sumdood” – as in “Sumdood just whacked me on the side of the head with a shovel” … which then led to a bunch of additional questions about why someone not singing “Hi Ho, Hi Ho” would be walking down a city street carrying a shovel over his shoulder to begin with, but that’s beside the point. Now it’s more of a vague group of people who are prompting emergency department visits all over the country. “They” said I look dehydrated. “They” said I have an abscess. “They” said this vomiting may be my appendix. Who are these mysterious medical advice savants? Who knows? When asked who “They” are, the patients respond with statements like “people” (meaning that they must be doing random polling on the streets alongside of the people asking whether Trump sucks), “my doctor’s office” (technically personifying a building, and, in addition when the people inside the building are called, they often disavow making any such statements to the patient), and then there’s “my Auntie” (which brings forth vivid pictures of a little old lady knitting a scarf while rocking in a rocking chair, hawking spittle into a spittoon and saying “your second cousin nearly died of appendicitis and all he had was vomiting – you should get that checked”). *** Came across a neat web site for women. Shows many different presentations of breast cancer by comparing boobs to lemons. Check it out. https://www.worldwidebreastcancer.org/ *** Oh. I’m going through my Medical Blog Links. Wow have a lot of blogs bit the dust in the past couple of years. If there are any medical blogs that you read which should be on the list, drop me an e-mail or leave them in the comment section. I’ll try to add them soon. Thanks!

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Happy Marriages, Rainbows, Yin and Yang

“She’s a peach,” the nurse quipped as I clicked the link assigning the new patient to my list. “A positive review of systems … if you know what I mean,” she winked. I like getting a head’s up about patients before I go to see them, but sometimes advance notice of a difficult patient gives me anxiety. I took a deep breath and put on a big smile as I pulled back the curtain. “Hi, I’m Dr. WhiteCoat. What brings you here today.” “Didn’t you read the chart? I’m not explaining it again.” “I did read your chart, but it looks like you have a lot of things going on, so I’m going to have to get some more information from you about all of them.” She rolled her eyes, sighed loudly, and gave me a brief end-expiratory “You’ve got to be kidding me.” I listened and took notes as the patient described her chest pain, her chronic dyspnea, the dry socket she had when her wisdom tooth was pulled 6 months ago, and how a tingling sensation sometimes begins in the fingers of one hand, runs up her neck, down her back and into her leg like someone is “ripping the nerves out of her body one at a time.” My “kill them with kindness” tactic seemed to be working … at first. But the more I asked questions about her eight different complaints, the more that the patient became impatient. Finally, she snapped. “You ask too many questions. THIS is why people hate coming to the emergency department.” “Well, I need to find out more about what is bothering you so I can try to figure out how to fix the problems.” “YOU’RE the problem and YOU’RE bothering me. Why don’t you just run some tests?” “But learning more about your problems helps me figure out what test need to be run, though.” “You don’t listen very well, do you?” By this time, I was getting frustrated. “Ma’am …,” I started, but she cut me off. “I bet your wife LOVES it when you leave for work in the morning.” Ooooh. Eeee. Oww. Oww. Poke me with those pointed barbs. I was going to be a smart ass and tell her that I work nights, too, but my inner peace took over and I bit my tongue. “Tell you what. Why don’t I … order some tests … to see if we can get to the bottom of all of these problems you’re having.” Then I left the room. About 15 minutes later, the nurse hunted me down and told me that the patient had pulled off her EKG leads and walked out of the emergency department while yelling at someone on her cell phone. One of the other doctors at the nursing station smiled and shook his head. I briefly explained what had happened. “That’s nothing. Yesterday, I had a lady tell me that men like me were the reason she became a lesbian.” We both got a good laugh out of that one. Later that day, though, I had a patient and her family ask me if I had an office where they could see me as patients outside of the emergency department. Ahhhh. That’s better. The yin and yang of my day has now been re-equilibrated.

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