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Author Archives: Birdstrike

Got A Light?

By Birdstrike MD I walk into the ED for the 7:00am shift.  I’m 24 hours post-night shift so my body thinks it’s 3:00am and my brain feels like it’s been embalmed for 3 days.  I take my last swig of triple dark-roast Starbucks and sign up for my first patient. Chief complaint: “Lost light” Is that a misprint?  Maybe it’ll be a quick and easy one to start the day, I think to myself.  That’s just what I need, so my coffee will have some time to kick in.  I’ll just send this guy off the Lowe’s or Home Depot, I laugh to myself, so he can get a new light.  I walk into room 13 and there’s a man laying in a fetal position on a stretcher, with the bed sheet over his head.  I walk up to the side of the bed and say, “Hello sir, I’m Dr. Bird, what can I help you with today?” “Well, doc, I’m in a bad spot.  I was holding on to a light bulb, and it just popped right in,” he says with a whimper, avoiding eye contact.  Looking at his face, I notice he is as white as the bed sheet.  He’s pale and looks like death. “What are you talking about?” I ask him. “Lift up the bed sheet,” he says, looking behind himself. I lift the bed sheet and he is lying in a pool of blood.  The back of his gown is soaked.  I glance up at the blood pressure monitor and the automatic cuff had just rechecked his blood pressure: 88/58.  “Sir, are you having rectal bleeding?” I ask. “I guess you could say that.  The light bulb just popped right in,” he says again. “What?  Oh…I get it.  You mean…you, put it up your rectum?” I ask, now knowing exactly what happened.  For an ER doctor, things like this are not shocking.  In fact, they are part of the portrait painted for us every day; the bell curve of the ER doctor’s experience. “And it popped!” Ouch, I think to myself.  O U C H !  “It broke?” “It exploded in there,” he cries.   2 IVs, bang! Fluid bags hang. Time to call the OR gang. KUB ordered, Let’s see the x-ray. “Am I dying, Doc? Is this my last day?”   There it is on the x-ray: one homicidal light bulb clearly visible inside one rectum cut to ribbons, with its countless shattered glass shards, doing their best to bleed the life out of a man. “Am I gonna make it doc?” he asks me again. “You’re going to make it,” I answer.  “You got yourself here quickly.  If you had waited any longer, you might not have.” “Doc, can you please tell my wife…” “Wife?” I interrupt, surprised. “And my kids…” “Kids?” I ask. “Yes, doc, we’re here on vacation.  It’s our first family trip to Disneyland.  You wouldn’t understand,” he says, as he pulls the bed sheet over his head, as if to crawl under a rock to hide and never come out. Just then the OR team barges in the room commanding, “We’re ready for him.  Let’s go!” “What do you want me to tell your wife?” I ask him. “Doc, please, a hemorrhoid.  Just tell her it’s a little hemorrhoid.”   ………………………………………………………………………………………………………………………………………. This author does not divulge protected patient information or information from real life court cases. Any post that appears to resemble a real patient, real person, real co-workers or trial can only be by coincidence. This author does not post, has not posted and will not post factual identifying information ...

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Why Patient “Satisfaction” Could Be Making You Sick

By  Birdstrike MD All patients should be treated with professionalism and respect.  We all want our patients leaving our care happy, healthy and satisfied, if at all possible.  However, sometimes patients don’t leave an Emergency Department very happy or satisfied.  Sometimes the doctor could have prevented it, but many if not most times, such dissatisfaction has little if anything to do with what the treating physician did, or didn’t do.  The reasons for a patient being dissatisfied with a particular healthcare encounter can be very complex.  It’s not so simple as to just include a line in a survey such as, “Were you satisfied with your doctor?”  Who should be held responsible for the results of these surveys, is where the crux of this debate lies. So why are Hospitals obsessed with “patient satisfaction”? It’s the same reason Walmart puts greeters at the front door (the ED), not the back door (in-patient floors) and the same reason the Government collects taxes and not sea shells: Money.  The question we really need to be asking is: Why is the obsession with patient satisfaction in the ED so soul-crushing to those that work there?  1-Lack of Control A patient pulls into the ED parking lot.  The lot is full.  He doesn’t feel well, he’s in a hurry and having to search for a parking spot irritates him.  The wait to see a doctor is long, too long.  Once finally in his room, he sees a drop of blood on the floor from the previous patient.  He’s disgusted.  Despite great care by the doctor, it biases his overall view of the experience.  As much as he tries to remain objective, the patient satisfaction score suffers.  The patient gives a “1 star out of 5” review after discharge, but writes in the comments, “Doctor and nurse were great, though!”  The tabulated score remains 1/5, or “FAIL.”  The doctor gets pulled aside at her next group meeting and is told she’s on watch due to low scores.  She’s never been fired from a job in her life, but now her job is in jeopardy, over something which she has no control. A patient leaves an ED satisfied.  He gets a patient satisfaction survey and throws it aside.  He has no need for it.  The visit went great.  It’s his preferred hospital for anytime he gets in a bar fight and needs to be sewed up.  He got in, got his knuckles stitched, and got a free Sierra mist and a meal tray.  On his way out the door, he tweets, “#CityGeneralERrocks!” on his smart phone to the world’s prospective ER “customers.”  Six weeks later, all has healed well, and there’s barely a scar.  Then, the bill comes.  “!&@!?#€!!!,” he thinks.  “$920?  Screw that place!”  He grabs the survey and nukes the hospital, doctor and nurse all with the lowest score possible.  He writes in the comments, “I would have rated you a ‘negative infinity’ if the scale went that low!” You can save a life, walk out of the trauma bay drained but proud, and be pulled aside and told that on last months survey, you didn’t get a patient a coffee “like they do at the car dealership.”  You are told, “Get those scores up.  Administration is watching.”  It translates into, “You suck.”  It’s not that big of a deal, right?  Maybe you should brush it off, but you are human.  You haven’t “evolved” to the “new way” yet.  You’ve heard of ER doctors losing their group contracts and therefore their jobs over things like this.  It bothers you. There’s a complete and utter ...

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A Case That Really Bugged Me

By Birdstrike M.D. “Here I am Well, I guess it’s no surprise Up to my knees in water Up to my ears in dragonflies”  -Gov’t Mule  I open my car door to walk in to work. I’ve never heard crickets as loud as the ones this summer in Georgia. A wall of steam-heat blasts me simultaneously as a giant BZZZ! BZZZ! dive-bombs my ear. Man, it’s hot in Georgia. And the bugs! I think to myself. I walk slowly towards the ED doors, barely moving, but still breaking a sweat. I walk through the double doors now enveloped by my refrigerated workplace. I pick up my first patient, tagged non-urgent: “6-year-old girl. Legs paralyzed.” That’s weird, I think to myself. Paralyzed? Non-urgent? Not a trauma? I walk in the room and there is a 6-year-old girl, sitting on the stretcher smiling, unconcerned. Her dad looks only slightly more concerned. “I can’t move my legs,” says the girl. “I was fine this morning, then after lunch, my legs started getting weak.” “Has she had any other symptoms like fever, headache, or weakness in the arms? How about, double vision? Rash, trouble swallowing, abdominal pain?” I ask. “No,” she says, with the infectious smile of a 6-year-old, as her dad also shakes his head in agreement. “Was she exposed to any chemicals,” I ask her father, “any sprays, or pesticides?” “Nothing at all,” he answers, puzzled. “La belle indifference,” I think to myself. Maybe this is Conversion Disorder. I do a full exam. Everything is normal, except for the fact that her legs do seem weak: very weak in fact, almost flaccid. And her leg reflexes: almost non-existent. It’s not a complaint you see every day in children, especially ones without trauma or a spinal cord injury. I go back to the physician charting area. I discuss the case with a few of my partners. “Is she faking?” asks Dr. Bill, 15 years my senior. “It’s probably Factitious Disorder. Remember, this department’s exploding with sick people right now.” “I vote for Guillan-Barré,” says Dr. Susan. “I also saw a kid with a spontaneous intracranial hemorrhage of the cerebellum once from an arteriovenous malformation and it presented sort of like this, but more with ataxia than weakness. You need to do a CT, LP, labs, and turf to Peds.” “Is there any double vision, or extra-ocular muscle weakness? I saw one like this 6 months ago. It turned out to be Myasthenia Gravis,” says Dr. Jim, as he leans over with a pained look on his face, scratching his legs violently. “You got anything for mosquito bites on you? Hydrocortisone cream, anything? I’m dyin’ here from these bites.” Whatever this turns out to be, it isn’t going to be something you see every day in the Emergency Department. I click on “board exam questions” in the hard drive of my brain. Miller Fisher syndrome? Lambert Eaton myasthenic syndrome? Organophosphate poisoning? Botulism? Some weird electrolyte imbalance? Encephalitis? Some rare porphyria variant? I’m digging deep, grasping.  She may need labs, brain CT, and possibly a lumbar puncture just to start. I walk back into the room to start over. Something doesn’t feel right about this. I sit down to take the history again. “Doc, I wanna’ ask you something…” says the dad. “Just a minute, let me examine her again,” I say, concentrating. I examine her again from head to toe, this time with my best textbook Physical Diagnosis exam. Her arms seem a little weak now, too. Or am I imagining it? BEEP!BEEP!BEEP!BEEP!BEEP!BEEP! screams a monitor from outside the room. “Doc, one more thing…” ...

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Medical School in the Big City, Vol. I: Blood in the Streets

By Birdstrike MD “Blood in the streets, the town of Chicago… Blood in the streets of the town of New Haven; Blood stains the roofs and the palm trees of Venice… Blood on the rise, it’s following me.” – Jim Morrison During my first year of medical school, my roommate and I decided to live downtown in the Big City, while we attended Big City Medical School. One late night, shortly after moving in, we were studying for our first big anatomy test. In through open windows billowed steam-thick August air and the sound of, Pop! Pop! Pop! “Fireworks,” I said to my roommate. “That was gun shots. Get used to it,” he shot back, without lifting his eyes off his brachial plexus diagram. “How do you know?” I asked. “I’ll show you,” he pushed a button on his watch and folded his arms. “Whatever….” I said, and went back to studying. “Hear that?” he said, as he cupped a hand behind his ear, and turned his head, as sirens crawled closer from the distance. He pushed the button on his watch again, with a beep. “14 minutes: a pretty pathetic EMS response time. Whoever got shot is sure to be dead by now. Don’t you listen to Public Enemy? ‘911’s a joke in yo town!’ By the way, did you hear that EMS ride-a-longs are no longer mandatory?” “No. Why is that?” I asked. “On the last one, the ambulance was shot full of holes,” he answered with a gunner’s grin. “Pretty cool, isn’t it?” That’s how “Medical School in the Big City” started. You definitely had the sense you could lose your life at any minute if you made the wrong move, at the wrong time, or for nothing at all. On day, I pulled my car up to the gated entrance to our new apartment complex. The swing-down gate was broken off and the maintenance man was bolting on a new gate-arm. I rolled down the window, and asked him, “What happened?” “Someone just drove right through and busted it off because they didn’t have their card. People just don’t care around here. Why swipe your card when you can just drive through and smash the gate? It’s a war zone around here,” he answered. “I know. The airbag was already stolen out of my car and we saw our neighbor’s car get repossessed last night,” I answered. “See that building over there?” he asked, pointing to the tall apartment complex across the street. “Yes,” I answered, as I looked at the nondescript brick buildings. “A baby fell out the 6th floor window last night,” he said, and laughed. “It lived, too,” he laughed again. “They always live. It happens every few months. The bushes or an awning always seem to break their fall,” he said shaking his head. That night I had my noise canceling headphones on and was studying. It was dark. It was late. I was caffeinated. I was determined to ace my next exam. BOOM! BOOM! BOOM! It must be the song. Crazy music nowadays… BAM! THE DOOR TO MY ROOM BLASTS OPEN A GUN IS IN MY FACE I’M GOING TO DIE RIGHT NOW HOLY @$#%&* !! The gun doesn’t go off. Behind the gun comes the panicked face of my roommate. I rip off my headphones. “Get out of here! Somebody just got shot! I heard the shots! They’re looking for the guy! Let’s go! LET’S GO!” screams my roommate. “What is going on? You scared the crap out of me!” I yell back at my roommate. “Go where?” “I don’t ...

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“Imagine,” the Lost EM Verses?

By Birdstrike MD Legend has it that prior to joining the Beatles, John Lennon might possibly have done a brief stint in an Emergency Department in Liverpool.  Who knew?  I had no idea, either.  Rumor has it, that this influenced him greatly, and that some lost verses to his masterpiece, “Imagine,” may have been found.  Neither Yoko, nor the Lennon family have ever confirmed or denied the legitimacy of such lost verses. Listening to the lyrics, it’s amazing.  How could this man have foreseen all that was to come? There’s only one answer: Pure Lennon genius. We are only left to imagine if these verses are real, and if so, what might have been.  It may be helpful to cue the official “Imagine” video by John Lennon, recite the lost verses aloud, and just dream… Hit it John: Imagine there’s no night shifts It’s easy if you try, No admin or C-suite, Obamacare’s not real, Imagine all the EPs, Working wide awake…aha. Imagine no Press Ganey, It isn’t hard to do, No scores to live or die for, And no metrics, too, Imagine all the EPs, Working shifts in peace….yoohoo. You may say I’m a dreamer, I do more than just triage, I hope someday you’ll join us, And all EPs will be as one. Imagine there’s no med-mal, I wonder if you can, No need for BS admits, No more unneeded scans, Imagine all the EPs, Practicing in peace…yoo-hoo. You may say I’m a dreamer, I do more than just triage, I hope someday you’ll join us, And all EPs will live as one. What do you think, could these be The Lost EM Verses of “Imagine”?

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Anonymous Physician Blogging: Unethical or Important Check and Balance?

By Birdstrike M.D.   “Don’t ask me nothin’ about nothin’, I just might tell you the truth.” – Bob Dylan   I just read an interesting post by Jennifer Gunter M.D. on KevinMD.com. Apparently, the entirety of what we are doing here at DrWhitecoat.com, and on internet communities and blogs like Student Doctor Network and Sermo, is unethical, according to the General Medical Council in Britain. How dare we not use our real names on social media as physicians and physicians-in-training? According to the British General Medical Council, “If you identify yourself as a doctor in publicly accessible social media, you should also identify yourself by name.” Otherwise, if you don’t, what you are doing is wrong, and unethical.  Really?  On one hand, I agree that any physician that posts publicly should post with the assumption that their identity could easily be discovered, if desired. Therefore, never post anything anonymously that you couldn’t live with, if your name ever ended up being attached to it. We shouldn’t be mocking patients, using profanity, or blogging like drunken sailors. Also, patient cases need to be devoid of all identifying information (18 HIPPAA identifiers) or even fictionalized to the extent that no patient could ever read a post and say, “That was me!” (For this reason, anything I post that resembles a “patient case,” if inspired by real events, has all of those factors deleted or changed so drastically, that the final product bears almost no resemblance to the inspiring event. The “facts” are drastically altered to the level of fiction, without altering the essential “truth,” hence the disclaimer, at the bottom of my posts.) Dr. Gunter, in her post, links to another blog with some very good points by Christopher McCann, where the need for some level of anonymity is essential for the needed role of whistleblowers. Just think of how many medical disasters, scandals and ethical horrors that could have been exposed or stopped if internet social media had existed in the past with the ability to retain a vague hope of at least temporary anonymity.  I think an outright ban on physicians posting under pseudonyms in the names of “ethics,” creates a chilling effect against speaking out against policies and procedures that may be harmful and unethical themselves.  Such a policy itself is an unethical policy, in my opinion.  In short, it suppresses free speech.  There are plenty of people in positions of great money and power, with a vested interest in enforcing such a chilling effect on free speech. “Don’t dare question, that which you see. Don’t rock the boat. Get in line ‘little soldier’. Don’t get in the way of our immensely profitable status quo.” Because one has a famous “real” name doesn’t make what he says, “Fact.” Just think of how much medical dogma in history, that has caused irreparable harm and was promoted proudly, authoritatively, and unquestionably by big “names” without basis in fact or evidence: bleeding patients with leeches, tapeworms for weight loss, lobotomies, smoking to treat asthma, heroin prescribed for the common cold in children, using mercury to treat syphilis, all the way to modern day unnecessary surgeries. How could I forget the Tuskegee Syphilis experiment, conducted by the US Public Health Service itself, where 600 African American men were allowed to rot with syphilis, and were never offered the cure when penicillin was invented? These were all treatments that were accepted by the medical community at the time and touted by doctors who weren’t afraid to use their “real” names.  Perhaps they should have been afraid, and perhaps if there had been an ...

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