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1209717_19610439The focus of this web site is medicine. In this blog, you’ll read about patient stories. The situations have been changed to be HIPAA compliant. Factual statements may or may not be true. I may change ages, gender or presenting complaints about patients. I may even entirely make up complete patient encounters from my fertile imagination. Trust me, if you think I’m writing about you, I’m not. There are billions of people in this world and readers send me stories about patients all the time. It isn’t you.
You’ll also read a lot about health care policy. I may throw in posts about life lessons, computers, and will even throw in family stories once in a while. If you’re looking for articles about politics, sports, or celebrities, you’re in the wrong place – unless the topics have some relationship to medicine.
If you want to add a guest post or to cross-post something from your blog, or if you have a patient story you want me to write about, e-mail me. See more information in the “About Me” page.

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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Helloooo … ooo … ooo [echo]

Lots of cobwebs in here. Heck. I don’t even recognize the new WordPress control panel. So I made a New Year’s resolution that I’ve already broken. I resolved to post once a week on this blog of mine. Here we are at Week 2 and … nothing. I counted. I have 24 pieces of paper sitting in a file on my desk with posts just waiting to be written. People have sent me stories to post and I’ve not been very good at checking e-mails, either. I’ve got another dozen or so half-written posts in an Evernote account. That’s enough for almost a year if I do one post a week. So what’s the holdup? I thought long and hard about why I stopped writing. The root cause of the problem was that I like writing about policy. What I think we should do in medicine and why. But writing a compelling post about a single topic sometimes takes all day. Time isn’t on my side in that regard. Family. Work. Disaster after disaster. But I miss writing. So I decided that instead of taking all day to write about a specific topic, I’d treat the blog kind of like an extended Twitter account. Twitter gets on my nerves any more. Yes, I agree that Donald Trump is a jerk. I don’t need a running account of his alleged inherently evil actions from every person who was upset that Hillary Clinton lost the election. Spend your energy on things more productive than the “Tweet” button. Give the guy a chance and see what he can do for the country. So I’ll just post short thoughts about things that cross my mind. Progress on health goals. Throw in some patient stories. Policy issues if I get motivated and have the time. Bring back the Open Mic days to see what’s on everyone else’s minds. I’m dictating things into voice recognition on my phone while driving. I tried it a couple of times and it works OK. Need to do quite a bit of spell checking, but it works. If nothing else, you’ll get some new #Dragonisms. I’m going to clean up the site a little too. When I get more time. There are a lot of old blogs to get off the “Links” page and a lot of new ones to add. What pushed me over the edge to get back to the keyboard was someone who just wrote me an e-mail thanking me for what I do for doctors. Here I am thinking I don’t do much of anything. But people apparently enjoy reading stories and they like someone who will write about what many people are afraid to write about. As in … how’s that Press Ganey bullshit going lately? We’ll see how this New Year’s resolution pans out. Don’t expect a lot … all three of you who still check this blog once in a while. At least I took the first step. Second step: My first patient post already written up. Check back tomorrow.

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