Life Lessons

So by popular demand*, or rather at least one person's demand, now at the end of my ER rotation I have more to blog about my actual ER rotation.

I'm sure everyone reading this has seen that awesomely cheesey poster that lists like a million things that you learn in kindergarten that make you a wonderful person. Well, this month in the ER I've compiled a similar list that will help make you a healthy person. At least as healthy as luck and/or stupidity will permit.

• Don't wear flip flops while mowing the lawn. Don't put your hand under a stalled lawn mower that is still turned on. Don't try to take a riding lawn mower out of the back of a pick-up truck all by yourself. All are really good ways to lose body parts. If you know the neumonic - it's usually a body part that you wouldn't use lidocaine with epinephrine on that you lose. If you don't know the neumonic, well, I'm not going to post it here because while I do like the attention from random google searches, that's not the attention I want.
• Don't cuss out homeless men with knives who ask you for money. They might stab you. A couple times.
• Don't zip your pants up too fast without looking to see what's still in the zipper. I didn't think that this actually happened, but as I discovered this month, it does. And it looks very painful.
• Don't lie to the doctor about what happened to you. For example, don't tell the doctors at 2 different hospitals that you fell off a swing if you actually were bitten by a cottonmouth snake. Some of them might believe you and your treatment might get delayed 6 hours and you might risk loosing body parts.
• Don't punch glass windows. Don't jump through glass windows. Don't lean all your body weight on glass windows. Don't push really hard on glass windows. Glass breaks. Broken glass is sharp. It will cut you. Deep. There will be blood. Lots of it.
• Don't insert objects PR. P stands for "per". R stands for a word that starts with R and sounds like "wrecked 'um". It might just disappear on you. And that's a really embarrassing story to have to tell the doctor.
• Don't think that you are too good for eye protection. Especially if you are breaking up concrete (it might just end up inside your eye) or working with methyl chlorobenzene (it might just burn your corneas right off).
• Don't think that vizine eye drops is all you need if you get methyl chlorobenzene in your eyes. And don't wait 2 days to go to the hospital.
• Don't do drugs. Especially fry (marijuana dipped in embalming fluid). It will make you crazy. Irreversible-forever-for-the-rest-of-your-life crazy.
• Don't think you no longer need your psychiatric anti-psychotic meds. You will go psychotic if you stop them.
• Don't think you don't need a seatbelt. Unless you are curious what it's like to break a steering wheel in half with your chest or go through the windshield.
• Don't put your feet over the passenger air bag. It will come out very fast and it will hurt you very badly.
• Don't accept unscreened blood transfusions from Mexico.
• Don't beat your child to death. The police are pretty good at figuring that one out.
• Don't let your kid ride a broken bicycle outside after 11 PM. It might just be asking for disaster.
• Don't come into an ER and ask for a pain medicine by name and dose. You won't get it, or much of anything else after that.
• Don't stop coumadin all of a sudden because you think it's not doing anything. If you had a stroke before and they put you on coumadin, it's pretty likely that you'll have another if you stop the coumadin.
• Don't get 20 tattoos and then be a cry baby about getting stitches. Or about getting shot by your father-in-law with a shotgun.
• Don't change your tire on a too-narrow shoulder of a busy 6 lane freeway. Unless you want to get hit by a car.
• Don't jaywalk and think you can beat any car. You can't. And cars weigh roughly 10 times what you do. And don't break as easily.
• Don't shoot at the police. They shoot back.
• Don't eat like an American.
• Don't think that you don't need pre-natal care. You do.
• Don't think that if the doctor told you to be on bedrest that this means don't go to work, but spend all day out and around town doing a million things.
• Don't bring all your personal belongings to the ER with you in a cardboard box. And then drop it all over the trauma bay as they are taking you out to a bed.
• Don't come to the ER and say you have a spider bite unless you saw an actual spider on you and saw and felt it actually bite you.
• Don't eat batteries.
• Don't come to the ER in a busy academic hospital unless you want some random medical student to anonymously blog about your stupidity.

So there you have it. Real convential wisdom for your bathroom wall.

*I say this is by popular demand, but I have no actual way of confirming this since apparently the popular demand all read this site previously via an RSS aggregator and never actually came and visited my site nor did they artificially inflate my self importance by raising my site visits counted by sitemeter.

McMarketing

We've all seen those golden arches saying "Billions Served." I'd even venture to say that there is not one single person reading this that has never eaten at a McDonalds. Remember when you were a kid and your parents would strap you into the car and drive you to go play in the ball pit and eat a handful of chicken mcnuggets soaked through with McDonalds brand honey? Remember the TV ads with McBurgler and Grimace and Birdie and Mayor McCheese? Remember how often you begged to go to McDonalds?

Turns out McDonalds knew what they were doing, and now there is scientific proof. According to this study out of this month's Archive of Pediatric and Adolescent Medicine kids can taste a difference in food presented in McDonalds packaging. The authors had 63 kids from 5 different low SES day cares to whom they provided 5 different foods, including hamburgers, french fries, and carrots, which were identical in all aspects aside from their packaging. The results of the study are probably predictable to any parent. Four out of the 5 foods tested turned out to that kids thought the McDonalds branded food tasted better. The only one that came out being even was the hamburger. They did find some influencing factors. Kids who ate at McDonalds more frequently were more likely to prefer the McDonalds packaged food. Also, kids who live in homes with increasing number of television sets are increasingly more likely to prefer McDonalds wrapped foods.

So I guess the lessons learend here are that you should 1 - let your kids eat less at McDonalds 2 - get rid multiple television sets and 3 - if you want your kid to eat carrots, put them in a McDonalds french fry box.

Welcome 1st years!

Although I doubt a single one of them will read this, here's a big fat welcome to all the new first years who I saw today at orientation. They looked so innocent, naive, and excited to be there. We'll see about that once their first block of tests rolls around.

I had a good time sitting with my born-a-radiologist friend labeling the newbies as they walked by. Like the nerdy, quiet looking foriegners - aka "pathologists". Or the guys overflowing with testerone as the pretended not to be flexing for the bleach blond barbie dolls - aka "orthopedics". Or the bleach blond barbie dolls - aka "OB/Gyn". Or the totally lost and clueless guys wandering around - aka "Medicine". Or the super white, never seen the sun before - aka "radiologists". Or the hardcore shaved headed giant - aka "emergency". Or the not so nerdy or quiet looking foreigners - aka "family practice". Ok, I'll quit being so, um, specialty-ist there before I alienate everyone. (TS, notice there's not a single psych joke there - just making up for that aggie dig earlier!)

Anyway, it reminded me of how far we've come and how different things seem now. It strange how 3 grueling years of med school can change the way you see things. It's also funny to think they've never experienced the joys of pimping, or scut work, or guaiac cards, or noon conference, or M&M, or grand rounds; yet here they all stood excited as ever to dive head first in.

Here's to those with the cleanest white coats in the school!

It's Broken

American health care. It's an entirely broken system.

While I don't necessarily believe in socialized medicine, what we have doesn't work. And it will only get worse. A major problem in health care is non-payment. Hospitals and doctors have horrible collection rates. Some collect as low as in the neighborhood of 20%. What that does, however, is forces costs to climb in an attempt to cover the cost of those who don't pay. A single dose of aspirin, which costs cents over the counter, can cost several dollars if you get it in the hospital. The ramification of this is that as people don't pay, everything will cost more, which will create more non-payment. Simple economics says cost will climb until the supply and demand curves intersect, the problem is that the demand/usage doesn't change despite the increasing cost.

So as costs climb, so does cost to insurance companies, which in turn creates higher cost of health insurance. Health insurance, however, does experience normal economic pressure and demand does drop with increasing cost. So fewer people will be insured every year as fewer and fewer can afford it. Which will create more non-payment. Which will raise the cost of health care. Which will decrease the number of insureds. Lather, rinse, repeat. Fortunately, I don't think it'll get to the point that health care ceases to exist, because at that point even politicians would be affected.

Beyond that, there is a huge amount of waste in the system today. Administrative costs of health care in America are astronomically higher than they are in other countries. For example, in the billing department of hospitals there is a full time staff of many people to keep up with the paperwork of billing each seperate insurance company or private payor. Each company has their own forms and documentation that has to be filled out in their own particular manner in order for them to even consider paying the claim. Across the border to the north, it takes one person to do all the billing for an entire hospital. Because it is standardized. One form. One location. What if America were to mandate that all health insurance companies accept one single form, like the Medicaid form? It would certainly cut out some administrative cost.

What if health insurance were an industry that was mandatorily non-profit and could not be traded on the stock market - so that health insurance companies would be responsible towards patients instead of stock holders?

What if health insurance were a mandatory benefit all companies with >15 employees had to include (not just offer, but include) for all employees (not just full time, but ALL)?

What if congressman and senators had to get their own private insurance and were not given free care?

What if we find a solution before the system collapses?

Traumatic Brain Injury

Once upon a time there was a man. His name started with "H" and ended in "omer Simpson". When he was a boy he was playing with his crayons. And then he lost one after shoving it up his nose. Years later he had a strange neurological complaint and went to Dr. Hebert, who discovered the crayon on X-ray. When asked why he never noticed it before despite Homer's numerous trips to the hospital with head trauma, Dr. Hebert showed the Simpsons how he always missed it by the way he routinely held X-rays up to the light to see them.

After succesful removal of the foreign body, Homer had a dramatic recovery and even became extremely intelligent. The problem was that he had built a life that centered around him being an imbicile and he quickly began alienating all those around him. In his intellectual nirvana, he realized he would never truly be happy this way and elected to re-insert a crayon into his nose to try to regain what he had lost. And in true Simpsons fashion, all came full circle nice and neatly in 22 minutes.

The reason I make note of this now, is that a German woman has had a quite similar experience, at least to the first part of that story. When she was 4 years old, she tripped and managed to lose a pencil into her cheek. It, unlike Homer's case, was actually quickly diagnosed but went untreated due to the lack of today's sophistocated medical technology. And then at age 59 she finally had surgery to remove almost all of the pencil - 55 years later. Thanks to the skilled ENT, she has reportedly stopped having headaches and nosebleeds. The question is, in a year will she feel so isolated by her own intellectual prowess that she elects to reinsert it?

Chief Complaint

I just finished my first night shift this month and am having trouble sleeping so I thought I'd say a word or two about E.R. Really, E.R. boils down to those two words - Chief Complaint. You are responsible for finding out why the patient is at the hospital and then figuring out if said chief complaint is worthy of hospital admission or worthy of a trip back home.

One of the coolest features of the EMR (electronic medical records for you lay-people) software our ER uses is that you can pull up a list of all the people in rooms, in waiting, and inbound and it tells you their name, location, how long they've been waiting or roomed, and what their chief complaint is. This is the absolute funnest tool in the ER. By far. Because if you happen to have a short break in the action, you can log on and see who's coming and why. I guess the other super cool part about it is that the people in triage are instructed to list the chief complaint exactly in the patients' own words and not to translate it into medical terminology.

So, from two nights worth of working, here's a short sampling of what came through.

• I broke a window and am bleeding - (Pretty accurate assessment I thought. I put 25 stitches in that person's arm. 24 beers + nagging spouse + glass = disaster waiting to happen)
• My parts are huge - (to clarify, those were man parts he referred to, and indeed they were perhaps the largest man parts I have ever seen.)
• bicycle in foot - (this was actually EMS's words since it was a small child who was crying. She really did have a bicycle impaled through her foot.)
• I chainsawed my leg - (disappointed I didn't get to meet this one)
• broken skull s/p jumping from moving vehicle - (this one was cheating too since the chief complaint actually came from doctors at another hospital. S/P means "status post" and is doctor-ese for "after".)
• broke my arms - (Yup. We didn't do much diagnosing past that one)
• woman problems - (enough said)
• f%$# you - (this guy wasn't too happy with being at the ER. He also said that was his wife's name. And his name. And his address. I guess that makes it all easy to remember)

Anyway, on a totally seperate note, I just wanted to give a nod to a not so average family for mentioning me in their blog. Sitemeter tells me that in the past 3 days I've doubled in traffic from people linking in from their page. Despite one of their members leaving deceptive comments on one of my posts.

It Blends!!

In my hunt for mindless activities to do this afternoon since I am home more days than at school this month(with the notable exception of being scheduled almost every Saturday and Sunday), I remembered vaguely having heard of the website Will It Blend? and decided to check it out. After all, one cannot study non-stop for their Step 2, unless of course your name is "First Aid".

Guess what! iPhones blend. And beyond that, blended iPhones sell for $901. As long as your ebay ad is explicitly clear that it is a blended iPhone and not a new iPhone.

Other exciting things that blend include:

glowsticks

iPod

EZ Cheese

video cameras

and even Bic ligthers.

All in all, it was pretty productive day for me.

Crushing

I suppose starting off with the title "crushing" on my first day of ER might imply some sort of intense physical trauma, but it's the only word that describes the horribleness I saw today.

It's more of an emotional horribleness.

So imagine this. You are a new 4th year medical student and your first rotation is an ER elective. You absolutely fall in love with it and decide, "This is IT! This is what I'm doing." You talk to lots of people and find out it's a really good idea to get at least one away rotation if that's what you're going into. Great. So you get on the ball trying to find one. Turns out the only ER program in a city you want to go to has a couple openings. You try as hard as you can to get it set up and are even told when and where orientation is the first day. So you DRIVE from Tennessee across the country to get there in time to start on August 1st.

So you get to orientation just as its starting. Some big burly guy at the front is counting people and says, "There's one more person here than there should be." You say that it's probably you because you've been trying to get all the paperwork ironed out still.

"I'm sorry, but you have to leave. We don't have you on our roll and so you can't be here for orientation."

What do you say? Well, how about, "All my stuff is at student affairs. They're getting it together so I can be here."

"No. I'm sorry. We don't have your stuff yet from them and so we can't enroll you, so you can't be here."

"Can I pick my shifts and do all this after I get it worked out."

"No. You can't be here. We don't have you on our rolls so you can't be in orientation and if you miss orientation you can't rotate this month."

"But I drove from Tennessee to be here...."

"Sorry, but no."

So, as it turns out, that's exactly what happened this morning. Some poor girl who came all the way from Tennesse got kicked out of orientation. Imagine lining things at home to live for a month in a different city and then getting there and the job you thought you were there for is still open, but since your paperwork wasn't finished before 7 am on day 1 you lose that whole month. And even though the administrative people beg and plea for the boss to let you stay, the boss says, "No. Rules are rules." And then you're totally screwed, because it turns out that the big, burly guy is actually the residency director for that school and you've now made a situation where you'll never get in to that school because you couldn't get your paperwork together in time.