Last weekend an intoxicated 16-year old Orinda teen died in a hallway during a party, a preventable loss that disturbs any sane person. It makes me obsess about why our culture encourages the use of alcohol as part of celebrating and socializing, where the adults were, why the other teens ignored a person who had obviously drank too much, and most importantly, what if someone had just called 911 earlier?
Everyone in that community and all of us who heard about this tragedy will live with the “what ifs” but I hope it encourages every parent to make sure s/he has talked to their teen about expectations for their behavior, sure, but also about what to do when things get out of hand! You can help them avoid living with the “what ifs” by checking out Doc Gurley’s great article for SF Gate this week that includes six practical tips that all teens should know about alcohol!
In addition to knowing how to recognize a medical emergency which you can find in Doc Gurley’s article, families also need (rules) agreements about what to do if a teen finds themselves in a situation where alcohol is being abused. Of course, parents have to be comfortable with the agreement, but some families have agreements that include:
no driving a car after consuming any amount of alcohol;
no being in a car with anyone who has consumed any amount of alcohol;
not staying at a party where anyone is drinking or has had too much to drink;
a parent can be called at any time of the day or night to:
intervene at a party;
pick up a teen who has been drinking;
take a friend home who has been drinking;
help talk to irate parents; and
talk to friends about alcohol use.
Most of these agreements include a “no consequence” clause for the teen – which means there is no anger, grounding, punishment, etc… associated with any of those activities. That does not mean there isn’t a serious conversation about alcohol use that may follow a good night’s sleep, shower, and 12-hour cool down period, but if your teen does drink, you really do not want them to drive, be in a car, or be a victim in any way – so, please make sure they know that you would rather them call you and be safe!
If you want to know what your teen knows about alcohol use and when to call for help, ask him or her to tell you exactly what they would do if someone at a party has passed out or puked on themselves. If it does not including calling 911 and you to pick them up, ask them why, and then make an agreement about what will happen in those situations – and then abide by the agreement!
People are basically sacks full of water. The skin keeps the water inside. Trust me when I say you want to keep your water inside.
The second post I ever wrote had to do with watching someone with burn wounds fade slowly away. In the end it had more to do with my own mortality. When I read it recently I was reminded of quite a few poignant stories. This is one.
Usually things happen in groups and, it seems, burn wounds are no exception. On two successive nights two severely burned patients came in. I got the first. My colleague got the second. My patient had 98% burn wounds (Usual story of being doused in petrol and being set on fire. Someone didn’t seem to like him). Only where his hair had been was he not burned. That means that 98% of the sack that is supposed to keep the water in was leaking.
Let me take this moment to say that it is not possible to survive 98% burn wounds in any setting. This patient was as good as dead, so whatever we were going to do would only partly help. The outcome could not be changed.
The immediate treatment for burns is to replace the fluid that is leaking out through the wounds where the skin used to be. The amount of fluid one gives is proportional to the surface area burned or the surface area leaking. In 98% that turns out to be quite an amazing amount of fluid. And that is what we did. I worked out the fluid needed, put up a good central line and started running it in. The next day he was still alive.
The next day was when the second burn wound patient came in. He had 95% burns and therefore was leaking pretty much the same amount as my patient. My colleague admitted him, but he treated him differently. My colleague knew that the end of the road was predetermined and didn’t see the point in prolonging the inevitable. He only gave him normal maintenance fluid which a normal person would require. He considered more as treatment and didn’t see the point in treating something that could not be treated. I considered that he may have a point. I went to see his patient.
His patient was not doing well. The loss of fluid had pushed him into a stuporous state. He didn’t seem to have long to go. I left. He died soon after.
My patient remained alive through that day too. Because of his wounds he could not lie in bed without extreme discomfort. But the soles of his feet had no skin so he could not stand either. The skin of his hands had all peeled off and they had swollen into useless immovable paws.
The head of the firm then decided we should take him into a shower and remove all remaining loose skin. I got the feeling he was trying to teach us some sort of lesson. The only thing I learned is that it is brutal to try to remove loose skin, even gently from such a patient. The patient was not having fun at all. I kept thinking why are we making the last days of his life any more miserable than they already are? The head then decreed that we would repeat this process in two days time. I felt sick at the thought. The wisdom of my colleague not treating his patient seemed much clearer to me then.
The next day when I arrived at work I was relieved to discover my patient had finally succumbed to the inevitable. It would not befall us to have to torture him the next day in order that we learned some mysterious lesson.
Life is good. I’m settling into my job at UGH (Undisclosed Government Hospital) and I have a couple of days off from work. I’m using my time constructively. My house looks like hell, but I am doing other important things like writing, reading blogs, and visiting Twitter.
Yes, I’m addicted to Twitter. I started tweeting when I hooked up with Pixel RN and Dr. Val at BlogHer last year. They showed the joys of micro-blogging and my life was changed forever. Twitter is great place to meet people using 140 characters at a time. You can hangout in cyberspace with people like Ashton Kutcher, Lance Armstrong, and Stephen Colbert. You can also hangout with a lot of great healthcare providers. I make new “friends” by putting the word “nurse” into the Twitter search engine. Then I sit back and see what pops up.
Yesterday, something very interesting caught my eye. Dr. Hess, a plastic surgeon, tweeted that nurses were being offered free plastic surgery. I love free stuff, so I followed the link in his tweet, and checked out his blog. He wrote a great post. I also checked out the link in his post to the New York Times. The upshot of the story is that some places in Europe are offering plastic surgery as a recruiting tool for nurses. The story talked about the enormous social pressure that some nurses are under to look good. It’s true. Even some hospitals in the United States are using young and beautiful nurses as a marketing tool to entice more patients into their facilities. Age discrimination is rearing its ugly head. I wrote this post about a nurse who lost her job because she was getting old and because she wasn’t pretty anymore.
I tweeted Dr. Hess. I told him that there wasn’t enough plastic on the planet that could make this sow’s ear into a silk purse. I also told him that I look forward to tweeting with him in the future. He wrote back and told me that he thinks that I’m charming. Just wait till he really gets to know me!
I have to get some things off of my chest. A guilty conscience is something that can cause lots of problems, both emotional and physical. As David said in Psalm 32:
For when I kept silent, my bones wasted away
through my groaning all day long.
For day and night your hand was heavy upon me;
my strength was dried upas by the heat of summer.
Sounds like David lived in Georgia.
So here are my confessions:
I stole a bagel yesterday. I went to Pannera Bread Company yesterday and ordered a blueberry bagel (toasted and sliced). I have a cup that allows me to get free coffee, so when the woman at the counter was slicing and toasting I went got myself some dark roast. I chatted there with a woman about the fact that light roast actually has more caffeine than dark roast. As I went to the counter I saw someone I recognized, said “hi,” grabbed my bag and headed out the door. It was half-way to work when I realized I was now a criminal.
This morning I went back and tried to pay for yesterday’s bagel but she wouldn’t let me. I think she wanted me to live with my shame. I put the appropriate change into a can collecting money for a kids cancer camp.
I watch American Idol. Yes, I watched most every episode this year. Those who think I am all counter-culture can express their shock and disgust. I enjoy hearing them perform – they were especially talented this year – and we watch as a family. You must remember that I started college as a voice major, so I do like to hear good singing.
I was kind of pulling for Adam (his last name is almost the same as mine), but I thought Chris and Danny were worthy as well.
Sorry to those who now think less of me.
Our office allows drug reps to visit and give samples. We even have them give us lunch. I know there are some who think that this is the hight of immorality, but I have found them to be quite valuable. We have done our best to keep a limit on their access to us – they are not allowed to detail us in the hallway, only when they bring us lunch. Only 1 rep at a time and no more than 6/day (never more than one from one company).
We have a person on staff who is dedicated to getting patients medications when they can’t afford them. She will work with the reps to find a program for them and will give samples when possible.
Why do we do lunch? One main reason: for our staff. I actually skip it often because I get fat if I eat too much at lunch. Their finances are tight and so supplying them with lunch saves them money. The docs will generally tell the flat truth to the reps (”I dont prescribe your drug very much”). I do find that they have brought me good information at times.
Our practice has always been a lower utilizer of brand drugs when we have been measured (mainly United Healthcare), so I don’t think this has had an undue effect on us. Still, the conscience nags when others feel that pharma is the spawn of satan.
I have checked my blog in a patient room. During the more acute compulsive blogging phases, I have checked traffic during a lul in the exam room. I do actually feel guilty about this and have stopped doing it. I have NEVER twittered in the exam room, however.
“It’s my OCD.” I hear that on and off from friends and patients who half-jokingly use the term to describe overly careful behavior (such as double-checking to make sure the stove is off) but don’t actually have obsessive-compulsive disorder. True OCD can be a devastating disease. Patients have intrusive, uncontrollable thoughts and severe anxiety centered around the need to perform repetitive rituals. They can be physical such as hand washing or mental such as counting. The behavior significantly interferes with normal daily activities and persists despite most patients being painfully aware that the obsessions or compulsions are not reasonable.
OCD affects 2-3 percent of the world’s population. We’ve seen characters with the disorder portrayed in television (e.g., Tony Shalhoub’s Adrian Monk) and in film (e.g., Jack Nicholson’s Melvin Udall in “As Good As It Gets.”) Yet it’s still associated with stigma, shame, and an alarming level of ignorance by many health professionals. On average, people look for help for more than nine years and visit three to four doctors before receiving the proper diagnosis. In an excellent review article on the subject, Dr. Michael A. Jenike, offers three helpful screening questions: “Do you have repetitive thoughts that make you anxious and that you cannot get rid of regardless of how hard you try?” “Do you keep things extremely clean or wash your hands frequently?” And “Do you check things to excess?” He suggests that answering “yes” to any of these questions should prompt an evaluation for possible OCD. Of course, these are just screening questions and keeping a spotless kitchen doesn’t mean you have a disorder.
For this week’s CBS Doc Dot Com, I interviewed Jeff Bell, KCBS radio broadcaster and author of Rewind, Replay, Repeat: A Memoir of Obsessive Compulsive Disorder and When In Doubt, Make Belief: Life Lessons from OCD. He poignantly told me about the mental anguish associated with his illness, how it threatened to sabotage his career and personal life. His OCD focused on a fear of unintentionally harming others. He found himself unable to drive a car because every time he hit a bump he was afraid he had run somebody over; each time, he needed to get out and check. Even walking to work presented a challenge. He explained that a twig on the sidewalk could stop him in his tracks and fill him with what he knew were irrational thoughts but was powerless to control. Maybe somebody would be harmed by the twig if he didn’t move it. But if he did move it then maybe somebody would be harmed who wouldn’t have if he had just left it alone.
Jeff Bell sought treatment and turned his life around. His message is that others can do the same. Highly successful approaches including cognitive-behavioral therapies and medication can help the majority of patients. But only those who ask for help.
Resources for OCD include: The Obsessive Compulsive Foundation, The Association for Behavioral and Cognitive Therapies, and The New England Journal of Medicine.
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