June 21st, 2009 by Dr. Val Jones in True Stories
Tags: DC, Disabilities, Metro, Physical Medicine And Rehabilitation, Priority Seating, Subway
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As many DC residents know, the local subway system has launched an etiquette campaign to insure that priority seating is given to the elderly and people with disabilities. The four seats nearest the center doors are clearly marked with “priority seating” signs, including “You don’t have to stand for this” posters. Conductors even read scripted reminders to riders at various stops.
So how is this campaign working out? I snapped a photo of this guy sitting in the priority section (and taking up 2 seats with his bags) – just after an elderly man with a cane limped by.
I gave him the evil eye… he returned the glare.
So I decided to feature him on my blog.
As a physician who works with people with disabilities this really gets my goat.
June 19th, 2009 by KerriSparling in Better Health Network, True Stories
Tags: Blueberry Muffin, Diabetes, Endocrinology, Glucose Control, Internal Medicine
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There’s stuff that’s bolus-worthy. New York style cheesecake. Chai tea on a snowy winter day. Wedding cake made out of red velvet with butter cream frosting. These indulgences are worth draining my pump reservoir for, and almost worth the spike I try to, but don’t always, avoid.
I’ve been very, very attentive to my diabetes lately. Logging all these numbers, sporting the Dexcom, trying to manage stress levels, exercising … whatever it takes to make me as healthy as I can be for the baby I want to have someday. But that wagon is hard to stay on all the time, and I have taken a risk or two in the last month. Like a trip on the Connecticut Wine Trail with some friends. And some pasta at Carmine’s last weekend with my sister-in-law.
And blueberry swirl cupcakes from Crumbs Bakery.
My diabetes control isn’t made or broken in one bite of a fluffy, delicious cupcake. Usually when I’m having a high sugar indulgence, I’m right on top of things, diabetes-wise. I bolus aggressively to avoid the high and I watch that Dexcom like a hawk for any subsequent lows. My management problems come more in the form of letting my numbers go untracked and pinging all over the place, letting highs creep up without corrections, then stacking boluses until I hit a nasty low, which I over-treat and rebound into a high … you know the cycle. It’s not the “one thing” but more my inability to care for more than an hour or two. The last few weeks of intensive management have been about keeping an eye on everything and not letting the cycle spin out of control.
And it’s hopefully working. My machine averages are down, I’m seeing many hours straight of flat-lines on the CGM, and knowing my Joslin appointment is at the end of July keeps my mind on task.
Besides, it’s not like I ate the whole cupcake. I split it with Chris and I asked for the estimated carb count before I took a bite.
But I did take the first, awkward bite.
And I did enjoy every other bite of it, too. Go ahead and judge! 🙂
*This blog post was originally published at Six Until Me.*
June 18th, 2009 by Bongi in Better Health Network, True Stories
Tags: Alcoholism, Burns, Compartment Syndrome, Emergency Medicine, Escharotomy, Full Thickness Burns, General Surgery, South Africa, Treatment
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In my line of work there is sometimes a fine line between cruelty and kindness. Sometimes the line can seem to blur. Hang around me long enough and you will probably be shocked at some stage.
The guy had apparently fallen asleep next to his fire. When he rolled over into it his alcohol levels ensured that he only woke up once his legs were well done. Someone found him and brought him in late that night.
When I walked into casualties I could smell him. You can almost always smell the burn patients. I took a look. The one leg actually wasn’t too bad. It had an area of third degree wounds but they weren’t circumferential. I could deal with that later. The other leg, however, had the appearance of old parchment from about mid thigh to ankle right the way around. This could not wait for later.
In third degree circumferential burns, the damaged skin becomes very tight. Constricting is actually a better description because unless it is released the taught skin will so constrict the leg’s bloodflow that if left untreated the patient’s leg will die. It is like a compartment syndrome only the entire leg is the compartment. Interestingly enough in third degree wounds all the nerves have been destroyed so in these areas the patient has no feeling whatsoever. That means when we do the release (an escharotomy which is cutting the dead skin along the length of the leg in order to release the pressure and thereby return the bloodflow) no anaesthetic is needed. You just cut the skin and as soon as you hit an area that the patient feels you’ve gone too far. If you do it right they will feel nothing. The longer you wait the higher the chance that he will lose his leg. I knew what I needed to do. I also knew my students might never get to see this again before they might have to do it themselves in some outback hospital in their community service year.
I asked for a blade and gathered my students around me. I sunk the knife through the dead skin and ran it down the length of the leg. The wound burst open as the pressure was released. The patient didn’t flinch. Quite a number of the students did. One excused herself and ran out. I think she might have been crying. Despite me telling them that it wasn’t painful and it was in the best interests of the patient to actually see it was more than most normal people could take.
When I wrote my last post and expressed a form of traumatic stress I found the contrast within myself compared to this incident quite interesting. everything seems to be relative and during the job there will be things that leave scars and many things that traumatise/desensitise us. I was ok doing what that one student obviously thought was gruesome and bizarre because I was convinced it was in the best interests of the patient. When I did this procedure which, on the face of it, is so much more brutal than taking someone to shower, I was ok, but the shower incident was terrible for me. I ended up hoping the student didn’t see me as quite that monsterous. I also hoped she would get over the trauma I had inadvertently caused her.
June 12th, 2009 by Bongi in Better Health Network, True Stories
Tags: Atrocity, Burn Victim, Burns, Fluids, Gasoline, General Surgery, Murder, South Africa, Tires
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Leaking
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.
June 11th, 2009 by DrRob in Better Health Network, True Stories
Tags: Confessions, Dr. Rob Lamberts, Drug Rep Lunches, MedPeds, Stealing
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Credit
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.
There. I hope my bones don’t waste away now.
*This blog post was originally published at Musings of a Distractible Mind*
