June 24th, 2007 by Dr. Val Jones in True Stories
1 Comment »
During my residency I kept a diary as a way to relieve some of the sadness related to the death and dying that I witnessed. I recorded various encounters in a series of vignettes. Although these are a bit long for a blog, I thought I’d share a few now and then in the hope that they’d preserve the memory of those who are gone. All personal data have been removed so that the identity of the patients is protected.
***
It’s 3:00am and I was paged to examine yet another patient who had fallen out of bed – to rule out a hip fracture.
Too tired to read the chart prior to examining the patient,
I thought I’d leap right into the physical exam. I assumed that the patient would be the usual
elderly woman who, in her sickened delirium, thought she was at home and tried
to walk by herself to the bathroom and fell en route.
I marched into the room and stopped at bed 23. All my pre-conceived notions evaporated as I
looked at the young man before me.
Emaciated and stiff, with all four limbs contracted, he lay on the bed,
clinging to a thin white sheet. The
whites of his eyes flashed in the darkness.
“Hi there.” I said, trying to seem casual at the sight of
the living corpse before me. “I’m Dr. Jones. I heard that you fell. Are you in any pain?”
His eyes suddenly fixed themselves on me and he spoke, not
with a thin raspy voice, but with the robust youthful voice appropriate to his
age rather than the decrepitude of his body.
“I’m in no pain,” he said.
“I was trying to sit down on the chair.
I thought it was against the wall, but it was actually a couple of feet
away. So when I leaned on it, it slid
and I fell on the floor.”
“Do you think you broke anything?” I asked, trusting in his
judgment as his mental status was clearly in tact.
“No, I just scraped my butt,” he said, pointing a frail
finger towards his sacrum.
“Did you hit the floor hard?” I asked as I used my pen-light
to examine his back side.
“Not really,” he said.
“Would you like me to order an X-ray of your pelvis to see
if you broke anything?”
“I don’t think I need it,” he said.
“Well let me see if it hurts when I rotate your leg in your
hip socket, ok?” I pulled down the sheet
and asked the young man to allow his right leg to fall to the side. As I looked down at his hip I gasped slightly
as his inner thigh came into view. A
gaping ulcer lay before me, deep to the bone, exposing tendons and ligaments
with pus, and red knobs of flesh surrounding a football sized hole in the man’s
groin. His paper-thin scrotum lay stuck
to his left thigh. The smell overcame
me, it was at once wet and fetid, with a hint of chemical odor from the
antibiotic ointment that was clinging ineffectively to the fringes of the wound.
“Oh my God. Does that
hurt?” I stammered.
“No, not at all.”
“And does it hurt when I rotate your leg in your hip
socket?” I asked, trying desperately to remain focused on the task at hand.
“No, it doesn’t.”
“Well, then,” I said, gathering my faculties. “I don’t think you broke your hip. And if you don’t want an X-ray, I don’t think
we need one. Perhaps you’d like to go
back to sleep and get some rest?”
“Yes, that sounds good,” he said, drifting off into a
morphine induced altered state of awareness.
I wandered out towards the nursing station, looking around
vaguely for the patient’s chart to make note of my “fall assessment.”
One of the nurses anticipated my need and handed me the
thick plastic folder.
“What does this patient have?” I asked.
“Oh, he has AIDS and metastatic anal cancer” she said as she collected some sputum in a clear plastic cup. “He’s 38 years old.”
“The same age as my boyfriend,” I thought to myself. “And why exactly did he fall?” I asked the
nurse.
“I was trying to help him to get to the commode,” she said printing something on a label. “He fell because I wasn’t strong enough to
hold him up. My right arm is a little
bit weak.”
“And why is your arm weak?” I asked, assuming that it was
because of a small strain injury.
“I have breast cancer,” she said, finally making eye contact
with me.
“Oh my God, I’m so sorry,” I said, feeling the weight of her
diagnosis amidst a ward of terminal cancer patients.
“Well, you know the funny thing is that my husband is
particularly upset. He doesn’t want me
to have a radical mastectomy. He says
that it would hurt to see my body differently than he’s used to… he likes to
think I’m still the bouncy cheerleader I was when we first met. To see me with only one breast is upsetting
to him. And quite frankly, I’m afraid he
won’t be attracted to me anymore. That’s
what scares me the most,” she said, becoming misty-eyed.
My pager let out a familiar series of beeps.
“I’m so sorry,” I said, squeezing the nurse’s shoulder. I paused and tried to be encouraging: “Well, even if you need a mastectomy – I’ve seen some great reconstructive surgeries
where the breast can be reformed at the same time with an implant. Maybe you’ll be a good candidate for that
surgery? I’m so sorry that I have to
run… can we talk later?”
“Sure,” she said, smiling faintly.
***
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2007 by Dr. Val Jones in Medblogger Shout Outs
2 Comments »
Welcome to the latest round up of the best of the healthcare
blogosphere. Today it is my pleasure to offer you your weekly dose of Grand
Rounds, optimized for your state of mind.
I believe that there are two basic types of blog readers, and so you’re
getting Grand Rounds 2 ways (with a dash of cartoons thrown in for extra “feel
good” measure):
- Just
the Facts: Distractible, hurried, currently in between seeing patients –
or perhaps your kids, cats, dogs, llamas are begging for attention… or
maybe you’re an ER nurse or surgeon who has no patience for long winded
stories? You’re category one and
should proceed directly to Grand Rounds IR (immediate release – below).
- All
the Details: Calm, peaceful, you enjoy good prose and a cup of chai
latte. You like reading all the
juicy details of a grand rounds line up and will spend hours picking
through the references – or maybe you’re an Internist or Psychologist who
knows that the best medicine is found in the details? You’re category two and should proceed
directly to Grand Rounds XR (extended release – next post).
Many thanks to Nick Genes, father of Grand Rounds (who acts
behind the scenes to ensure the success of each host), and please check out
next week’s Grand Rounds at Code Blog: Tales of a Nurse.
Grand Rounds IR (asterisk
= honorable mention for great writing)
Happy Posts
*Starbucks Caters to Diabetics
Woman Saved by Bush Pilot in Frozen Tundra
*CEO Says He’s Sorry
Prayer Can Reduce Arthritis Risk?
*Disaster Unpreparedness [Cartoon]
Med School Graduation Ceremony [Cartoon]
Nurse uses Star Trek Mentor to Set Course for Kindness
Galaxy
Shrink Rap Podcast: Prank Call with Dr. Phil McGraw &
More [Cartoon]
*Cape Cod Vacation Derailed by Flood, Stroke, Famine & Infection
The Evils of Hand Washing
Sad Posts
Triage in the ED [Cartoon]
*Sad Cases in ED
Elderly at Risk of Death From Tranquilizers [Cartoon]
Life as a Nurse Assistant in Vermont
Hot Topics
Infanticide
Hucksterism
Healthcare Outsourcing (podcast) [Cartoon]
Blog Censorship A
Blog Censorship B
Arrogant Docs [Cartoon]
Should Kim See Sicko?
Helpful Tips
To Fend off Bears
To Get the most out of Medicine, Web 2.0 style
To Get into Medical
School
To Avoid Kidney Damage from Contrast Agents
To Perform A Pyloromyotomy [Cartoon]
To Diet Successfully – Gluten Free [Cartoon]
Case Reports
Wii-itis
Rare pancreatic tumor
Uncategorized
Cost-benefit analysis of genetic testing
Commencement Speech for Harvard Medical
School Graduation
New Alzheimer’s Research [Cartoon]
New Genetic Research
Book Recommendation for Type 2 Diabetes
For the full text version complete with cheerful commentary, please go to Grand Rounds XR
(next post)
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
June 11th, 2007 by Dr. Val Jones in Medblogger Shout Outs
5 Comments »
…continued from Grand Rounds 3.38…
GRAND ROUNDS XR
(asterisk = honorable mention for great writing)
Happy Posts
*Kerri from Six Until Me tells the heart-warming story of a
Starbucks Barista who understood her diabetic needs and treated her with
special care.
Traveling Doc from Borneo Breezes Blog, submits a post about
the bush pilots of the Canadian north.
Even though it’s summer time you’ll shudder at this arctic tale of a
native woman whose life was saved by a bush pilot and an Australian surgeon.
Tony Chen of Hospital Impact submits a post by Nick Jacobs, the CEO of Winder Medical Center.
In it Christopher apologizes for being ill tempered and snapping at a
woman who posted a paper sign on the wall.
Dr. Jolie Bookspan of the Fitness Fixer Blog offers a
fascinating look at the physical healing power of prayer. Jolie reports that the movements involved in
Muslim prayer (including standing, bowing, kneeling, and sitting) can promote
flexibility, increase quad strength, and burn up to 80 calories/day. She explains that similar prayer posturing
(found in Russian Orthodox prayer and some forms of yoga meditation) may be
equally useful.
Rita Schwab at MSSP Nexus Blog writes a really funny post
about disaster preparedness. She muses
about how she had been taught to hide under her school desk in case of a
bombing, and even then (at the tender age of 8) wondered how the desk vs. bomb
equation would really pan out for her.
But the real amusement comes when you click on her link to the CDC’s
recommended communication releases on such plagues as tularemia. Yes, the bacterium found in rabbits and
rodents (that perhaps 125 hunters succumb to each year in this country) is not
contagious from human to human and causes flu-like symptoms. I’d give this a fear factor of 1 out of 10. [Cartoon]
Dr. Bruce Campbell of Reflections Blog describes the medical
school graduation ceremony – the first time “doctor” is officially tied to the
graduate’s name. [Cartoon]
Mother Jones, RN from Nurse Ratched’s Place, confesses to
being a trekkie. She did find a good
role model in nurse Chapel, though. Now
here’s my confession: I’ve been known to utter a few “Damn it, Jim-s!” when
asked to do non-medical related work at my current job.
Roy
at Shrink Rap pulls a “Jerky Boys” style practical joke on Dinah. He uses prerecorded audio clips of Dr. Phil
McGraw to simulate a live Skype conversation with her, and gets Dr. Phil to ask
Dinah outrageous questions and give her bizarre advice such as, “I want you to
live as a gay woman.” Poor Dinah falls
for it for a short time… and it’s rather funny, especially if you enjoyed the
Jerky Boys prank call to Hooters with Arnold Schwarzennegger clips. [Cartoon]
Laurie at a Chronic Dose tells a hilarious story of 3 chronically ill family members who experience a comedy of errors during a vacation in Cape Cod. Somewhere between the brain aneurysm, flood, sunburn turned staph cellulitis, and cell phone lost in the ocean, there’s humor in the midst of tragedy.
Susan Palwick from Rickety Contrivances of Doing Good describes the evolution of hand washing requirements for all staff (including chaplans) at her hospital.
Sad Posts
ERnursey from ERnursey: Stories from an Emergency Room Nurse
gives us an eye-rolling perspective on exactly how emergency departments are
abused by drug-seekers and non-emergent cases of ridiculousness. Triage ain’t easy. [Cartoon]
*Type B Pre-med from the blog by the same name, offers a
tear jerking slice of life from the ED.
A woman with breast cancer finds out that it has metastasized to her
brain while a 9 year old sexual assault victim waits for the doctor to see him
next.
Christian Bachmann from Med Journal Watch reminds us that
tranquilizing medications are associated with shorter lifespans in the demented
elderly population. [Cartoon]
Matthew at Path Lab tells the sad story of a bariatric patient’s woes in the hospital, and what daily life is like for nurse assistants.
Hot Buttons
Dr. Tara Smith at Aetiology, discusses the tragedy of
infanticide, and the events that led up to the recent murder of a newborn in Iowa. She asks whether designated “safe havens”
(where mothers can drop off unwanted babies, no questions asked) are not
promoted enough by the media or if the state of mind of a woman who has just
given birth to an unwanted baby wouldn’t be receptive to that messaging.
Dr. Hsien-Hsien Lei interviews the CIO of Suracell Personal
Genetic Health to try to get to the bottom of whether or not nutrigenomic
testing is a form of hucksterism. This
quote followed an objection about nutrigenomic supplements costing more
than similar products in health food stores: “Well, our clients like paying
more for what they believe is something better than the cheaper versions.” Orac should take a look at this.
David Williams of Health Business Blog submits a
thought-provoking podcast of a recent interview he conducted with the founder
(founded in 2002) and creator of Planet
Hospital, Rudy
Rupak. Rudy starts the podcast
explaining that his company arranges surgical treatment for travelers who need
emergent care in foreign countries, but later on explains that the primary
income stream for Planet
Hospital involves
healthcare outsourcing for American women who are “too wealthy for Medicaid and
too young for Medicare” and want cosmetic procedures or IVF done at a lower
price. Rudy then explains that he has a
program called “the best of both worlds” where plastic surgeons travel overseas
to perform their procedures for cash – outside of malpractice laws and with
lower overhead. [Cartoon]
Henry Stern, at InsureBlog comments on the recent loss of
Flea and other medical bloggers. He says
that “There’s a creeping reticence in the blogosphere… and maybe that’s a good
thing.”
Amanda from It’s All About the Walls marries her frustration
with her own health issues with some frustration at the apparent censorship of
certain bloggers.
N=1 from Universal Health offers this challenge – doctors
should try to get outside of their egocentric shells and get to know (and learn
from) all of the knowledgeable, competent allied
health professionals around them, especially nurses. [Cartoon]
Kim at Emergiblog expresses deep inner conflict about going to see Michael Moore’s new movie, Sicko. If she goes, she donates $10 to his cause, if she doesn’t go she’ll be left out of a hot topic of conversation. This is a tough call, fair sister.
Helpful Tips
Dr. Auerbach from Healthline describes how to handle
encounters with bears. I didn’t realize
that humans should respond differently, depending on the kind of bear. Check out what to do if you run into a
Grizzly versus a Black Bear.
Bertalan Meskó from Science Roll lists some “Web 2.0”
activities for patients and physicians alike.
But Bertalan forgot about Revolution Health!
Sarah (a bubbly Aggie from Texas A&M) has some
practical tips on how to get into medical school.
Dr. Joshua Schwimmer from Healthline explains that
Gadolinium used to be the contrast agent of choice for patients with kidney
disease (since the regular iodine-based agents can cause “contrast
neuropathy”) but now new cases of a scleroderma-like condition (called
“nephrogentic systemic sclerosis”) have been associated with Gadolinium. Bottom line: if you have kidney disease, any
sort of contrast dye is risky!
Dr. Lisa Marcucci from Inside Surgery offers up the
technical how-to’s for an open pyloromyotomy to repair baby stomachs. Some little ones are born with a narrow,
thickened area in the junction between the stomach and the intestine so food
can’t pass through. But thank goodness
for surgeons like Lisa who can fix them in a jiff! [Cartoon]
Chronic Babe describes her impulsive eating habits and what
she’s going to do to try to avoid chocolatey, salty days in the future. [Cartoon]
Case Reports
Dr. Ves Dimov of Clinical Cases and Images – Blog –
discusses the New England Journal’s recent case report of Acute Wiiitis
(contracted as an overuse injury from the Nintendo video game Wii remote
control). He rightly points out that as
far as medical nomenclature is concerned, “itis” is more appropriately appended
to the name of the affected body part (e.g. tendon-itis). As far as we know, a Wii remote is not part
of the human body – though one can see how the NEJM editors couldn’t resist
accepting the resident physician’s title selection.
Dr. Iñarrito-Castro from Unbounded Medicine presents a
fascinating case report of an exceedingly rare pancreatic tumor. Beautiful imaging and photos.
Uncategorized
Dr. Keith Robison of Omics! Omics! Blog describes his
thought process of what it might take to determine the underlying genetic cause
for one little girl’s unknown syndrome.
In the end he suggests that it might cost $1 million (to map her entire
genome) and result in no clinically useful benefit. In this cost-benefit analysis, it looks as if
mom got it right – love the child as she is, and spend your money on mobility
enhancing equipment.
Dr. Joe Wright submits his commencement speech (for
Harvard’s graduating class of MDs and DDSs) for your consideration.
Girlvet from Madness: Tales of an Emergency Room Nurse
describes some promising research in Alzheimer’s Disease and how her own mom died in a nursing home from complications of the disease. [Cartoon]
Nurse JC Jones from Healthline, highlights the recent
Wellcome Trust announcement of significant advances in the genetic
underpinnings of several major diseases. She includes a recent photograph of
James Watson (of Watson and Crick fame), who is now 79 years old.
Rachel from Tales of My Thirties highly recommends a book
about Type 2 Diabetes.
SPECIAL BONUS POSTS
Now, because Dr. Val has a keen eye and is very meticulous, she has rounded up some savory morsels that she found on her own – these posts were not formally submitted to Grand Rounds 3.38, but will be included because she’s sure their authors wouldn’t object:
Dr. Richard Reece from MedInnovationBlog summarizes Regina Herzlinger’s arguments for consumer driven healthcare.
PandaBearMD explains why he believes that Chiropractors are quacks – and other controversial issues.
Kevin, MD points out that while websites designed to allow patients to rate doctors are gaining acceptance, websites that allow clients to rate lawyers are causing a legal meltdown.
Dr. Stanley Feld (former President of the American Association of Clinical Endocrinologists) takes a very well argued swipe at Dr. Steve Nissen’s recent article about Avandia in the New England Journal of Medicine.
Dr. Charles exposes the quackery of Dr. Heimlich (of the Heimlich maneuver).
Dr. Au from the Underwear Drawer accidentally summarizes the difference between men and women in a conversation with her husband about whether or not to save an old medical school name tag.
Dr. Rob from Musings of a Distractible Mind offers some hilarious genetic explanations for male/female differences.
Hallway Four captures a fascinating disconnect between what a patient thinks a doctor is doing and what a doctor is actually doing.
Dr. Hildreth at the Cheerful Oncologist gives us 8 ways to cope with a malpractice lawsuit.
Dr. Scalpel presents a case of a scratch (plus toenail fungus) sufferer presenting for a work excuse.
#1 Dinosaur argues that obese doctors are more empathic counselors for obese patients who wish to lose weight.
TBTAM recounts a sexual history dialogue in which a patient had condoms delivered at 5am from a local deli.
Ian from ImpactEDnurse continues the condom refrain with an interesting analogy: how practicing “safe nursing” is like practicing safe sex.
FLASHBACK: And for the all time coolest classic blog post… let’s go back to GruntDoc circa 2004 for a look at the scariest menace in the ED: “Some Dude.”
Thanks for reading! Hope you’ll tune in for our regular Wednesday feature of Revolution Rounds – the best of the 27+ person Revolution Medical Blogger team posts, organized and served up friendly by yours truly.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 19th, 2007 by Dr. Val Jones in Medblogger Shout Outs, True Stories
No Comments »
Although these 3 stories are incredibly sad, they serve to
illustrate the realities of this imperfect world – and how heavy some “crosses”
are for people. We should count our
blessings when things go right for us, and reach out to those who are suffering
in unimaginable ways…
From Hallway Four: A
40 year old woman was seen for difficulty breathing and eventually diagnosed
with pneumonia and fluid-overload secondary to need for dialysis. This
lovely lady had been diagnosed recently with kidney cancer of her right kidney
and had undergone nephrectomy (removal of the diseased kidney).
Ordinarily, this would still have left her with one good kidney, which is all
you need. But, as luck would have it, this lady had donated her left
kidney to her ailing sister three years prior.
From Charity Doc: A father of a 7 y/o little boy brings him
into the ED last night reporting that his mother’s boyfriend had beaten him
black and blue with a belt, an assertion that the mother did not deny. The couple had
been divorced for a little over a year. On physical exam, the little boy had
indeed not been spared the rod at all. His buttocks and back were ecchymotic,
black and blue with scattered scabbed marks from numerous whippings and
beatings. It was unbelievable. [Child
protective services ruled that the child should go home with the mother
because] the mother has legal custody of the kid and we can’t send him home
with his father.
From a story relayed at a Rehabilitation Medicine
conference: A set of conjoined twins were born fused at the hip. They were sickly, sharing a circulatory
system that was insufficient to serve both of their needs. The doctors had to make an educated guess as
to how to dissect the two apart from one another – there was only one set of
male genitals, and three legs. They
carefully studied the anatomy and decided to part the twins, giving the
healthier appearing one two legs and the genitalia, leaving the other with only
one leg and no genitals. Several weeks
after the surgery the first twin (with the 2 legs) died. The second twin is still alive, is in his 20’s,
and has been in and out of jail for drug trafficking.
Makes our own problems seem pretty trivial, doesn’t it?
This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
May 4th, 2007 by Dr. Val Jones in True Stories
No Comments »
A few weeks ago I tripped and fell on the sidewalk. I went down on hands and knees and scraped my left knee pretty badly. The onlookers pretended not to notice, I suppose sparing me the embarrassment of asking if I was ok. I dusted myself off and bled down my leg en route to work.
Since then I kept the wound moist with neosporin and band aids, allowing the skin to heal with minimal scarring. But as I marveled at how painful this little patch of road burn is, I remembered a young girl I met about a decade ago who had a much more serious burn.
Inga was camping with her parents in a synthetic tent. They had spent the day fishing and canoing near a campground somewhere in Eastern Europe. They were huddled together inside the tent in the cool of the evening, speaking animatedly about the day’s events and the beauty of nature when Inga accidentally knocked over the kerosene lamp situated near the exit flap. The kerosene spilled out onto the tent and the fire ignited immediately. The tent began to melt in the fire and the zipper got stuck in the hot plastic material. The unimaginable screams of her dying parents as they burned alive, trapped in this tent, brought help just in time to save Inga’s life.
But Inga was horribly disfigured by the fire. She spent nearly a year in the hospital, receiving skin grafts and fighting off infections. She was eventually able to return to school, but was treated like an outcast. Her former friends were too horrified by her appearance to welcome her back and she spent most of her days sitting alone in the corner, covering her face with a scarf, blaming herself for the death of her own parents.
Her story reached the compassionate ears of a plastic surgeon friend of mine. He traveled to Eastern Europe to meet Inga and see if he could help her. As it turns out, she had no living relatives and was dirt poor. He could see that the medical team taking care of her had carefully covered the defects in her skin, but had not attempted to restore a normal appearance with modern plastic surgery techniques.
The surgeon knew that it would take many surgeries over many years to give her the best result possible. After some debate and soul searching, he decided to sponsor Inga to come to America where he committed to taking care of her financial needs and to giving her a new life.
I first met Inga after she had been in the states for several years. She looked like a burn victim, with tight facial skin and abnormal contours – but compared to how she appeared in the photos of when she first arrived (with no nose or cheek flesh at all) this was a huge improvement. She was meeting with the surgeon to have a seroma evacuated from under her left cheek. He had to remove the extra fluid with a large syringe.
As I watched him numb the area and sink a deep, large bore needle into this young girl’s face, I cringed internally but tried to appear unphased for her sake. She didn’t flinch, but sat staring forward bravely, her grey eyes fixed on the wall in front of her. I saw a tear well up and trickle down her disfigured cheek during the procedure and I instinctively reached for her hand. The tears continued in silence. This burn had penetrated so much deeper than the skin.
I haven’t seen Inga since, though I’ve heard that she’s doing well in school, has made some good friends, and is planning to become a nurse one day. Her decision to devote her life to caring for others is a beautiful example of “paying it forward.”This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
