Correct Diagnosis, 99.8% Of The Time

Yellow Feet

 

Those pink feet tell you this photo was posed with a live person.
Ask me how I know.

Some people think fixed and dilated pupils is how you know someone's dead. Others will tell you it's flat brain waves, or asystole on the EKG monitor.

They're wrong.

I was reminded of this fact by the real actual everything-proof acme of you looking down at your own body from outside it, and knowing things are bad.

As someone observed at his own son's funeral, "Being dead is like being stupid. Everyone knows it but you."

But I've gotten pulses back from asystole. It's rare, but not unheard of. I've even seen patients recover from what everyone in the room thought was certain death. Some of them even walked out the front door some days later, to the astonishment of the doctors and staff.

But nobody - NOBODY - who comes in with feet the color of parchment, ever comes back.

I'm pretty sure while the spirit of the former person hovers around, while we all push drugs and do compressions, Death, courtesy of Terry Pratchett, shows up to put the final stamp of approval.

"Wow, I look pretty bad, I wonder if I'll..."

"NO. SORRY. YOU WON'T."

"Are you sure? I mean, I was pretty young and healthy and..."

"AS IF THAT MATTERS. BUT NO, I'M AFRAID NOT. LOOK AT YOUR FEET."

"Wow! Why are they so yellow?"

"BEGINNING TO BE RATHER OBVIOUS WHY, DON'T YOU THINK?"

"Oh. OH! Yeegads! So I'm really...?"

YES. QUITE. SHALL WE BE OFF, THEN? I'VE GOT SEVERAL MORE STOPS JUST YET THIS TRIP..."

And no matter how many more rounds of epi, and bicarb, and calcium, and whatnot, we give,  nor how hard the tech is pumping your rib cage to circulate them around, once we see the parchment yellow Feet Of Death, it's because we just can't squeeze enough blood through your corpse to turn your tootsies that lovely shade of rose pink they ought to be, and would be, if you hadn't already toddled off with Death at some point annoyingly prior.

One minute you were coming home from a party, and the next thing you know, some bony-handed gentleman is dropping you off at the reception desk at the Pearly Gates.

And all the king's horses, and all the king's men, can't undo the rude unhinging of the mechanism of life visited upon you by Fate, Physics, and Physiology.

We're all really sorry about that. Hand to God, we are. But there's just some things we can't fix, and your fate was sealed long before you got to our back door, no matter how much everyone, including people we haven't even met yet, wish it were not so.

I really fucking hate that. I thought, long ago, that one day I might have gotten over it.

But this many decades in, I'm afraid that's just never going to happen. And I suppose if it ever does, that's the signal it's time to get out of this business for good.

It was a long night. It'll be better after I finally get some sleep.

Better still, after I spend a long, quiet day in the park enjoying fresh air, warm sunshine, and a brilliant blue sky, and see the things you can no longer see, and go to the places you will never again go.

But in the pitch darkness of 3 AM, it's just cold. And the only thing making it easier for me is knowing I'll never hear the moans and wails when your parents are located, and get the call no one wants to make, nor be there when the sheet comes back, and they see it's really you there on that table.

Seeing your yellow feet is bad enough. I'm oh so glad I don't have to see the whole show in this tragedy. And I'm really hoping it doesn't cross my mind again tomorrow night.

Sufficient unto each day are the troubles thereof.

O, you can just bet they are.

Diagnosis Of The Week

Thanks for stopping by, and helpfully signing in with everyone's favorite chief complaint:
tummy ache.

Sometimes, you helpfully narrow it down to a flank or a quadrant, and other times, not so much.

Which is why it's called Mystery Abdominal Pain.

Which occasions the triage nurse getting out their deerstalker cap and meerschaum, and playing Sherlock Holmes with you, crossed with a really thorough police interrogation. (Tip to family members: shaddup, and let us get the answers the patient has. We'll be happy to let you fill things in afterwards, but first things first, 'kay?)

For the anatomically vague, a brief lesson.
Chest pain is rather straightforward, there being far less "stuff" to deal with: heart, two lungs, ribs and muscles. Yes, there are other things there for more detail-oriented folks, but that's the highlights. And even then, >5 out of 10 patients with chest pain go home with a diagnosis of "atypical chest pain", which means it's probably not a heart attack, pulmonary embolism, broken ribs, aortic aneurysm, tumor, or 27 other things, and we don't know what it is, but we're relatively certain it isn't going to kill you - tonight, anyway.

Abdomens are a bit more problematic. You have a diaphragm, esophagus, stomach, liver, gall bladder, two kidneys, pancreas, spleen, two different intestines, an appendix hanging out down in the corner, and for those with the internal plumbing option, a full set of female tackle for gestating and producing offspring.

Things that'll kill you relatively soon are things like appendicitis and an ectopic pregnancy. Everything else may only make you wish you were dead. We'll be focusing on the life-threatening options first, and trying to narrow things down as we move along.

Either way, to find out, we're going to need to do a few things. Things like blood tests for standard labs, a CT and/or ultrasound, and we need your pee to make sure you aren't pregnant. For the record, the more sure you are that you "couldn't possibly be" so, without a picture of your uterus in a jar, for any female between about 5 and 50, generally just convinces us you're lying at worst, and mistaken at best, so work with us, and just give up the pee, 'kay?

This is where you can shine, and help yourself: see that computer you're reading this on? When you finish, go to your word processor, and type in your allergies, medical history (that means the things someone with "M.D." after their name has actually clinically told you you have, not the things you Googled before you came in or think you have), along with any surgeries, and a pretty good breakdown on your problem as you understand it.

Unless you had 42 abdominal surgeries in your teens, we really don't want the entire unexpurgated life history of your alimentary canal since 3rd grade, but if you do have some serious issues, by all means fill us in. Start with why you're here right now.

Then, if applicable, recall your last menstrual period, particularly if it seems to have been 8 or 9 months ago.

And if you have an IM, gastro, gyno, renal, etc. specialist(s) you see or have seen, by all means, their name and phone number.

Minus points if you deny significant history, and then we find a scar around your middle big enough to swap body parts, or even find those cute little nicks on the sides that tell us someone's been worked on by laparoscopy.

And for f***'s sake, NO, YOU CAN'T HAVE ANYTHING TO EAT OR DRINK, UNLESS IT'S
1) A COUPLE OF CHIPS OF ICE TO WET YOUR MOUTH AFTER THE OPIATE PAIN RELIEVER MAKES YOU FEEL LIKE YOU'VE BEEN SUCKING ON COTTON SOCKS, OR,
2) IF YOU'RE REALLY LUCKY, YOU CAN GUZZLE SOME OF THAT NUMMY RANDOM FRUIT-FLAVORED CT CONTRAST.

Re-read that menu above, and note that it doesn't contain double cheeseburgers, anchovy pizza, or Flaming Hot Jalapeno Cheetos, or anything else, whatsoever. Try and remember that sneaking that stuff in past us anyways is all fun and games, until your surgery is delayed because the risks of anesthesia are too great with your recent meal, so now you have to sit around and feel your appendix bursting, because the anesthesiologist isn't going to risk getting sued when you vomit during surgery, aspirate, and become a bigger brain-dead vegetable head than you were when you snuck the Monster Whopper with Fries down your gaping maw while waiting for the CT scan.

But please, do understand that if you keep pushing the point, eventually we'll realize you don't just have an abdominal problem, you also have the brain of a stegosaurus pulsing, peanut-like, somewhere inside your great empty cranial vault.

Patient Safety tip: we also frown on people laughing at sit-coms while they wait yet subsequently reporting that their pain is a "10 out of 10"; ditto if we had to wake you up to ask you how much it's troubling you. Imagine Wile E. Coyote, the boxful of knives and sharp objects, and the rock ledge he fell off of landing on your tenderest spot - if you're feeling that, and we walk in to see you doubled over, sweating, moaning, and writhing, we'll buy it. Otherwise, we'll write down your "10", then record "patient was in no distress, smiling and laughing" which is medical chartese for "horrible actor, terrible liar, and no Oscar nomination". Doubly so if you're "in pain" when we ask, but look just fine when we sneak a peek over your shoulder a minute later from the hallway (trust me, we do this a lot - thank the local drug seeking junkies); if that happens, you're so busted. Please, I beg you, don't be that guy. It's cold in Siberia, and mentally, everyone will banish you there.

If you do all this, you'll save us a lot of wasted effort, and yourself several extra wasted hours on what's liable to be a 2-4 hour process. Which, despite everyone's best intentions, still may fail to find a diagnosable condition or cause for your pain. Which doesn't mean you don't have anything, just that we can't tell you what it is, how to fix it, or when it will go away.

And a lot like the atypical chest pain patient, if we send you home, it means whatever it is isn't going to kill you imminently, even if you still think you're going to die.
The same is true for your child, and for the same reasons. When you get bored, fed up, or exasperated with the process, remember you came to us for a good reason, and we aren't kidding when we make you sign the AMA form, and list possible outcomes starting with "DEATH". We yell because we care.

But you may still need to follow up with a specialist, rather than come back here serially after refusing to do the follow up, because "the mystery pain is back". Which quote is how we'll soon lovingly refer to your return visit if you keep pulling this schtick without doing what you were told.

Live and learn.

Diagnosis Of the Week

Here you are, 24/7/365.

What you have is a shiny, red, painful, growing-like-a-goldfish-in-a-Doctor-Seuss-story bump, somewhere on your body. Your neck, arm, armpit, or some less public region.

What you think you have is how you sign in: "Spider bite".
What the doctor will tell you have is an "Abscess".

Thus, the correct diagnosis can only be "MRSA Spider bite".

Regular spider bites are relatively fairly rare.
For the entomologically tutored, the only venoumous spiders on the North American continent at least, are two:
Black Widows (lactrodectus mactans), and
Brown Recluses (loxosceles reclusa).

So unless you physically sighted one of the two above-named species at the scene of the crime, tiptoeing off with a guilty look on his or her multi-eyed face, and furthermore have, now and in your body, the signs and symptoms of insectoid envenomization with arachnid neurotoxin, please, stop blaming your little problems on spiders.

MRSA, carried not by the imaginary MRSA Spider, on the other hand, is a particularly disease-resistant strain of the bacterium Staph aureus, which someone you've come into contact with has given to or deposited upon you, and which may even now have colonized your body. We know this because you've been seen here for three other "spider bites" in the last six months. Laymen not medically trained often refer to this little factoid as a "clue", not a license to impugn the motives and culpability of every arachnoid in your world.

There's a way around this. Actually several.
1) Wash your nasty ass, ideally daily, and using not only fairly warm water, but also a decent scrub brush or cloth, and any number of personal hygiene products hitherto strange to you, most specifically soap. Lather, rinse, repeat.
2) Encourage the unheard of approach of similar behavior amongst your spawn, your clan, and your significant others.
3) Get a prescription for the antibiotics to kill the MRSA, and actually follow the directions and take the pills, on schedule, until they're all finished. I know how hard this is, but make an effort.
4) Do the same for every one of your spawn, clan, and significant others who have a similar history of recurrent "spider bites".
5) Scour your nasty hovel, with any number of bacteriocidic products, like Lysol, Pinesol, etc. Going as far as to actually burn your shanty to the ground is a bit extreme, but as I haven't seen your living conditions, I'm not going to rule it out immediately, sight unseen. Desperate circumstances may indeed demand desperate measures.
6) While you're at it, avail yourself of such radical notions as sweeping, vacuuming, throwing away garbage, and killing all bugs, rodents, and other vermin in your hovel. Clean out the places they live, and deprive them of the food they eat.

I know how hard it is to not live like a hobo in a third world roach motel, but think of it this way: an hour with a mop and a bucket of warm water, followed by a long hot shower, hurts a lot less than having our P.A. slash into that big nasty welt on your butt and dig around to get all the pus out. Your efforts, unlike ours, won't usually make you let out blood-curdling screams, and housework seldom, if ever, leaves lasting scars. Unlike an I&D.

It's your hide, and so is the choice.

But the needles and scalpels are all us, baby.

Diagnosis Of The Week

Given: a waiting room filled with patients, multi-hour waits for beds, and any number of which waiting visitors to the ER are complaining of acute onset abdominal pain, nausea/vomiting/diarrhea. Trashcan from home optional.

Medically, as events unfold, you would certainly be right to assume with a high likelihood of success that many of those patients are suffering from what is variously known as Traveller's Curse, Montezuma's Revenge, the Food Court Two-Step, or, in medical parlance, gastroenteritis.

And you'd be right.

But the most correct diagnosis would be : Not Dying Any Faster Than The Rest Of Us.

I say this because for most any but the uber-frail, the pregnant, the very young, or the very old, they aren't.

Gastorenteritis is a fecal-oral vector, meaning of course that someone, somewhere didn't lave los manos, and thus got their peanut butter in your cakehole. Maybe right before they made or served you your burrito platter, or grabbed that doorknob, or when their cute baby had an accident on that nifty plastic seat on the shopping cart that's now yours. It might even have been your baby.

For whatever reason, your bowels have now made you their bitch, because in a blatantly evolutionary move to self-preserve, they have, in a matter of hours since you so foolishly ate without washing your hands (or someone helpfully didn't wash theirs), decided to hold serial nuclear launch drills for everything not attached to you GI tract, from both ends.

Which, in short order, finds you alternately pointing one of your ends or the other at the porcelain altar whereon you will worship, in between those oh-so-soothing periods of momentary respite laying on the cool bathroom floor.

But eventually, even though all good things must come to an end, this hasn't, so during a temporary truce with your innards, you and/or some soul of your intimate association ends up driving you to see me.

Some things you should know, in managing your own care, not to mention expectations, while you wait.

There are generally two phases to gastroenteritis.
In Phase One, you're afraid you're going to die.
In Phase Two, you're afraid you're not.
I know that by the time you and I chat at the ER entryway, you're likely well into Phase Two.
Please believe me when I tell you that after an unfortunate encounter with a hygiene-challenged server at the local mall's food court a couple years back, in which I was re-acquainted with the syndrome of which I speak now, I truly do feel your pain.

That fact notwithstanding, please accept as gospel, that unless you produce either the winning Powerball ticket, serial 24K solid gold nuggets, or the body of Jimmy Hoffa, there is nothing in your barf that I, the other staff, the doctors, or anyone in North America wants to "take a look at". I don't care if you ate alphabet soup and coincidentally horked up the entire Revelation of St. John, in Greek, or launched out something that's the spitting image (you should forgive the pun) of DaVinci's Mona Lisa. Keep it to yourself, and leave it at home. Don't even use a clear bag.

And please, right after you ate tomato and red pepper salad, shredded beets, and two helpings of ice cream with strawberries, don't come up to me and tell me you/your spouse/your child/Sumdood in the seat next to you is "throwing up blood". For heaven's sake not if you needed a knitting needle and a magnifying glass to spot the "blood fleck" in your precious child's puke. If you didn't see a fountain that looks like Yul Brenner's Nile-side lawn ornament in "The Ten Commandments" spewing a bucket of it, it's probably not. We'll check it, but as a rule, when I see your 6 year old you rushed in here at midnight after you waited 6 hours for every nearby Urgent Care to close first, and he's watching TV and eating Flaming Hot Cheetos, I'm not buying a diagnosis of his esophageal varices ripped asunder, no matter what you googled on the internet before you came in, m'kay?.

On that subject, stop "checking" to see if you can't keep anything down by continuing to stuff things in your maw. No, really. When I ask how often you/your spouse/your child/your spouse who's acting like a child has been vomiting, and your answer is "every time he eats/drinks something", I'm going to gobsmack you with the mackerel revelation from the Groucho Marx School Of Medicine, and tell you to stop eating and drinking stuff. If this is news to you when you/they have abdominal pain, nausea, vomiting, and diarrhea, put "brain death" on the sign-in sheet under "additional complaints".

Thanks for bringing a bucket, trashcan, lawn bag, whatever. Bonus points if it was clean and empty when you left home. But don't use my trashcan, or sinks, for your sudden urges. I get barfierre bags free where I work, and there's no limit to how many I'll give you, esp. if I see you filling them serially. But the first time you miss because the trash can next to my desk, or the sink with the strainer where I wash my hands looked like a better spot, or because the bag I gave you is in your purse, pocket, or backpack, instead of ready in your hand, please understand that you're now on My List, and have been mentally moved from "In Pain" to "Being A Pain". Work with me, and I'll work with you. Screw me, and...well, you get the idea.

Be advised further: you can bleed on me, and I won't bleed on you. You could spit on me, and I won't spit on you. You can even pee on me, and I won't pee on you. (What I will do won't be nice, but it won't strictly be eye-for-an-eye retribution.) But, I want to make it absolutely clear, if you puke on me, it's coming right back at ya, and believe me, I wasn't sick today, so I've got a lot more material handy to work with. Use the provided bag, not my scrubs, my lap, or my face. JCAHO frowns on me shoving your head in a bucket, but they aren't here, and I am. Once again, participate in your care by not making me want to kill you.

That goes out in the waiting area too. Spewing a fountain once is guaranteed to get you some space out there, but moving to a new area, and then repeating the process, is liable to add "victim of assault" to your check-in complaint list.

Please - pay special attention here - I have, no $#!^, worked on more movies and TV shows than you've seen, and with any number of Emmy and Academy Award-winning directors and actors. So I know good acting. And bad acting. And the nurse in your ER, even without my experience, can spot it too, because we've seen the triage movie short subject "Death Of A Whiner" an average of 6000 times in our careers, and it never, ever, ever works. The part you're auditioning for is "The Invisible Man", because that's how you're going to be treated, likely as not. Skip any inclination to dramatic endeavors, and stick to your day job.
 
I know you're miserable. I know if only you could go back in time a couple of hours or days, you'd have skipped tuna, and gone with a nice fresh salad bar salad. But between your first set of vitals and until I've finally got the space for you to get seen, get some meds, perhaps some IV fluids, and anything else the Dr. thinks appropriate, and despite what you perceive as an end-of-life event, you likely really aren't dying any faster than the rest of us are.

Take the word "patient" to heart, and believe me, the soonest I can get you to a bed, to cash in your ticket for the Zofran Express, I'm going to do it. And until you're officially diagnosed, there's always the possibility that more may be going on, so yes, you needed to be here. But try to understand why we maybe took the 70-year old with stroke symptoms, or the 55 year-old lady with chest pain first.

Diagnosis Of The Week

Nigh on Impossible Stick and IDDM diabetic patient (and family entourage) on their 3rd visit in 7 days, and their 15th in 3 weeks time.

Pt. totally out of it, with a blood sugar reading of 1246 on initial lab draw.

After yet another half-night's being carefully flown down to the mid-300s, and yet another overnight ICU admit, pt. candidly admits to doing level best to kill most of half a gallon of delicious mint-chocolate chip ice cream that day.

While the initial urge to call this Sugar Suicide is a good choice, sober reflection will correctly diagnose this condition as
Low Grey Matter Titer.

And my state's Health and Welfare and Penal Codes notwithstanding, I'm firmly of the opinion that a diabetic eating a tub of ice cream meets the textbook legal definition of Informed Consent For Therapeutic Headslapping, (normally an independent intervention, but also backed up resolutely by the ER doc, as usual) and a serious argument for having granted Power Of Attorney to do the same to the rest of the Tard Family, for watching these proceedings from lunchtime to ICU, inclusive.

That scene in Harry Potter: Goblet Of Fire, where the dragon spews fire at the rock he's cowering behind is what I'm calling tonight's "patient education" portion of my nursing interventions for this patient. And if I can find a brochure for the local mortuary to hand them for the inevitable funeral planning, while everyone in the room is alert, conscious, and breathing, it should be the cherry on their cake. (You should forgive the pun.)

Diagnosis Of The Week

My batting average at diagnosis/guesstimating fractures is nearly a perfect 1.000 average. By which I mean, I've been, I recollect, 100% wrong when thinking a bone is fractured, and complementarily 100% wrong when thinking a bone isn't fractured. This has been confirmed by diagnostic radiology studies in a lengthy host of instances. I note with some measure of reassurance that many of my colleagues are similarly handicapped in the Superman x-ray vision department. Which is why my default answer to someone is that we need to get an x-ray and actually see.

The one exception to this abysmally bad knack for prognostication is the subject of today's little chat. That exception is the Stevie Wonder Fracture. Some people who aren't radiologists or orthopedists, and are doubtless destined to be future Final Jeopardy contestants, may pride themselves on knowing every obscure type of bone fracture in the atlases and professional references.

You will not, however, find the Stevie Wonder Fracture listed therein.
Fortuitously though, it needn't be.
Because, quite simply, any anatomical structure with an underlying osseous substrata which is so obviously malformed as to require a broken bone is, in fact, a Stevie Wonder Fracture.

When 10 year old arrives, self-splinting a forearm in the shape reminiscent of the Mark Of Zorro, and it's so brokedy-broke that a blind person, without any medical training whatsoever, and forced to assess solely by Braille, would diagnose a broken bone, you have sighted (pardon the unintentional irony) a Stevie Wonder Fracture.

When the wannabe ski bunny arrives, and I or one of my colleagues tells you, in a style reminiscent of Blaine Edwards/Damon Wayons in the "Men On" segments of In Living Color, that your arriving patient has a leg with "3 snaps in a Z formation", you can report to the doctor with 0% chance of error that the patient has a Stevie Wonder Fracture.

Nota bene that there is no requirement for the bones to be currently nor at any time subsequent to original injury, actually protruding through skin to any degree. The true benefit of the Stevie Wonder fracture diagnosis is that it doesn't rely on such cheap parlor tricks as actually seeing the jagged fragment of a formerly intact bone in order to justify the diagnosis. And besides, that'd be cheating.

Diagnosis Of The Week

Once upon a time, prior to entering nursing school, using the time-honored "try before you buy" approach, I took patient care out for a test spin. While doing volunteer patient care with some of the best medical professionals (paid or unpaid) I've ever been privileged to work with, we had occasion to do a lot of community events.

One especially notable one was an annual two-day air show which always drew upwards of 500,000 visitors for the two days. Because jets are cool, and entry was free.

The plus for us was, with that many bodies, we were going to get business. The minus for the city involved was, with that many bodies, there was no way they were getting an ambulance into the site, and even if they did, it would create more problems than it solved. So for everything from sore feet to heart attacks, we were it.

Mind you, were were up to the task, both from a personnel stand-point, to the fact that we essentially set up a 20-bed treatment area in the former airfield fire station, which became Airshow ER for those two days every summer.

But bureaucracies run on paperwork, so every year, after things wound down, the local supervisor of constables would come around, and get the low-down on the numbers and categories of patients we'd treated, for everyone from the airport manager to the mayor, and 27 agencies in between the two.

So one year, Fearless Leader is giving Lieutenant Doright the annual tally of victimology: 

"We watered 20,000 cups worth of participants;
 had 852 people needing sunscreen;
6 difficulty breathings, resolved;
2 chest pains, both transported by city fire; 
3 diabetic emergencies;
8 pedestrian-versus-airplanes..."

"Sorry, I thought the planes were parked. Did they run over the...?"
"Oh no, sorry, what happens is, the people are walking around the parked planes with missile racks hanging down and sharp wings and such, and not paying attention as they gawk, and they bonk into them headfirst.
 Where was I?...
okay, 11 foot injuries;
412 heat-related complaints, all recovered after treatment;
and 4 elderly patients FDGB."
"Sorry, what's an FDGB. I've got 20 years on the street, and I've never heard that one before from the city paramedics."

"Fall Down. Go BOOM!"
"Gotcha. Don't take this personally, but I think you guys enjoy this business too much." 



Dear Readers, from that day to this, one of my solemn healthcare missions in life is to make FDGB as commonly used and accepted as SOB, GSW, AAA, and countless other acronyms in the medical field. I didn't invent it, it's in the Public Domain, in fact it's even made it into the Urban Dictionary after 20+ years usage, but it accurately summarizes any number of medical runs and sign-ins that you'll see in the course of your career.

So I humbly request that you join me in proudly using FDGB, every time it applies.

Diagnosis Of The Week

Teenage male, suffering from closed head injury with no LOC, multiple contusions and abrasions, and two phalangeal fractures, secondary to testing out the nifty new 1/4 pipe plywood bike ramp he and his buddies built in the driveway, sans helmet, prior experience with helmets or ramps, or any other rationale for building it or trying it out other than "Because we could." Because 14 year olds are invincible and immortal.

Enterred onto tracker board as "Failure To Fly".

Attaboy from Rapid Track doc, golf clap from nurse, tech, and secretary.

Discharge Instructions: referred to warning on box of Superman Halloween costumes, given link to internet website of Hollywood Stuntmen's Association, and read riot act regarding lack of appropriate head protection.

Just doing my job, folks.