F. N. Stein and IBS Computing announced today that they have completed design and construction of the next generation of smart phones. The new ultra portable phones are completely implantable, combining the latest in biocompatible materials with the most powerful nanotechnology ever developed.
“This new technology far exceeds the technology offered by the existing I- Phone or Android systems. The Q Phone, as it is called, comes in two parts which are implanted under the skin of the user, a receiver implanted in front of the ear and a transmitter implanted beneath the buccal mucosa within the mouth,” stated Dr. Stein, CEO of F.N. Stein.
He went on to add that the convenience and power of these phones will bring new meaning to the term “smart” phone.
“If the existing technology is called smart, these will have to be dubbed genius”, Dr. Stein gushed. “It will no longer be necessary to carry your phone in your pocket or on your belt and you can get rid of those ugly Bluetooth ear pieces once and for all.”
Dr. Stein went on to explain that the new phone automatically integrates with signals from your brain to dial a contact in a nanosecond. Conversations are completely private as the transmitter can send a clear signal even if it is only the faintest whisper. Incoming calls are audible only to the receiver and text messages are transmitted directly to the cerebral cortex. It will no longer be necessary to fumble with your phone or push buttons or “swipe” icons back and forth. The Q Phone is 100% intuitive and functions are executed with only a quick thought.
“The Q Phone goes far beyond “hands free”, Dr. Stein proclaimed. “It’s almost speech free. The controversial ‘driving while texting’ debate will become ancient history as these phones free the driver to concentrate on the road, even while sending out and receiving messages with just a thought.”
There are already hundreds of thousands of useful and unique “apps” for the Q Phone. Besides the obvious GPS or reading apps, the new technology expands the possibilities, making this phone truly worthy of the name “genius”.
Expected to be among the more popular applications is the new Date Buddy. This completely free app will be your coach during those trying moments when you are trying to make time with that hot babe at work. Instead of the usual fumbling for the right words, the Date Buddy will automatically monitor the conversation and transmit witty sayings to the subscriber, guaranteeing that the target will be swept away by the users dashing and debonair manner.
For the user expecting to appear on “Jeopardy” the Q Phone has instant access to the entire Internet, discreetly and secretly. The Wikipedia app can bring the entire online encyclopedia to the tip of your tongue instantly guaranteeing that even the dullest user will appear intelligent and sophisticated.
“We’re expecting to be able to release these implantable phones before the second quarter of 2011. We’re still working out a few bugs with the implant technology. Right now it requires a visit to the doctor to have the devices properly implanted. We’re hoping that a self implantation kit will be feasible before the final version is released”, Dr. Stein reported.
There was no immediate comment from representatives of Google, makers of the Android platform; however, Steve Jobs was quoted as saying “This implantable phone is pirated from technology developed by Apple. The IPhone 5 was slated to be such a device. We intend to file a patent infringement suit in Superior Court next week.”
Dr. Stein laughed off Mr. Job’s comments, saying that he had been working on this sort of device for decades.
More information is available at http://www.geniusqphone.com
We at “Heard in the OR” will keep you posted as this story develops.
Saturday, August 28, 2010
Saturday, August 14, 2010
Don't Think
I read a missive from hospital administration recently, posted on the wall in the physicians work area at one of the hospitals. The message read something along these lines:
“Per JCAHO* regulations physicians should refrain from writing orders allowing for a range of medication to be administered. Specifically, pain medication orders should not say:
Dilaudid 1-2 mg IV Q3h prn pain
Instead such orders should be written:
Dilaudid 1 mg IV Q3h prn moderate pain
Dilaudid 2 mg IV q3h prn severe pain
Orders written in the former manner, allowing for a range of dosage allow the nurse administering the medication to make independent judgment decisions. Such decision making is not permitted under the nursing licensure.”
My reaction to this directive was that the lunatics are in charge of the asylum and everyone should run for cover. Nurses are to become robots, methodically passing out meds and dutifully charting when the patient last belched, while ignoring their patients overall wellbeing. I asked several of the nurses in various hospitals their opinion of this rule. I pointed out that, to me, there wasn’t any difference between the two orders. What they said was a bit disconcerting. The nurse is supposed to ask the patient about the severity of their pain and then medicate accordingly. So, if the patient responds that he is feeling severe pain he is given the higher dose, no questions asked.
Now, I’ve been in practice for over twenty years and I can tell you that pain; its intensity, quality, severity and every other aspect is the most subjective of clinical symptoms. I’ve had patients, who have undergone a very minor procedure, tell me the pain is the most excruciating they’ve ever felt, while others, who have just undergone a major abdominal surgery with a stem to stern incision, report only mild discomfort.
There are patients who appear nearly comatose after surgery, barely arousable, but will state that their pain is severe and will request their medication every three hours on the dot. In this situation, what is the nurse to do? Blindly administer the higher dose prescribed for severe pain or actually think that the patient’s pain may not be as severe as reported and give the lower dose, and/ or call the doctor to have the medication adjusted.
No matter what, a good nurse has to use her best judgment to care for her patient in the most compassionate, but also clinically appropriate, manner possible. Patients, who are human, have widely varying ideas of what the hospital experience should be, particularly when it comes to pain. For some, pain relief means completely numb from head to toe; for others it means just enough medication to have the edge taken off. Most are somewhere in the middle. The nurse serves as the doctor’s eyes, learns to make a proper judgment and provides a continuous image that complements the snapshot the doctor receives on daily rounds.
The idea that nurses not be allowed to think echoes the words of one of my medical school instructors, Dr. John Adams. In the early 1980’s I was at the University of Rochester Medical School in upstate New York. Dr. Adams was the classic curmudgeonly surgeon. Loud, intolerant of ignorance or incompetence by subordinates, he often chastised the residents on his service for writing orders with a dosage range in the way that is now prohibited. He must be working for the JCAHO, because his exact words were:
“Don’t write Demerol 50-75 mg IM q3h. That allows the nurse to think; we don’t want the nurses to think. Their job is to do what they are told to do.”
Who would have thought chauvinistic Dr. Adams was such a visionary?
Actually, I don’t think that he had such a low opinion of nurses, rather, I believe, he was trying to drive home a message to the residents and students: orders should be clear and specific. Such clarity allows the nurse to perform her task efficiently and provide the patient with the best care possible. Doctors and nurses are a team, working together to help an individual who is sick or injured recover and return to a normal life.
Years ago I read a study on factors affecting outcomes on critically ill patients. I don’t remember which journal it was in, but the study looked at ICU patients and a number of variables that could have an effect on the patient’s recovery. The only variable that made any difference was the quality of nursing care.
This makes perfect sense to me. The critically ill patient requires continuous monitoring. Most of the time it is the nurse that is at the bedside checking vital signs, urine output, oxygenation and every other parameter that may be indicative of the patients well-being. The best ICU nurses will pick up on subtle changes that could be harbingers of impending deterioration in the patient’s clinical condition. If such nurses are shackled by the “don’t think and don’t make judgment” rules, these critically ill patients will suffer.
Besides acting as physician’s eyes, nurses also provide a level of protection for the patient. If an order is written or a medication prescribed that seems to be in error the nurse is there to question it. Despite what some doctors may believe, we physicians are not perfect and sometimes errors are made. A vigilant nurse often picks up on this, questioning the order; calling the doctor for a “clarification” (correction). Sometimes it is an omission that needs to be brought to the doctor’s attention. In all situations the nurse is the patient’s advocate, doing his or her best to smooth the often bumpy road to recovery.
Doctor’s, by necessity, approach patient care from a very different angle than nurses. Medical School and residency teach us the underlying pathophysiology and the clinical manifestations of various diseases and medical conditions. We take this information and establish a diagnosis and institute a therapeutic plan. Our primary purpose is to see that the disease process is properly treated and see the patient to a complete recovery or at least keep chronic diseases under control.
Nurses share in this goal, but along the way they are often called upon to provide comfort, counseling and to allay fears. The nature of their profession allows nurses to do this in a way doctors cannot. The best nurses always seem to find the time to sit with their patients, provide reassurance and still manage to do all the ridiculous charting and filling out of seemingly endless forms that generate reams of paper that no one ever looks at.
In the middle of these essential activities the nurse often have their carefully planned schedule disturbed by a million other tasks, usually accommodating the interruption with a smile and a shrug of the shoulders. I know that when I have asked nurses to help with a bedside procedure they are only eager to help and always insist on finishing up all the cleaning and reordering of the patient room when I am finished. I sometimes wonder if it is eagerness to do all they can to help or if they really want to be sure that the patient’s room is properly returned to an orderly state.
Nurses are truly amazing in their ability to calm anxiety, inform ignorance, allay fear, provide comfort, stroke egos (especially OR nurses), see us all at our worst moments and invade our most intimate places and do it all with a smile and a wink that says “I know you don’t feel well now, but just give us a little time and you’ll back home with your loved ones before you know it.
I may be a bit biased towards nurses. After all, I married one; Laura, my wonderful, beautiful, intelligent wife of twenty five years, the cutest little nurse I had ever seen, always took the time to talk to her patients, share their feelings and make sure that all their treatment was delivered in the best, most professional manner. When we first met I think I used to exasperate her by my asking for patients’ vital signs and her appraisal of their condition. But, we shared our concern for the patients’ well being and have continued to share for twenty five years.
Nurses and doctors, along with surgical technicians, respiratory therapists, physical therapists, occupational therapists, speech pathologists, patient care aids and all the other allied health personnel, share a common goal; that is to treat the sick and injured and allow them to return to happy, healthy, productive lives. The doctor provides the diagnosis and overall therapeutic plan, institutes the plan’s delivery and makes alterations and interventions when necessary. The nurse provides the monitoring, the immediate delivery of therapy, nurturing, comforting and compassion on a continuous basis. If our nurses are not allowed to “think” our patients will end up suffering, with longer stays in the hospital and some, I am sure, will never leave the hospital.
It is something for all of us to think about.
*Joint Commission on accreditation of Healthcare Organizations
“Per JCAHO* regulations physicians should refrain from writing orders allowing for a range of medication to be administered. Specifically, pain medication orders should not say:
Dilaudid 1-2 mg IV Q3h prn pain
Instead such orders should be written:
Dilaudid 1 mg IV Q3h prn moderate pain
Dilaudid 2 mg IV q3h prn severe pain
Orders written in the former manner, allowing for a range of dosage allow the nurse administering the medication to make independent judgment decisions. Such decision making is not permitted under the nursing licensure.”
My reaction to this directive was that the lunatics are in charge of the asylum and everyone should run for cover. Nurses are to become robots, methodically passing out meds and dutifully charting when the patient last belched, while ignoring their patients overall wellbeing. I asked several of the nurses in various hospitals their opinion of this rule. I pointed out that, to me, there wasn’t any difference between the two orders. What they said was a bit disconcerting. The nurse is supposed to ask the patient about the severity of their pain and then medicate accordingly. So, if the patient responds that he is feeling severe pain he is given the higher dose, no questions asked.
Now, I’ve been in practice for over twenty years and I can tell you that pain; its intensity, quality, severity and every other aspect is the most subjective of clinical symptoms. I’ve had patients, who have undergone a very minor procedure, tell me the pain is the most excruciating they’ve ever felt, while others, who have just undergone a major abdominal surgery with a stem to stern incision, report only mild discomfort.
There are patients who appear nearly comatose after surgery, barely arousable, but will state that their pain is severe and will request their medication every three hours on the dot. In this situation, what is the nurse to do? Blindly administer the higher dose prescribed for severe pain or actually think that the patient’s pain may not be as severe as reported and give the lower dose, and/ or call the doctor to have the medication adjusted.
No matter what, a good nurse has to use her best judgment to care for her patient in the most compassionate, but also clinically appropriate, manner possible. Patients, who are human, have widely varying ideas of what the hospital experience should be, particularly when it comes to pain. For some, pain relief means completely numb from head to toe; for others it means just enough medication to have the edge taken off. Most are somewhere in the middle. The nurse serves as the doctor’s eyes, learns to make a proper judgment and provides a continuous image that complements the snapshot the doctor receives on daily rounds.
The idea that nurses not be allowed to think echoes the words of one of my medical school instructors, Dr. John Adams. In the early 1980’s I was at the University of Rochester Medical School in upstate New York. Dr. Adams was the classic curmudgeonly surgeon. Loud, intolerant of ignorance or incompetence by subordinates, he often chastised the residents on his service for writing orders with a dosage range in the way that is now prohibited. He must be working for the JCAHO, because his exact words were:
“Don’t write Demerol 50-75 mg IM q3h. That allows the nurse to think; we don’t want the nurses to think. Their job is to do what they are told to do.”
Who would have thought chauvinistic Dr. Adams was such a visionary?
Actually, I don’t think that he had such a low opinion of nurses, rather, I believe, he was trying to drive home a message to the residents and students: orders should be clear and specific. Such clarity allows the nurse to perform her task efficiently and provide the patient with the best care possible. Doctors and nurses are a team, working together to help an individual who is sick or injured recover and return to a normal life.
Years ago I read a study on factors affecting outcomes on critically ill patients. I don’t remember which journal it was in, but the study looked at ICU patients and a number of variables that could have an effect on the patient’s recovery. The only variable that made any difference was the quality of nursing care.
This makes perfect sense to me. The critically ill patient requires continuous monitoring. Most of the time it is the nurse that is at the bedside checking vital signs, urine output, oxygenation and every other parameter that may be indicative of the patients well-being. The best ICU nurses will pick up on subtle changes that could be harbingers of impending deterioration in the patient’s clinical condition. If such nurses are shackled by the “don’t think and don’t make judgment” rules, these critically ill patients will suffer.
Besides acting as physician’s eyes, nurses also provide a level of protection for the patient. If an order is written or a medication prescribed that seems to be in error the nurse is there to question it. Despite what some doctors may believe, we physicians are not perfect and sometimes errors are made. A vigilant nurse often picks up on this, questioning the order; calling the doctor for a “clarification” (correction). Sometimes it is an omission that needs to be brought to the doctor’s attention. In all situations the nurse is the patient’s advocate, doing his or her best to smooth the often bumpy road to recovery.
Doctor’s, by necessity, approach patient care from a very different angle than nurses. Medical School and residency teach us the underlying pathophysiology and the clinical manifestations of various diseases and medical conditions. We take this information and establish a diagnosis and institute a therapeutic plan. Our primary purpose is to see that the disease process is properly treated and see the patient to a complete recovery or at least keep chronic diseases under control.
Nurses share in this goal, but along the way they are often called upon to provide comfort, counseling and to allay fears. The nature of their profession allows nurses to do this in a way doctors cannot. The best nurses always seem to find the time to sit with their patients, provide reassurance and still manage to do all the ridiculous charting and filling out of seemingly endless forms that generate reams of paper that no one ever looks at.
In the middle of these essential activities the nurse often have their carefully planned schedule disturbed by a million other tasks, usually accommodating the interruption with a smile and a shrug of the shoulders. I know that when I have asked nurses to help with a bedside procedure they are only eager to help and always insist on finishing up all the cleaning and reordering of the patient room when I am finished. I sometimes wonder if it is eagerness to do all they can to help or if they really want to be sure that the patient’s room is properly returned to an orderly state.
Nurses are truly amazing in their ability to calm anxiety, inform ignorance, allay fear, provide comfort, stroke egos (especially OR nurses), see us all at our worst moments and invade our most intimate places and do it all with a smile and a wink that says “I know you don’t feel well now, but just give us a little time and you’ll back home with your loved ones before you know it.
I may be a bit biased towards nurses. After all, I married one; Laura, my wonderful, beautiful, intelligent wife of twenty five years, the cutest little nurse I had ever seen, always took the time to talk to her patients, share their feelings and make sure that all their treatment was delivered in the best, most professional manner. When we first met I think I used to exasperate her by my asking for patients’ vital signs and her appraisal of their condition. But, we shared our concern for the patients’ well being and have continued to share for twenty five years.
Nurses and doctors, along with surgical technicians, respiratory therapists, physical therapists, occupational therapists, speech pathologists, patient care aids and all the other allied health personnel, share a common goal; that is to treat the sick and injured and allow them to return to happy, healthy, productive lives. The doctor provides the diagnosis and overall therapeutic plan, institutes the plan’s delivery and makes alterations and interventions when necessary. The nurse provides the monitoring, the immediate delivery of therapy, nurturing, comforting and compassion on a continuous basis. If our nurses are not allowed to “think” our patients will end up suffering, with longer stays in the hospital and some, I am sure, will never leave the hospital.
It is something for all of us to think about.
*Joint Commission on accreditation of Healthcare Organizations
Sunday, August 8, 2010
Backyard Nature
The World Around Us
This evening I sat in my backyard next to our swimming pool and watched the myriad activity in the bushes and the trees that line the rear edge of our yard, separating our home from the neighbor behind us. From the near edge of the pool I watched as a Cardinal timidly foraged for food beneath the bushes. He would pick up a few seeds, stop and look around, then pick up a few more. This went on for about five minutes and then he made his escape, taking short hops through the bushes, presumably returning to Mrs. Cardinal.
A few feet away, a much bolder Blue Jay was in engaged in similar activity. Bolder than the bright red Cardinal, the Jay took few pains to hide himself and loudly announced his presence, once he had returned to the safety of some higher branches. The big black crows are even bolder, every Spring staking claim to the small park in front of my home. They can be seen on the ground and in the trees at the four corners of the park, a bit reminiscent of “The Birds”, although I don’t think anyone has ever been attacked.
I live in a suburban area, close to some wooded areas and several bayous. Surprisingly, this populated neighborhood is teeming with a variety of wildlife. Besides the aforementioned birds, there are finches, doves, squirrels, rats, field mice, frogs, lizards, a rare snake and at least one turtle. Sitting outside in the late afternoon seems to afford the best view. The heat of the day has diminished and nighttime predators are not on the prowl.
So, in the early evening it is possible to see numerous lizards scurrying about or catching the last few rays of the departing sun. If I watch closely I can usually see lizards racing along the top of the fence or sunning themselves on top of the stone Hippo statues that guard our pool.
In a few weeks I will be treated to the hummingbird spectacle. Every year for about two weeks, in late August and early September hummingbirds stop in Houston on their way south. We always set up a feeder and manage to attract some of these diminutive birds. Watching their social order is sort of a metaphor for humanity. Usually, one hummingbird will claim the feeder as his own. He will take a drink and then fly away to perch on the nearby tree, all the time keeping his watchful eyes on “his” feeder. If any other hummingbirds try to approach he will swoop in and chase them away. Of course, the other hummingbirds want their fill of the sweet, fake nectar, so they will team up. One pretends to go in for a drink and allows himself to be chased away and, during this pursuit the others will saunter in for a leisurely swig. Not unlike many people really.
The rats and mice that I see create something of a dilemma. I know that they are vermin and carry disease, but it just doesn’t seem right to kill them. For a while we had a bird feeder in the backyard. This feeder fed not only birds, but also squirrels, mice and rats. There were several nights when our dogs would be outside barking nonstop and, when I investigated, I found them looking up at one or more rats taunting them from a branch high above the ground.
My dogs, actually, are very efficient at keeping our home free of such vermin. Before we took down the birdfeeder I found five dead rats in a week’s time. One afternoon I inadvertently witnessed the spectacle. In the middle of the day the three dogs, two Basset Hounds and a West Highland White Terrier, were outside barking in the continuous manner that signaled that they had something cornered. When I checked it out I saw them standing around something that was on the ground. Before I could intervene, Genevieve, our fat Basset Hound made a surprisingly quick lunge and in an instant a big rat lay dead. Don’t let anyone tell you that Basset Hounds are slow and lazy; she made very quick work of that execution. Needless to say, I took the bird feeder down that day and didn’t find any more dead rats.
There have been other rodents that have invaded our home. There was the time I went to check on our dogs early in the morning. They had been doing there nonstop barking routine, but by the time I went to see what all the fuss was about the noise had stopped. When I checked on them I found a baby possum lying stiff on the floor by their doggy door. I looked at it, lying rigid on the floor and assumed it was dead, but then my wife and I began to wonder; there wasn’t a mark on the little beast. We picked it up in a towel and carried it outside, locking the dogs inside. We laid the little critter among the bushes behind the pool and, as we suspected, the baby possum picked its head up, looked around and scurried away. It seems that possums really do play possum.
More recently, I sat and watched a field mouse make its was around the side of our house. It saw me studying its movements, but pretended I wasn’t there as it walked between our garbage cans and then stopped at our back door, reared up on its hind legs and pushed against the doggy door. Luckily, for the mouse, it was too small to push the door open, because just inside the door, asleep on a cushion was our West Highland Terrier, Coconut. I am sure that Coconut would have made short work of that mouse. Unable to break into our house, the mouse went on his way, still unperturbed by my presence.
In my recently released novel, “Joshua and Aaron”, the hero, Joshua Smith is given a pair of “goggles” that allow him to see the teeming life that exists apart from humanity, in the city around him. He is told that “we see and hear what we’ve been trained to see and hear.” There is a wonderful world around us; full of life; a gift from God. All we have to do is take the time to sit and watch; it’s a spectacle better than anything television or the internet can provide.
This evening I sat in my backyard next to our swimming pool and watched the myriad activity in the bushes and the trees that line the rear edge of our yard, separating our home from the neighbor behind us. From the near edge of the pool I watched as a Cardinal timidly foraged for food beneath the bushes. He would pick up a few seeds, stop and look around, then pick up a few more. This went on for about five minutes and then he made his escape, taking short hops through the bushes, presumably returning to Mrs. Cardinal.
A few feet away, a much bolder Blue Jay was in engaged in similar activity. Bolder than the bright red Cardinal, the Jay took few pains to hide himself and loudly announced his presence, once he had returned to the safety of some higher branches. The big black crows are even bolder, every Spring staking claim to the small park in front of my home. They can be seen on the ground and in the trees at the four corners of the park, a bit reminiscent of “The Birds”, although I don’t think anyone has ever been attacked.
I live in a suburban area, close to some wooded areas and several bayous. Surprisingly, this populated neighborhood is teeming with a variety of wildlife. Besides the aforementioned birds, there are finches, doves, squirrels, rats, field mice, frogs, lizards, a rare snake and at least one turtle. Sitting outside in the late afternoon seems to afford the best view. The heat of the day has diminished and nighttime predators are not on the prowl.
So, in the early evening it is possible to see numerous lizards scurrying about or catching the last few rays of the departing sun. If I watch closely I can usually see lizards racing along the top of the fence or sunning themselves on top of the stone Hippo statues that guard our pool.
In a few weeks I will be treated to the hummingbird spectacle. Every year for about two weeks, in late August and early September hummingbirds stop in Houston on their way south. We always set up a feeder and manage to attract some of these diminutive birds. Watching their social order is sort of a metaphor for humanity. Usually, one hummingbird will claim the feeder as his own. He will take a drink and then fly away to perch on the nearby tree, all the time keeping his watchful eyes on “his” feeder. If any other hummingbirds try to approach he will swoop in and chase them away. Of course, the other hummingbirds want their fill of the sweet, fake nectar, so they will team up. One pretends to go in for a drink and allows himself to be chased away and, during this pursuit the others will saunter in for a leisurely swig. Not unlike many people really.
The rats and mice that I see create something of a dilemma. I know that they are vermin and carry disease, but it just doesn’t seem right to kill them. For a while we had a bird feeder in the backyard. This feeder fed not only birds, but also squirrels, mice and rats. There were several nights when our dogs would be outside barking nonstop and, when I investigated, I found them looking up at one or more rats taunting them from a branch high above the ground.
My dogs, actually, are very efficient at keeping our home free of such vermin. Before we took down the birdfeeder I found five dead rats in a week’s time. One afternoon I inadvertently witnessed the spectacle. In the middle of the day the three dogs, two Basset Hounds and a West Highland White Terrier, were outside barking in the continuous manner that signaled that they had something cornered. When I checked it out I saw them standing around something that was on the ground. Before I could intervene, Genevieve, our fat Basset Hound made a surprisingly quick lunge and in an instant a big rat lay dead. Don’t let anyone tell you that Basset Hounds are slow and lazy; she made very quick work of that execution. Needless to say, I took the bird feeder down that day and didn’t find any more dead rats.
There have been other rodents that have invaded our home. There was the time I went to check on our dogs early in the morning. They had been doing there nonstop barking routine, but by the time I went to see what all the fuss was about the noise had stopped. When I checked on them I found a baby possum lying stiff on the floor by their doggy door. I looked at it, lying rigid on the floor and assumed it was dead, but then my wife and I began to wonder; there wasn’t a mark on the little beast. We picked it up in a towel and carried it outside, locking the dogs inside. We laid the little critter among the bushes behind the pool and, as we suspected, the baby possum picked its head up, looked around and scurried away. It seems that possums really do play possum.
More recently, I sat and watched a field mouse make its was around the side of our house. It saw me studying its movements, but pretended I wasn’t there as it walked between our garbage cans and then stopped at our back door, reared up on its hind legs and pushed against the doggy door. Luckily, for the mouse, it was too small to push the door open, because just inside the door, asleep on a cushion was our West Highland Terrier, Coconut. I am sure that Coconut would have made short work of that mouse. Unable to break into our house, the mouse went on his way, still unperturbed by my presence.
In my recently released novel, “Joshua and Aaron”, the hero, Joshua Smith is given a pair of “goggles” that allow him to see the teeming life that exists apart from humanity, in the city around him. He is told that “we see and hear what we’ve been trained to see and hear.” There is a wonderful world around us; full of life; a gift from God. All we have to do is take the time to sit and watch; it’s a spectacle better than anything television or the internet can provide.
Sunday, August 1, 2010
Dr. Write
CC: SOB and Abd pn.
HPI:
65 y-o WM w/ hx of CHF, CAD, IDDM, Htn, &SLE was admitted @BMC c/o CP, SOB, LUE edema and UTI for 7 days. Pt. also c/o no BM for 1 wk. and + LGIB. Pt. also c/o abd. Pn and N&V for 2 wks. (-) flatus x 3 days.
PMH:
As in HPI. + CHF, CAD, s/p CABG, LGB, BIH and ORIF LH.
NKA
MEDs: see list.
FH:
n/c
SH:
Cig: 2 ppd x 30 yrs. Etoh (-) ret.
ROS:
See HPI
PE:
VSS, AF
HEENT: NC/AT, PERRLA, EOM’s nl,
Neck: NT, (-) Br.
Pul.: Cl. To A &P
CVS: RRR, nl S1S2 w/o m, S3 S4, (-) JVD
Abd: (+) BS, w/o HSM, B9
Rectal: WNL
Ext: w/o C, C, E, pulses 2+
Neuro: NLS
A/P:
65 yo WM w/ MM Probs. Plan CT A/P, CXR, EKG, CC cath.
Consult GS, Card, GI, Pulm.
CCM.
I will happily accept any one's translation of this perfectly plausible History and Physical.
HPI:
65 y-o WM w/ hx of CHF, CAD, IDDM, Htn, &SLE was admitted @BMC c/o CP, SOB, LUE edema and UTI for 7 days. Pt. also c/o no BM for 1 wk. and + LGIB. Pt. also c/o abd. Pn and N&V for 2 wks. (-) flatus x 3 days.
PMH:
As in HPI. + CHF, CAD, s/p CABG, LGB, BIH and ORIF LH.
NKA
MEDs: see list.
FH:
n/c
SH:
Cig: 2 ppd x 30 yrs. Etoh (-) ret.
ROS:
See HPI
PE:
VSS, AF
HEENT: NC/AT, PERRLA, EOM’s nl,
Neck: NT, (-) Br.
Pul.: Cl. To A &P
CVS: RRR, nl S1S2 w/o m, S3 S4, (-) JVD
Abd: (+) BS, w/o HSM, B9
Rectal: WNL
Ext: w/o C, C, E, pulses 2+
Neuro: NLS
A/P:
65 yo WM w/ MM Probs. Plan CT A/P, CXR, EKG, CC cath.
Consult GS, Card, GI, Pulm.
CCM.
I will happily accept any one's translation of this perfectly plausible History and Physical.
Saturday, July 24, 2010
Donuts
A Tribute
I brought a dozen donuts home this morning. I stopped at “Riley’s Donuts” on my way home from the hospital and picked up a variety of donuts and kolaches. There is no great, special significance about donuts or kolaches except that the act of bringing donuts home after making rounds at the hospital is a tribute to Dad.
Donuts a tribute to Dad? It isn’t hard to understand, really. Growing up on Sunnyside Road in Scotia, New York, Dad worked as a doctor, specifically a Urologist in solo practice. Every weekend, unless he was out of town, he left at about 8:30 am to make rounds on his hospital patients. At the time I didn’t really understand what “rounds” meant and even on the rare occasion I accompanied him, I still didn’t know. (Accompanying him to the hospital meant sitting in the lobby, being watched by the volunteer in the Gift Shop). I always had this vision of him walking in a great circle, somehow seeing his patients along the way.
Anyway, he usually returned home at about 11:00 and when he walked through the door I would look to see if he was carrying anything besides the newspaper. A single bag meant Dunkin Donuts, always welcome on a Sunday morning; two bags was even better, deli from Gershon’s. I recall that he returned with one or the other about half the time.
I never knew if there was any rhyme or reason to the appearance of these goodies, but I know I looked forward to them. I suspect now that he really liked donuts and corned beef and Mom certainly didn’t mind not having to prepare anything.
Dad was a bit mysterious in ways like this. He would do things seemingly for no obvious reason, as if it was expected, that it was part of his job as dad. Saturday mornings he would make pancakes for everyone before he left for work. Usually he was gone when I came downstairs, but the pancakes would be waiting there, sometimes a little cold, but always delicious; they were one thing that Dad was very adept at cooking.
The other unexpected, but always welcome, treat was going to “Twin Freeze” for ice cream. This was, and still is, the ice cream half of “Jumpin’ Jack’s” drive in in Scotia. Until I was about eleven I never realized that Jack burgers and loaded steak sandwiches even existed; the food part of the drive in was a separate building. Jumpin Jack’s, to me, was only Twin Freeze and the soft ice cream was a special treat. Even today, it is one of my first stops when I visit Scotia. Growing up, it was an often unexpected pleasure to take the short drive around the lake to Twin Freeze, to check out the special flavor of the day, but almost always settle for a hot fudge sundae with chocolate ice cream; an indulgence that was usually consumed by the time we pulled in the driveway at home.
Of course it wasn’t just desserts that were special to Dad. He had nine sons and, although he was always interested in whatever activity we were involved with, the one thing that he would do with us was teach us all to sail. My brother Charlie wrote about family sailing’s origins on Collins Lake in a small pram in his book “Centerboard”, but for me sailing began with the “Rebel”. The “Rebel”, nicknamed the “Tub”, was a boat that was kept at our summer camp on Sacandaga Lake. Dad was always looking for a crew, and when I became old enough I was drafted. He taught me the intricacies of tacking, luffing, coming about, hard to lee and all the other components of sailing that were necessary to navigate the ever changing winds on Sacandaga Lake.
But more than the sailing lessons it gave me time alone with him; time to talk about what he thought was important, raising his family, being a doctor, plans for the future. I was never a big talker, but I was a pretty good listener. Dad could be stubborn at times and he occasionally clashed with some of my brothers. Sailing gave him time to soften his resolve and find a compromise. I learned a great deal from him at these times. And, there was the time we sailed through the swarm of bees. We never knew why they were out there in the middle of the lake, but we managed to sail right through the heart of the swarm, thankfully emerging unscathed.
Other things about Dad stick in my head. When something adverse happened, which was unavoidable in a family with nine boys, he always responded with a cool head and kept everything in the proper perspective. If there was a car accident his first thought would be “is anybody hurt?” Damage to the car was secondary. He intervened when necessary, but allowed us all to grow and develop in our own way. I think he was pleased with the three of us that decided to go into medicine, but he was just as pleased with my other brothers in various other professions.
Dad loved us all although he very rarely said it. His concern for each of us as different individuals showed this love and even today, if some difficulty arises, I will frequently stop and think “What would Dad do?”
Dad just celebrated his 95th birthday. He still shows concern for me and always asks about my family’s well being. He suffers with so many of the ravages of advanced age, poor eyesight that keeps him from watching his beloved Yankees as closely as he’d like, poor hearing, congestive heart failure, arthritis. He would say “It’s tough growing old, but it’s better than the alternative. When I wake up in the morning and I’m still breathing; it’s a good day.”
And so when I buy donuts on a Sunday morning it’s a tribute to Dad. But, also, like Dad, I really like donuts.
I brought a dozen donuts home this morning. I stopped at “Riley’s Donuts” on my way home from the hospital and picked up a variety of donuts and kolaches. There is no great, special significance about donuts or kolaches except that the act of bringing donuts home after making rounds at the hospital is a tribute to Dad.
Donuts a tribute to Dad? It isn’t hard to understand, really. Growing up on Sunnyside Road in Scotia, New York, Dad worked as a doctor, specifically a Urologist in solo practice. Every weekend, unless he was out of town, he left at about 8:30 am to make rounds on his hospital patients. At the time I didn’t really understand what “rounds” meant and even on the rare occasion I accompanied him, I still didn’t know. (Accompanying him to the hospital meant sitting in the lobby, being watched by the volunteer in the Gift Shop). I always had this vision of him walking in a great circle, somehow seeing his patients along the way.
Anyway, he usually returned home at about 11:00 and when he walked through the door I would look to see if he was carrying anything besides the newspaper. A single bag meant Dunkin Donuts, always welcome on a Sunday morning; two bags was even better, deli from Gershon’s. I recall that he returned with one or the other about half the time.
I never knew if there was any rhyme or reason to the appearance of these goodies, but I know I looked forward to them. I suspect now that he really liked donuts and corned beef and Mom certainly didn’t mind not having to prepare anything.
Dad was a bit mysterious in ways like this. He would do things seemingly for no obvious reason, as if it was expected, that it was part of his job as dad. Saturday mornings he would make pancakes for everyone before he left for work. Usually he was gone when I came downstairs, but the pancakes would be waiting there, sometimes a little cold, but always delicious; they were one thing that Dad was very adept at cooking.
The other unexpected, but always welcome, treat was going to “Twin Freeze” for ice cream. This was, and still is, the ice cream half of “Jumpin’ Jack’s” drive in in Scotia. Until I was about eleven I never realized that Jack burgers and loaded steak sandwiches even existed; the food part of the drive in was a separate building. Jumpin Jack’s, to me, was only Twin Freeze and the soft ice cream was a special treat. Even today, it is one of my first stops when I visit Scotia. Growing up, it was an often unexpected pleasure to take the short drive around the lake to Twin Freeze, to check out the special flavor of the day, but almost always settle for a hot fudge sundae with chocolate ice cream; an indulgence that was usually consumed by the time we pulled in the driveway at home.
Of course it wasn’t just desserts that were special to Dad. He had nine sons and, although he was always interested in whatever activity we were involved with, the one thing that he would do with us was teach us all to sail. My brother Charlie wrote about family sailing’s origins on Collins Lake in a small pram in his book “Centerboard”, but for me sailing began with the “Rebel”. The “Rebel”, nicknamed the “Tub”, was a boat that was kept at our summer camp on Sacandaga Lake. Dad was always looking for a crew, and when I became old enough I was drafted. He taught me the intricacies of tacking, luffing, coming about, hard to lee and all the other components of sailing that were necessary to navigate the ever changing winds on Sacandaga Lake.
But more than the sailing lessons it gave me time alone with him; time to talk about what he thought was important, raising his family, being a doctor, plans for the future. I was never a big talker, but I was a pretty good listener. Dad could be stubborn at times and he occasionally clashed with some of my brothers. Sailing gave him time to soften his resolve and find a compromise. I learned a great deal from him at these times. And, there was the time we sailed through the swarm of bees. We never knew why they were out there in the middle of the lake, but we managed to sail right through the heart of the swarm, thankfully emerging unscathed.
Other things about Dad stick in my head. When something adverse happened, which was unavoidable in a family with nine boys, he always responded with a cool head and kept everything in the proper perspective. If there was a car accident his first thought would be “is anybody hurt?” Damage to the car was secondary. He intervened when necessary, but allowed us all to grow and develop in our own way. I think he was pleased with the three of us that decided to go into medicine, but he was just as pleased with my other brothers in various other professions.
Dad loved us all although he very rarely said it. His concern for each of us as different individuals showed this love and even today, if some difficulty arises, I will frequently stop and think “What would Dad do?”
Dad just celebrated his 95th birthday. He still shows concern for me and always asks about my family’s well being. He suffers with so many of the ravages of advanced age, poor eyesight that keeps him from watching his beloved Yankees as closely as he’d like, poor hearing, congestive heart failure, arthritis. He would say “It’s tough growing old, but it’s better than the alternative. When I wake up in the morning and I’m still breathing; it’s a good day.”
And so when I buy donuts on a Sunday morning it’s a tribute to Dad. But, also, like Dad, I really like donuts.
Thursday, July 22, 2010
Summer of 1974
The summer of 1974 stands out in my mind, mostly because of the days I spent in Saratoga at the famed racetrack. I was sixteen and the first part of the summer was spent at driver’s ed., where I did my best not to cause any angina among the various shop teachers who were earning extra money putting their lives on the line with a bunch of neophyte drivers.. A few odd jobs painting houses and such gave me a bit of money to waste at the track when it opened in August.
In those days the meet was only four weeks, but it had already started to take on the aura of prestige and celebrity it currently enjoys. Its legend as the graveyard of favorites had been reinforced the previous year as the great Secretariat, fresh from his smashing Triple Crown performance went down to ignominious defeat at the hands of the unheralded Onion, appropriately trained by the giant killer Allen Jerkens.
But, it was now a year later and the track beckoned again. Even though I had gone through driver’s ed I still didn’t have my license so transport to the track became problematical. When I couldn’t bum a ride from any local acquaintance I would walk over to Route 50, stick out my thumb and hope for the best. I usually started at a about 11:00 am, allowing myself plenty of time to make it by post time at 1:00.
Of course sometimes I was picked up very quickly and arrived very early, with an hour or more to kill before the first race. I took full advantage of these times to visit the local attractions or have lunch somewhere on Broadway. My favorite ways to pass the time, however, were either going to the National Museum of Racing or walking through the Rose Garden at the Yaddo.
The museum was almost always empty when I went. I would walk into a dark entry and as soon as the lone woman saw that she had a customer the lights would go on and I would wander through the rooms, perusing the paintings of famous horses, looking at famous silks and just enjoying the history that was recorded. The previous year I had written my term paper for Frank Palmer’s tenth grade Social Studies class on the history of thoroughbred horse racing, most of the details elegantly plucked from the pages of the Encyclopedia Britannica. The history I had actually learned seemed to come alive in the sculptures and paintings in that museum.
My other favorite attraction was the Yaddo. This is a mansion that had been built by financier Spencer Trask and, in 1900 was converted into an artist’s retreat. The very impressive mansion was off limits to visitors, but anyone could walk through the Rose Garden which was situated a short walk from the road and, besides providing a very peaceful way to kill time, also allowed me to speculate on what it was like inside the home and at times made me wish that I was a starving artist, just so I could go inside.
The main focus of those excursions to Saratoga was the racetrack. My interest in horse racing started at age nine when I won $4.20 on the first wager I’d ever made, hooking me with the delusion that I could actually generate some sort of profit from being smart, at least smart enough to pick a few winners. So, the money I earned from various odd jobs went straight to my pool of cash designated for the track.
The track that year had a few highlights. The first memorable occurrence was Maria Isabel. She was not a person; she was a filly running in the ninth race one day. She stands out for two reasons: she was the single best bet I’ve ever seen in any race, at any track, in any year since I started betting on horses and I made the largest wager on her I’d ever made up until that time. Anyone not familiar with the intricacies of handicapping the races may not appreciate what she was, but based on her past performances and conditioning she appeared to be at least five lengths faster than any of her competitors. Her times were about a second faster, she was running at her optimum distance, she had just run a credible race against better horses five days before and she was going off at 7/2, an excellent price for a horse that looked so outstanding on paper.
Seeing her in person did nothing to shake my confidence, so I bet $15 to win on her, a huge amount of money for me in those days. The race went exactly as expected, even though in midstretch she was briefly blocked. She found a hole to sneak through, however, and won going away by three lengths. I remember my hand shaking a bit as I cashed my tickets and I felt a bit of trepidation as I contemplated hitchhiking home with what seemed to me to be a lot of money in my pocket. One of the memorable things about that day was that I had a hard time finding a ride. As it turned out I did a lot more hiking than hitching and didn’t walk through our kitchen door until about ten pm. That single bet is so memorable that Maria Isabel is mentioned as a best bet of the week in my novel “Joshua and Aaron”.
The most memorable thing about the track that summer was Ruffian. Anyone that has read my books or visited my website knows of her significance. She was a two year old in 1974 and was the most impressive, overpowering filly the racing world had seen, perhaps ever. The tone for her career was set by her maiden victory by fifteen lengths, running 5 ½ furlongs in 1:03, equaling the track record at Belmont Park. She was coming to Saratoga undefeated and never headed (that is she had never been in second place at any point of any race).
She was running in the Spinaway Stakes against a local favorite, Laughing Bridge, who was owned by local businessman Neil Hellman. Laughing Bridge had been very imposing in stakes races earlier in the meet and their showdown received much hype in the local papers.
I convinced my mother to let me drive up to the track that day, with an older friend accompanying me to make it legal. The day was a bit showery, but the track was labeled as fast. When we saw Ruffian in the paddock my friend and I were both struck by her appearance. She was big for a two year old filly, but she also was a bit washy (sweaty), perhaps appropriate for the humid day, but it seemed to be more sweat than I would have expected.
Ruffian was the overwhelming favorite despite all the attempts by the local media to build up Laughing Bridge. In typical Ruffian fashion she jumped to the early lead, passing the quarter in a quick 22 1/5 seconds. She maintained her lead at the half in a quicker 44 4/5 and at the top of the stretch showed me something that impressed me more than any horse I’d ever seen. As if she were toying with her valiant competition up to that point and she decided it was time to put all the false media hype to rest and she proceeded to run away from her overmatched competition. She pulled away by almost thirteen lengths in the dazzling time of 1:08 3/5, which equaled a long standing track record; remarkable for a two year old filly.
Of course Ruffian’s racing career became legend and her end was tragic, as she broke down during her match race against the top 3 y-o colt Foolish Pleasure the following year and she had to be destroyed. Still, her brief racing career captured the imagination of millions and, for a short time, she became a symbol for women’s rights.
After that summer, I don’t think I ever hitchhiked again. My wife still thinks I was crazy for doing it, but those were different times; sometimes it seems like a different world. I don’t make it to upstate New York during racing season very often these days and the times I have gone to the track it’s not the same. There are no more free seats at the top of the stretch, the crowds are overwhelming and the quality of the racing seems to have diminished. Still, the summer of 1974 remains a fond memory; a reminder that summer days could be carefree and the only worry was how to get home from the track.
In those days the meet was only four weeks, but it had already started to take on the aura of prestige and celebrity it currently enjoys. Its legend as the graveyard of favorites had been reinforced the previous year as the great Secretariat, fresh from his smashing Triple Crown performance went down to ignominious defeat at the hands of the unheralded Onion, appropriately trained by the giant killer Allen Jerkens.
But, it was now a year later and the track beckoned again. Even though I had gone through driver’s ed I still didn’t have my license so transport to the track became problematical. When I couldn’t bum a ride from any local acquaintance I would walk over to Route 50, stick out my thumb and hope for the best. I usually started at a about 11:00 am, allowing myself plenty of time to make it by post time at 1:00.
Of course sometimes I was picked up very quickly and arrived very early, with an hour or more to kill before the first race. I took full advantage of these times to visit the local attractions or have lunch somewhere on Broadway. My favorite ways to pass the time, however, were either going to the National Museum of Racing or walking through the Rose Garden at the Yaddo.
The museum was almost always empty when I went. I would walk into a dark entry and as soon as the lone woman saw that she had a customer the lights would go on and I would wander through the rooms, perusing the paintings of famous horses, looking at famous silks and just enjoying the history that was recorded. The previous year I had written my term paper for Frank Palmer’s tenth grade Social Studies class on the history of thoroughbred horse racing, most of the details elegantly plucked from the pages of the Encyclopedia Britannica. The history I had actually learned seemed to come alive in the sculptures and paintings in that museum.
My other favorite attraction was the Yaddo. This is a mansion that had been built by financier Spencer Trask and, in 1900 was converted into an artist’s retreat. The very impressive mansion was off limits to visitors, but anyone could walk through the Rose Garden which was situated a short walk from the road and, besides providing a very peaceful way to kill time, also allowed me to speculate on what it was like inside the home and at times made me wish that I was a starving artist, just so I could go inside.
The main focus of those excursions to Saratoga was the racetrack. My interest in horse racing started at age nine when I won $4.20 on the first wager I’d ever made, hooking me with the delusion that I could actually generate some sort of profit from being smart, at least smart enough to pick a few winners. So, the money I earned from various odd jobs went straight to my pool of cash designated for the track.
The track that year had a few highlights. The first memorable occurrence was Maria Isabel. She was not a person; she was a filly running in the ninth race one day. She stands out for two reasons: she was the single best bet I’ve ever seen in any race, at any track, in any year since I started betting on horses and I made the largest wager on her I’d ever made up until that time. Anyone not familiar with the intricacies of handicapping the races may not appreciate what she was, but based on her past performances and conditioning she appeared to be at least five lengths faster than any of her competitors. Her times were about a second faster, she was running at her optimum distance, she had just run a credible race against better horses five days before and she was going off at 7/2, an excellent price for a horse that looked so outstanding on paper.
Seeing her in person did nothing to shake my confidence, so I bet $15 to win on her, a huge amount of money for me in those days. The race went exactly as expected, even though in midstretch she was briefly blocked. She found a hole to sneak through, however, and won going away by three lengths. I remember my hand shaking a bit as I cashed my tickets and I felt a bit of trepidation as I contemplated hitchhiking home with what seemed to me to be a lot of money in my pocket. One of the memorable things about that day was that I had a hard time finding a ride. As it turned out I did a lot more hiking than hitching and didn’t walk through our kitchen door until about ten pm. That single bet is so memorable that Maria Isabel is mentioned as a best bet of the week in my novel “Joshua and Aaron”.
The most memorable thing about the track that summer was Ruffian. Anyone that has read my books or visited my website knows of her significance. She was a two year old in 1974 and was the most impressive, overpowering filly the racing world had seen, perhaps ever. The tone for her career was set by her maiden victory by fifteen lengths, running 5 ½ furlongs in 1:03, equaling the track record at Belmont Park. She was coming to Saratoga undefeated and never headed (that is she had never been in second place at any point of any race).
She was running in the Spinaway Stakes against a local favorite, Laughing Bridge, who was owned by local businessman Neil Hellman. Laughing Bridge had been very imposing in stakes races earlier in the meet and their showdown received much hype in the local papers.
I convinced my mother to let me drive up to the track that day, with an older friend accompanying me to make it legal. The day was a bit showery, but the track was labeled as fast. When we saw Ruffian in the paddock my friend and I were both struck by her appearance. She was big for a two year old filly, but she also was a bit washy (sweaty), perhaps appropriate for the humid day, but it seemed to be more sweat than I would have expected.
Ruffian was the overwhelming favorite despite all the attempts by the local media to build up Laughing Bridge. In typical Ruffian fashion she jumped to the early lead, passing the quarter in a quick 22 1/5 seconds. She maintained her lead at the half in a quicker 44 4/5 and at the top of the stretch showed me something that impressed me more than any horse I’d ever seen. As if she were toying with her valiant competition up to that point and she decided it was time to put all the false media hype to rest and she proceeded to run away from her overmatched competition. She pulled away by almost thirteen lengths in the dazzling time of 1:08 3/5, which equaled a long standing track record; remarkable for a two year old filly.
Of course Ruffian’s racing career became legend and her end was tragic, as she broke down during her match race against the top 3 y-o colt Foolish Pleasure the following year and she had to be destroyed. Still, her brief racing career captured the imagination of millions and, for a short time, she became a symbol for women’s rights.
After that summer, I don’t think I ever hitchhiked again. My wife still thinks I was crazy for doing it, but those were different times; sometimes it seems like a different world. I don’t make it to upstate New York during racing season very often these days and the times I have gone to the track it’s not the same. There are no more free seats at the top of the stretch, the crowds are overwhelming and the quality of the racing seems to have diminished. Still, the summer of 1974 remains a fond memory; a reminder that summer days could be carefree and the only worry was how to get home from the track.
Saturday, July 10, 2010
Talking to Patients
Years ago I read an article about what patients could or should expect from a visit to their doctor. There were four patients that recounted their experiences during recent doctor’s appointments. The length of time they had to wait, the details of their visit including actual time spent with the doctor were included. One of the patients complained that the doctor spent most of his time talking to her. I would bet that this particular doctor was the most thorough and conscientious of all the doctors that were presented in that article.
When a patient walks into a doctor’s office for the first time, the doctor faces a myriad of possibilities. In my practice, which is general surgery, I usually assume a new patient has or is suspected of having a surgical problem. Of course this differs from the primary care physician setting where the problem could be anything from headache to hemorrhoids. It is the primary care doctor’s task to sort out all the endless possibilities and determine the best medical approach for each. This is their great challenge, one that may be faced twenty times a day or more.
Fortunately, for me, the surgeon has a task that is a bit easier, at least initially. When I am asked to see a new patient, most of the time there is some information that comes with the request, usually something short and simple, ie: Gallbladder disease, abdominal pain, cold leg, etc. This very brief summary gives me a bit of direction, although occasionally it can lead in the wrong direction.
So, the first, and often the most useful, thing that I do is to sit and talk to the patient. Probably 98% of the time the patient will tell me what’s wrong and all that I need to do is confirm this presumptive diagnosis with the physical exam and appropriate testing. This is true for almost any condition, be it acute appendicitis or hemorrhoids.
But, how does simple talking do all this? The things that go through a doctor’s head, at least mine, when I take a history from a patient are myriad. First and foremost is, “Is this patient ‘sick’.” By this I mean does the patient seem to have a severe, possibly life threatening condition that warrants immediate hospitalization and possibly emergency surgery? Patients that cannot sit up, are afraid to move or are unable to give any history because they are too ill usually need to be in the hospital. It is one of my unwritten rules that patients that look sick usually are. Experience teaches doctors, particularly general surgeons, to be vigilant, assume the worst and do all that we can to achieve the best outcome.
But, I’ve strayed away from the point of this article. Talking to patients is the single most important part of patient visits. When I went to medical school the greatest amount of time was spent on learning the natural history of the many various diseases, all the possible presenting symptoms and signs and how to obtain this information from a sick patient. Unlike House I don’t believe that patients always lie. Most want to get better and most of the time the questions that I ask cannot be answered in misleading way. Starting with the simple question, “What brought you in here today?” and then paying attention to the patient’s answer will, in a few minutes, provide almost all the information necessary to begin that individual on the road to recovery.
Approaching a patient with abdominal pain provides an excellent example. In the days before routine CAT Scans the evaluation of patients presenting with abdominal pain required the skills of a detective; the history and physical exam, along with limited diagnostic testing, were the mainstays of diagnosis. The abdomen, in the days before CAT Scans and MRI’s, was a black box filled with vital organs and often inaccessible except through surgery.
The abdomen is usually divided into three segments, epigastrium, which is above the umbilicus (belly-button), mid-abdomen, the level of the umbilicus, or hypogastrium, which is below the umbilicus. The first thing I will usually ask is where did your pain start. Sometimes I get an answer like “In the bathroom”; some people are so literal. But, once properly directed, the starting point of the pain will go a long ways to narrowing the choices for the offending organ.
Epigastriium usually means stomach, duodenum, gallbladder, liver or pancreas. Mid-abdomen refers to the small bowel or the right side of the colon and hypogastrium usually refers to the left colon. These divisions are in no way arbitrary, rather they correspond to the nerves that supply the various organs and where the nerves will refer pain. For instance, the gallbladder sits in the right upper abdomen, but very often gallbladder pain is felt in the middle. This is because the visceral nerves refer the pain to the middle. Only after a gallbladder becomes more inflamed do the parietal nerves come into play and the pain then becomes localized over the offending organ.
Duration, quality and associated symptoms all direct me to a working diagnosis that only needs to be confirmed. Physical exam, blood/urine tests, imaging studies primarily are used to confirm the working diagnosis and to eliminate other possibilities. I’ve learned that relying solely on imaging studies is often misleading.
For instance, just recently I was called from the Emergency Room at one of the hospitals and informed of a patient that the admitting physician wanted me to consult. The ER physician said she had right sided abdominal pain and that an ultrasound had revealed gallstones. The white blood cell count was elevated, but she was otherwise stable. This patient, as presented to me, was properly admitted to the hospital, but a patient with these clinical findings generally is not a life and death emergency and can usually be seen later in the day. It is very rare for uncomplicated cholecystitis (gallbladder inflammation) to require immediate surgery.
I saw the patient a few hours later and the history that I received led me to very different diagnosis. Her pain was in the right lower abdomen, unusual for gallbladder disease, and she said it was very severe. She also had a history of severe cardiac disease. There was associated nausea and constipation. Physical examination revealed severe tenderness in the right lower abdomen and no tenderness in the right upper abdomen, where the gallbladder usually resides. I began to be concerned that she could have had appendicitis, which would require emergency surgery. The other possibility I considered was ischemic colitis (inflammation of the colon caused by poor blood supply), also a serious condition that could be a life threatening emergency.
When I checked the tests that had been done I saw that a CAT scan had also been done, which seems to be almost routine these days. The findings were thickening of the cecum, which is the first part of the colon, and a normal appearance of the appendix. With all this information I determined that the patient likely had ischemic colitis, but that surgery was not necessary at that time. The following day she had a colonoscopy which definitively confirmed the diagnosis and she is now recovering; responding to the non-operative therapeutic regimen that was started. She still has her gallbladder and her asymptomatic gallstones.
What is apparent is that properly talking with the patient, obtaining a clear history, points the physician in the right direction. Talking to patients is a skill that is easy to develop and actually saves time and money. It often takes no more than five minutes to gather the most pertinent history from a sick patient and, as I’ve shown, the rest of the workup flows out from this relatively short, but very informative interview.
So the next time you go to your doctor and he or she spends most of your appointment talking to you, be thankful; thankful that you have a doctor that cares enough to take the time find the right answer in the right way.
When a patient walks into a doctor’s office for the first time, the doctor faces a myriad of possibilities. In my practice, which is general surgery, I usually assume a new patient has or is suspected of having a surgical problem. Of course this differs from the primary care physician setting where the problem could be anything from headache to hemorrhoids. It is the primary care doctor’s task to sort out all the endless possibilities and determine the best medical approach for each. This is their great challenge, one that may be faced twenty times a day or more.
Fortunately, for me, the surgeon has a task that is a bit easier, at least initially. When I am asked to see a new patient, most of the time there is some information that comes with the request, usually something short and simple, ie: Gallbladder disease, abdominal pain, cold leg, etc. This very brief summary gives me a bit of direction, although occasionally it can lead in the wrong direction.
So, the first, and often the most useful, thing that I do is to sit and talk to the patient. Probably 98% of the time the patient will tell me what’s wrong and all that I need to do is confirm this presumptive diagnosis with the physical exam and appropriate testing. This is true for almost any condition, be it acute appendicitis or hemorrhoids.
But, how does simple talking do all this? The things that go through a doctor’s head, at least mine, when I take a history from a patient are myriad. First and foremost is, “Is this patient ‘sick’.” By this I mean does the patient seem to have a severe, possibly life threatening condition that warrants immediate hospitalization and possibly emergency surgery? Patients that cannot sit up, are afraid to move or are unable to give any history because they are too ill usually need to be in the hospital. It is one of my unwritten rules that patients that look sick usually are. Experience teaches doctors, particularly general surgeons, to be vigilant, assume the worst and do all that we can to achieve the best outcome.
But, I’ve strayed away from the point of this article. Talking to patients is the single most important part of patient visits. When I went to medical school the greatest amount of time was spent on learning the natural history of the many various diseases, all the possible presenting symptoms and signs and how to obtain this information from a sick patient. Unlike House I don’t believe that patients always lie. Most want to get better and most of the time the questions that I ask cannot be answered in misleading way. Starting with the simple question, “What brought you in here today?” and then paying attention to the patient’s answer will, in a few minutes, provide almost all the information necessary to begin that individual on the road to recovery.
Approaching a patient with abdominal pain provides an excellent example. In the days before routine CAT Scans the evaluation of patients presenting with abdominal pain required the skills of a detective; the history and physical exam, along with limited diagnostic testing, were the mainstays of diagnosis. The abdomen, in the days before CAT Scans and MRI’s, was a black box filled with vital organs and often inaccessible except through surgery.
The abdomen is usually divided into three segments, epigastrium, which is above the umbilicus (belly-button), mid-abdomen, the level of the umbilicus, or hypogastrium, which is below the umbilicus. The first thing I will usually ask is where did your pain start. Sometimes I get an answer like “In the bathroom”; some people are so literal. But, once properly directed, the starting point of the pain will go a long ways to narrowing the choices for the offending organ.
Epigastriium usually means stomach, duodenum, gallbladder, liver or pancreas. Mid-abdomen refers to the small bowel or the right side of the colon and hypogastrium usually refers to the left colon. These divisions are in no way arbitrary, rather they correspond to the nerves that supply the various organs and where the nerves will refer pain. For instance, the gallbladder sits in the right upper abdomen, but very often gallbladder pain is felt in the middle. This is because the visceral nerves refer the pain to the middle. Only after a gallbladder becomes more inflamed do the parietal nerves come into play and the pain then becomes localized over the offending organ.
Duration, quality and associated symptoms all direct me to a working diagnosis that only needs to be confirmed. Physical exam, blood/urine tests, imaging studies primarily are used to confirm the working diagnosis and to eliminate other possibilities. I’ve learned that relying solely on imaging studies is often misleading.
For instance, just recently I was called from the Emergency Room at one of the hospitals and informed of a patient that the admitting physician wanted me to consult. The ER physician said she had right sided abdominal pain and that an ultrasound had revealed gallstones. The white blood cell count was elevated, but she was otherwise stable. This patient, as presented to me, was properly admitted to the hospital, but a patient with these clinical findings generally is not a life and death emergency and can usually be seen later in the day. It is very rare for uncomplicated cholecystitis (gallbladder inflammation) to require immediate surgery.
I saw the patient a few hours later and the history that I received led me to very different diagnosis. Her pain was in the right lower abdomen, unusual for gallbladder disease, and she said it was very severe. She also had a history of severe cardiac disease. There was associated nausea and constipation. Physical examination revealed severe tenderness in the right lower abdomen and no tenderness in the right upper abdomen, where the gallbladder usually resides. I began to be concerned that she could have had appendicitis, which would require emergency surgery. The other possibility I considered was ischemic colitis (inflammation of the colon caused by poor blood supply), also a serious condition that could be a life threatening emergency.
When I checked the tests that had been done I saw that a CAT scan had also been done, which seems to be almost routine these days. The findings were thickening of the cecum, which is the first part of the colon, and a normal appearance of the appendix. With all this information I determined that the patient likely had ischemic colitis, but that surgery was not necessary at that time. The following day she had a colonoscopy which definitively confirmed the diagnosis and she is now recovering; responding to the non-operative therapeutic regimen that was started. She still has her gallbladder and her asymptomatic gallstones.
What is apparent is that properly talking with the patient, obtaining a clear history, points the physician in the right direction. Talking to patients is a skill that is easy to develop and actually saves time and money. It often takes no more than five minutes to gather the most pertinent history from a sick patient and, as I’ve shown, the rest of the workup flows out from this relatively short, but very informative interview.
So the next time you go to your doctor and he or she spends most of your appointment talking to you, be thankful; thankful that you have a doctor that cares enough to take the time find the right answer in the right way.
Subscribe to:
Posts (Atom)