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Physical Exam: Treasure Chest

It has been a long time since I did a post on the physical exam.  For those who have not read them, I have done a series on the nuances of a physical exam from the perspective of one who has done them for 20+ Years.

For those of you who were relieved by the fact that I wasn't doing these any more, I offer you my sincerest apologies.

The usual exam of the chest is written as follows:

Chest: CTA

This translates: clear to auscultation, which means:

"I didn't hear anything abnormal in the lungs with my stethoscope"

The chest exam is generally, in fact, the lung exam.  Since breathing is something I recommend all of my patients do, I am always interested in listening to the lungs.  I want to make sure there are no signs my patients will stop performing this activity.  But before we go to the lung exam, let me touch on the other part of this exam.

Wall to Wall

The outside of the thorax is referred to as the chest wall.  It is always important to have good walls.  Walls keep bad stuff out, and walls keep good stuff in.  Like the walls of ancient cities, walls protect those within from nasty invaders.  The more precious the thing inside, the higher the walls.  There isn't much in your body more precious than your heart and lungs. 

Your chest wall is made to withstand the onslaught of pokes, punches, nunchucks, and other foreign invaders that try to get in and cause havoc.  The ribs give strength and support, while the space between the ribs, the intercostal space, gives the chest the ability to expand and contract.   

floridaretirementThe intercostal space is often mistaken for the intercoastal waterway, which is a waterway along the Atlantic coast of the US, allowing people to safely go by boat from New Jersey to Florida (a very common migration pattern during the winter).  While the intercoastal waterway plays a vital role in the economy of the Sunshine State, it does not expand and contract with breathing, nor is it flanked by ribs on either side.

The main bad thing that can happen to the ribs is a fracture.  Broken ribs, while very painful, are not treated with anything other than pain medications.  It is not feasible to put a cast on a rib fracture, and the intercostal space serves to splint the broken rib quite well.  The one exception to this is a flail chest, where several ribs are broken in more than one place.  This causes the segment between the fractures to pull in when a person inhales, and can cause significant breathing problems.

Image Credit

The main bad thing that can happen to the intercostal space is for people from New Jersey to try using it to get to Florida.

A rib fracture is diagnosed on physical exam by the clinician pushing on various parts of the chest wall and saying, "does this hurt?"  When the patient either curses or tries to physically harm the examiner, the rib fracture is confirmed.

Inspire, don't Expire

The examination of the lungs is done as follows:

  1. Take the stethoscope out of the freezer
  2. Place it on the patient's back, telling them to breathe deeply
  3. Chuckle to yourself when they find they cannot breathe out

The clinician usually listens to the various parts of the chest: the lower and upper parts of the lung on the back, and the lungs on the front of the thorax.  There are several sounds that are listened for:

  •  Rhonchi - a rattling or rumbling sound, kind of like a garden hose when the water has just been turned on.
  • Rales - a crackling sound, like when paper is crinkled.
  • screamingWheezes - a high-pitched whistling sound made on exhaling.
  • Transmitted breath sounds - sound a lot like rhonchi, but they come from above the vocal cords (i.e. a head full of snot).
  • Rub - a soft brushing sound, like when sandpaper goes on wood.
  • Decreased (or absent sounds)
  • Loud screaming - the sound most pediatricians hear on the chest exam.

Rhonchi are present when there is excessive phlegm in the larger airway tubes leading to the lungs.  They tend to happen with bronchitis, which defined as: a condition that causes lots of phlegm in the large tubes leading to the lungs.  Bronchitis is not usually caused by bacteria, and requires antibiotics only a small percent of the time.

Rales are present when there is fluid in the lungs themselves.  This is either caused by infection (such as pneumonia) or the backing up of fluid in heart failure.  Rales are generally not good.

Wheezes are the cardinal physical exam sign for asthma.  They occur when the medium-sized airway tubes are inflamed and constrict, making it easier to breathe in than out.  Wheezes also occur in the pediatric condition known as bronchiolitis, usually caused by the respiratory syncytial virus (RSV).  Louder wheezes are actually often better than softer wheezing, as the latter may be a sign that not much air is able to get out.  In general, the longer it takes for a person to exhale, the worse their problem is.

freeA Rub happens when the sack that surrounds the lungs, called the pleura, becomes inflamed.  The job of the pleura is to allow the lungs to expand and contract smoothly without sticking to the inside of the chest wall.  When it becomes inflamed, it is called pleurisy.  Pleurisy is usually caused by a virus, and feels like someone is stabbing you in the chest with a pencil every time you take a deep breath.  If you think you may have pleurisy, first check to see if someone actually is stabbing you with a pencil.  That condition is known as annoying little brother syndrome.

Rubs are difficult to hear, and are a handy way to make medical students feel stupid.  This is done when the resident or attending physician listens to the chest and says: "if you listen carefully, you can hear a rub."  The students listen and only hear normal breath sounds and the distant chuckling of the teaching physician.  The student then pretends to hear it clearly, saying something like: "wow, that's the best rub I have ever heard."  This causes the humiliation to be passed on to the other medical students in the room.

Decreased breath sounds happen due to a decreased movement of air.  This can be due to a problem with the lung itself (such as emphysema), or the pleural space (such as as a fluid collection, or an effusion, and a collapsed lung, or pneumothorax)A pneumothroax happens when air gets in the pleural space surrounding the lung.  This can happen from trauma, illness, or can just happen spontaneously.  Collapsed lungs are quite painful, and often require a tube being placed in the intercoastal waterway intercostal space, called a chest tube.  You don't ever want to get a chest tube if you can help it.  They hurt like heck.

Other Stuff

There are other things doctors sometimes do on the chest exam:

  • Percussion - this is where the examiner places one finger on the chest and taps it with the other.  The resonance of the "thump" can sometimes give clues to diagnosis.  Some physicians just like the rhythm.
  • Tactile Fremitus - this is where the hands are placed on both sides of the chest (on the back!) and the patient is told to say "Ninety-Nine."  If the vibration of the chest is decreased, there may be an effusion present.  This also serves well in confusing the patient.
  • Egophony - Egophony is elicited when the examiner places the stethoscope on the chest and tells the patient to say the long "E" sound.  In normal lungs, the E sounds like "E."  If there is fluid on that part of the lung, the E sounds like "A."  This also confuses patients.
  • Whispered Pectoriloquy - This technique is performed by the examiner having the patient whisper "Ninety-Nine" while listening to the lungs with the stethoscope.  If there are problems with the underlying lung tissue, the whispering will be much louder.  By the time you are doing whispered pectoriloquy, the patients ask to see your medical license.

The origin of the use of the word "Ninety-Nine" in these techniques is not well understood.  Many have suggested other words.  Toward the end of the millenium, some progressive medical schools were instead teaching the students to have patients say the lyrics to Prince's popular song, "Tonight I'm going to party like it's 1999."

prince

Most of these techniques are seldom used in our country.  It has been replaced with a more effective procedure: filling out a chest x-ray requisition.

Conclusion

That's about all I have to say about the lung exam.  It really is a quite important part, with many visits of patients to the office centering on problems related to breathing. 

Now, before you go to another web site, I want you to put your hands on your computer monitor and say "Ninety-Nine."

Thanks.  That helped a lot.

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Blast from the past: The shortness of Life

The following post appeared in my blog on 8/29/06

Warning! Those of you expecting a goofy and silly post, this is not one (in fact it is quite serious).

My nurse cried.

He was one of our favorite patients. He missed his appointment today, and since that was not his nature, I called to see what was up. I got his son on the phone who told me, "He's dead. He shot himself on Sunday." I couldn't believe it and confirmed that this was, in fact, the right number. He left a note saying he was tired of being sick all of the time and he was sorry to do it this way.

The thing is, he would have been one of the last patients I would expect to do something like this. He was in his 70's and had been fairly sick over the past week, but I was doing what I could to get him better. He had multiple long-term illnesses, including diabetes, but they were generally well-controlled. He was very fond of me and especially my nurse. He seemed to truly enjoy talking and would make me laugh with some wry comment when he came in.

We first won him over when he transferred care from another doctor. He was surprised at how aggressively we went after his diabetes, but felt so much better for it that I had won a lifelong patient. Then we were able to get him his medications for free through patient assistance programs. After that, he started sending his friends (mostly women) to me to be their doctor. He was well-loved by the ladies, but not in a sensual way - they seemed to have a genuine affection for him. That affection is what we too felt for him.

He spoke slowly and with a gentleman's southern drawl. He was known to my staff by his first name, and he was one of those patients I was always happy to see. He gave us absolutely no warning about what was going on inside of his head. When I saw him last week I was concerned about his health, but he never told me how he was feeling.

This abrupt ending makes me take stock of my actions. I do my best to spend enough time with my patients, but tend to get behind and have to hurry to not get any later. I try to listen to what they are really saying (as the famous saying among doctors goes: the patient will always tell you what is wrong with them - you just need to listen to what they are really saying). I try to practice by that rule and listen to what they are really trying to tell me. Yet I get caught up in the rush, the phone calls, the drug-seeking patients, the anxious mothers, and the pile of forms that I have put off filling out. I am trying to manage their diseases by evidence - getting their numbers just right and making sure they have gone to the right specialists. That's good care, right?

There are other distractions too. I spend (too much) time blogging and reading blogs. I go around giving talks to doctors about computers. I am the senior partner of a business, so we have all of the financial headaches to worry about. Dare I leave out the fact that I have a wife and four kids at home who need me? Life is busy. Life is busy.

So what does it mean in this context that I laid my hands on a man who later in the week committed suicide? I was one of the last people to physically touch him while he was alive. Did I miss anything? I don't really think so. He wouldn't have wanted me to worry about him. But I am glad for all of the time I did spend with him. I am glad that I got to enjoy him as a person for the time he was on this earth. I am glad I was one of the good things in his life. I am strangely glad that I knew him enough to be so saddened by his abrupt end.

There will be no funeral. There will be no good-bye. We just have the memory of this gentle southern man who kept it all inside. Maybe I could have done differently, but I won't go there. I can't go there and keep from going crazy. I got to add more to his life than most did. I need to carry that fact into the exam room tomorrow when I see other patients. Yes, there is a lot to do. But there is really no greater honor to be allowed to serve these people. I can't forget that. We all can't forget that.

Good-bye, Jimmy. Thanks.

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Favorite

Doctors are not unbiased; we do have favorite patients.  There are some people who make you smile when you see them on your schedule.  You try not to treat anyone differently from a medical perspective, but there are just some people you feel glad to know.

One of my favorite patients is dying right now.

She has been my patient for nearly the entire time I have practiced.  She and her husband have been regulars in my office, and it has been an absolute privilege to be their doctor.  I would do it for free.  Really.  They both grin when I walk into the room, with him usually giving a silly chuckle.  She would stand up and open her arms for a hug, which she always got.

She is in her 80's and is an African-American who has lived in the South for her entire life.  I never asked her what it was like, but when I asked her what she thought about a black man being a candidate for president she paused, teared up a little, and told me it was wonderful.  I can only imagine.

My nurses commented how, despite her age, she was a beautiful woman.  She carried herself with incredible class and dignity, yet was quick to laugh at my jokes (which is no small feat in and of itself).  She and her husband had worked hard to raise their family right, and whenever I talked with their children it was clear that the work paid off.  All of their kids are college-educated and are carrying on the incredible legacy of their parents.

Yesterday I got a phone call from the cardiologist who took care of her, telling me how she had gone downhill quickly and that she was now in hospice.  It was clear that he felt the same way I do about this woman and her family.  "When the family walked on the ward, all of the hospital staff knew that they were something really special," he told me.  We shared with each other what incredible respect and affection we had for her and her husband.

As a doctor there is a necessary line you have to draw.  You cannot become too emotionally involved or invested in your patients; if you do, you will not last long.  There is too much suffering and death you will inevitably see for you to not set up significant boundaries in this area.  My job is not to keep my patients alive forever; it is to walk alongside of them through the physical and emotional trials they endure, making the journey as healthy and comfortable as possible.  Each year I practice I will lose a certain number of patients - some expected, some not.

This situation blurs that line.  I am very sad to be losing such a wonderful part of my life.  My heart is heavier than usual.  But even now I remain guarded.  I have to carry on with my job, see other patients, and continue being father and husband.  Still I will do what I can to make it to her funeral (I have only done that a handful of times).  I owe her that respect.

Her impact is huge.  The world is a much better place for her and her husband being here.  My life is much better.

Thank you.  It has been an incredibly honor.

If only I could get one more hug.

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226 Comments

Shame

Obese-woman-460x276

I saw a gentleman in my office for his sciatica.  He was having severe pain radiating from his lower back, down to his calf.

I was about to describe my plan to him when he interrupted me saying, "I know, Doc, I am overweight.  I know that this would just get better if I lost the weight."  He hung his head down as he spoke and fought off tears.

He was clearly morbidly obese, so in one sense he was right on; his health would be much better if he would lose the pounds.  On the other hand, I don't know of any studies that say obesity is a risk factor to ruptured vertebral discs.  Besides, he was in significant pain, and a lecture about his weight was not in my agenda.  I wanted to make sure he did not need surgery, and make him stop hurting.

This whole episode really bothered me.  He was so used to being lectured about his obesity that he wanted to get to the guilt trip before I brought it to him.  He was living in shame.  Everything was due to his obesity, and his obesity was due to his lack of self-control and poor character.  After all, losing weight is as simple as exercise and dietary restraint, right?

Perhaps I am too easy on people, but I don't like to lecture people on things they already know.  I don't like to say the obvious: "You need to lose weight."  Obese people are rarely under the impression that it is perfectly fine that they are overweight.  They rarely are surprised to hear a person saying that their weight is at the root of many of their problems.  Obese people are the new pariahs in our culture; it used to be smokers, but now it is the overweight.

The fear/disdain of obesity has reached into areas where it should not be.  I regularly have to tell mothers of chubby babies that it is perfectly fine for their child to be that way.  Children under three generally regulate their eating to what they need.  I do not believe a baby can become obese on breast milk or formula.  Now, if they are giving the child french fries and burgers, that is a different matter.

Instead of patronizing obese patients with a lecture, I try sympathizing with them.  Just because something is simple doesn't make it easy.  How do you quit smoking?  You just stop smoking.  We should just pull out of Iraq.  There should be peace in the middle east.  People should stop hurting each other and start being nice.  All of these are good ideas, but the devil is in the details.  Losing weight is a struggle, and it really helps to have people giving you a hand rather than knocking you down.

Don't get me wrong, I don't deny the health risk of obesity.  I do my best to work on weight loss with my patients.  But the idea that their personal worth lies on their BMI is extremely damaging.  There are a lot of screwed-up skinny people out there; just look at super-models.  It is a lot easier to lose weight when you actually like yourself and want to do something about your health.  Our culture of accusation and shame simply makes obese people hate themselves.  If you hate yourself, why should you want to take care of your body?

Is obesity a problem?  Sure it is.  But we need to get off of our self-righteous pulpits.  Obese people should not be made into a group of outcasts.  The "them" mentality and the finger-wagging are no more than insecure people trying to feel better by putting down others. 

It sounds a lot like Junior High.

If we really want to help with obesity, we need to grow up.

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16 Comments

Dear Insensitive Person

I am not sure if you are absolutely clueless or have a mean-streak, but your "friend," and my patient came into my office in tears.  She feels betrayed and abandoned in her terribly difficult situation.

Perhaps you have forgotten what it is like to have kids.  Do you think it is easy to see your child self-destruct in front of your eyes?  Yes, I know that parents can make this worse by "enabling" them, but do you think it is easy to pull back?  Personally I think that she is doing very well at balancing the need to pull back and the impulse to be a mother.  She is doing better than I would.  This is her son going committing slow suicide before her eyes.  I can't imagine the pain.

I find it very disturbing to see how quickly people feel they could live another person's life better than it is being lived.  No, I find it sickening.  It is the pinnacle of arrogance to assume that you would do any better if you had the same life experiences and traumas that she is doing.  She does not need to be told how to live her life, she needs compassion.  Compassion means you identify with the emotion and feel it alongside of this sweet woman.  She is torn up.  She is battered and bruised.  And all you can do is tell her what a mess she made?  She showed you her open wound and you threw acid on it.  Shame on you!

You don't realize how deeply you have hurt her, but I saw it in the exam room.  She won't sob in front of you - she would be afraid you would criticize her tears.  She won't even express pain to you.  You have cut yourself off from her by poisoning one of the only sources of comfort she had.  Now she doesn't know where to turn.  She doesn't know where to go for comfort.  She is distraught and destroyed.

You probably feel very smart and righteous in your proclamation of your opinion, but I see you as foolish and utterly selfish.  Is life a game of who is the smartest?  Is life a contest of who can make the most "good decisions?"  No, life is about caring for those who come to us with needs, hurts, and loneliness. 

I do hope you learn, although I suspect you will have to go through hell to really understand what this sweet woman is feeling.  I pity you.  I also feel like planting my fist in your face for what you did to her (no, I would never do it, but just thinking about what you have done fills me with rage).

Blessed are the meek.

Blessed are the poor in spirit.

Blessed are the peace-makers.

I pray that she finds comfort.  I hope that you find reality.

Sincerely,

Dr. Rob

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Hi Doc!

michael-jackson-waving-wearing-glasses"Hi Dr. Rob!"

I look up and see a familiar face and smile. I am out shopping and one of my patients has recognized me.

This kind of thing happens pretty often - especially in certain stores. Our town is of moderate size (around 200,000) and so this is somewhat dependent on where I am going, but it can happen any time, any place. When you take care of 4000+ people (and cover for more than twice that number), the odds are in favor of you being recognized at some point.

They are usually somewhat tickled at seeing me in jeans or shorts, and simply say "hi" to me. Most of the time I can get away without dealing with medical questions, although that does happen from time to time. To some extent, the reaction depends on my relationship with the patient, which varies widely:

  • Infrequent visitors - these are patients that I don't recognize because they don't come to my office very often. It is always uncomfortable to me when they say hello, as I have to deal with my poor face-recognition skills. Sometimes I come out and ask them their name, but most of the time I just act like I am as thrilled as they are to see me in public. It is rare that these people ask me anything medical. My response to them is usually, "uhh.....hi!  Good to see you....how have you been doing lately?"
  • Frequent flyers - They may have been sick a lot lately, but generally they are just "high utilizers."  They are willing to take up a lot of time in the office, so they are also likely to do so outside of the office.  They are very likely to ask medical questions.  While I don't want to look like I am trying to avoid them, I am generally trying to get away without too many visits.
  • Really sick patients - These patients are ones where I not only recognize them, but can recite their medication list and what my plan of action is on their current medical situation. These are the patients I will worry about when I am not in the office. I usually am glad to see them as I want an update on how they are doing.  I am more likely to ask them questions.
  • People who I enjoy - There are certain patients I am drawn to.  They are either like me in many ways (for that they get my deepest sympathy), or they are just good to talk with.  I am happy when they come into the office and also when they bump into me at the hardware store.  I would enjoy having these people over to my house for dinner, although I haven't ever crossed that line.
  • Friends who became my patients - I have a number of people who I knew outside of the office who became my patients.  Most likely this is from church, so I see them weekly.  I have no problem with them asking questions, as they are usually very aware of the boundaries in our relationship.  If they need to come in, I will tell them and they are fine with that.
  • People who think they are my friends - These folks know me slightly from outside the office and use that as license to "easy access" to me.  My office staff created the Rob Rule, which states that people who call asking for an appointment with Rob are generally not really my friends, but just trying to act like them.  If I see these people in public, I do my best to duck and cover.  I am likely to get into a prolonged uncomfortable conversation with these folks.
  • Kids I care for - I almost always am happy to see the kids - especially when they run up and hug me.  This is one of the perks of doing pediatrics.  The parents sometimes corner me, but not too often.

apu I was just in the hardware store when the cashier asked me, "are you a doctor?"  When I said my name she became very apologetic, as obviously I am her doctor and she did not recognize me.  The irony of it is that I had no idea she was my patient.  She looked vaguely familiar, but I had to reassure her that there was absolutely no offense taken.

Rural Doctor did a great post about a lady asking her questions in the check-out line.  A small town doctor must have it harder, as there is much more chance of anonymity here where I live.  She has no way to avoid it.  I don't think I could handle that.

Still, there are certain stores where I am nearly guaranteed to see one or more of my patients.  One of the docs I work with refuses to go to certain stores for this reason.  To me it is the price for the job I do.  The good news is that people are generally happy to see me, and when my wife is with me they tell her what a good doctor I am. 

They hope I'll give them a discount on their next visit when they do that.

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Ten Dumb Things About Medicare

  1. Reimbursement - At least in my field, it is nearly impossible to run a practice off of what it pays.  Most physicians who are on Medicare offset its bad reimbursement with private insurance or procedures that are outside of Medicare.
  2. Prevention is discouraged - A person cannot come in if they are well.  They have to develop a disease before being seen.  They tried to fix this with the "Welcome to Medicare Physical," but the rules were so laborious, it is nearly impossible to take advantage of this.
  3. Fraud Accusations - If you do anything that is not by the rules, you are defrauding the government.  This includes choosing to not charge any of your non-Medicare patients.  If I choose to make less money on my poor patients by not charging them I am committing fraud because I am not offering that same discount to my Medicare patients.  Docs routinely down-code notes to avoid coming under scrutiny for fraud.
  4. Part D - The pharmacy benefit has helped some people, but the concept of the "donut hole" has caused many of my patients to go off of medications they need.  The system is so complex with so many Part D plans that I never know if a medication is covered until the patient tries to fill it.
  5. Stupidity - Drug companies give discount cards or coupons to us to give to our patients.  Medicare patients cannot use these cards.  Obviously it is not in anyone's best interest for Medicare patients to pay less for medications.
  6. Balance Billing - We must always accept whatever Medicare says they will pay and not balance bill the patients.  I can't set my prices.  Furthermore, the other insurance companies pin their fee-schedules on Medicare's rates.  There will never be "transparent pricing" as long as this is the case.  We cannot charge what we choose to charge.
  7. The RUC - The RVS update committee sets the Medicare fee-schedule.  It is dominated by specialists, and so it protects the interests of specialists over primary care.  It is so tied to special interest groups that it is hard to believe it is used as an "unbiased" source of advice for the fee-schedule.  Actually, it is a travesty to the system.
  8. Dropping Out - If you drop off of Medicare as a provider, you cannot reapply for 2 years.  This stung us when we tried to hire a physician who had previously dropped off of the list.  He simply could not see our patients.  I am not sure I understand the rationale for this.  Are they just spiteful?
  9. Sustainable Growth Rate - On the surface, this looks OK.  If we can't afford Medicare, it automatically cuts the reimbursement.  The problem is that the cut will be equal across all areas.  This hits primary care extremely hard, making it even more difficult to afford to take Medicare.  Specialists can afford to have office visits reimbursed less because they make most of their money off of procedures.  Are they hurt too?  Yes, but they are not living on the edge like PCP's.
  10. PQRI - The new "pay for performance" system is a mess.  The system is based entirely on billing (by putting in special modifiers when you bill), and reimburses a very small amount.  Plus, you don't ever know how you are doing and whether you will qualify for the bonus.  I look forward to my $30 check...if I get anything.

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21 Comments

Baby Therapy

218301wcEB_w Today was nuts. It was absolutely nuts. My auto repair shop had called last week telling me the parts they ordered to fix my windows were in. Today was my first chance in a week to get my car fixed.

After dropping my daughter off at school, I drove over to the auto shop. I was greeted by a delightful elderly man there who asked me if I needed a ride home. I told him I did, and he directed me to where the Courtesy Van was parked. I climbed in and we headed toward my home.

We had a pleasant conversation about our city and all the history he had experienced over the many years he lived there. At his request, I punched my address on the GPS device so he could know exactly how to get to my house. I am not sure why he wanted me to do this, because he totally ignored anything it said. He had a better way.

GPS-500 Each time he went off of the prescribed course, the GPS would state it was "recalculating directions" and then try to get us back on the way it knew to be the quickest route. GPS devices are great inventions, although they do have their quirks. I was in Oregon once in a rental car and asked for directions to the nearest Wal-Mart. It gave me directions to a Wal-Mart in Las Vegas, over 1000 miles away. Perhaps my driver knew better. I gave him the benefit of the doubt.

By about the fifth time the GPS announced it was "recalculating directions," my driver was getting annoyed. He grabbed the GPS and started trying to reprogram it. Why he did not just push the little "off" button, I was not certain. Perhaps he felt that if he pressed enough buttons, the device would realize that his directions were superior and stop "recalculating directions". With his attention fixed on the task of educating this new-fangled device, he neglected the fact that we were driving through a residential neighborhood. We were headed us directly at a car parked on the right side of the street.

"Car!" I said forcefully, digging my fingers deep into the fabric on my seat. He looked up in time and redirected his course, dropping the GPS, which once again tried to recalculate our course (I was hoping it was trying to find a very wide road).

We wound around the back roads of our town and my driver decided to show me some sites of historic interest. "This is the oldest cemetery in the city," he said, pointing to the right. I let off a little prayer that we would not be in need of a cemetery any time soon.

do-not-enter"Turn Left" said the GPS in a voice that was sounding a bit perturbed at this point. We went straight, turning left at the next intersection. I noticed a "do not enter" sign that we drove quickly past.

"I think this is a one-way street" I offered, as the GPS once again recalculated our course. The drivers coming at us scowled and shook their heads. We passed another cemetery, and my driver again pointed it out. Was he trying to tell me something?

Cemetery

The rest of the trip was uneventful (aside from the refrain of "Nearer Oh God to Thee" that ran through my head). I thanked my chauffeur for the ride as I stepped quickly out of the car. There were deep indentations on the seat where my fingers had embedded themselves. He told me to call him if I needed another ride, and I smiled graciously to hide my abject horror at the thought. I think he wants to show me all the funeral homes in town. As he drove away I fell on my knees and kissed the ground.

After talking myself out of a stiff drink and filling my wife in on my near-death ride of horrors, I drove with her to work. I did the driving - not that I don't trust her, but I thought another ride in the passenger's seat would only lengthen my emotional recovery. When we got to my office, she drove home, leaving me there without a means of transportation. She would either pick me up after work, or I would mooch a ride from my partner.

The day seemed to be settling down and I saw my first two patients. As I wrapped up with the second, there was a hard knock on the door. "Labor and Delivery is on the phone. There is an emergency C-Section at the hospital."

As pediatricians, we have to attend C-Sections or complicated deliveries at one of our local hospitals. My training in newborn resuscitation was 14 years ago, and the number of times there are truly sick babies at these deliveries is quite low. I can go years between having to intubate or resuscitate a child - which is fine with me. But this always makes these deliveries a somewhat tense affair. The problem of our rusty skills is balanced with the high level of experience of the Nursery nurses who are there to "help us." The truth is, they could probably do it just as well without us.

2 So here I was in my office without a car, needing to get to the hospital quickly. The other pediatrician in our group is in Siberia right now (really, he is on a mission trip - he did not get sent there for being behind on medical records). I was the only one who could attend this delivery. I begged a car off of my other partner, who explained that the Air Conditioning was not working. I didn't care; I had to hurry to the hospital and be at this C-Section. So I drove the hot car through mid-day traffic to our hospital, which is about 7 miles from our office. Luckily, I don't have to drive by any cemeteries on the way.

By the time I arrived at Labor and Delivery, the baby was already born and was thankfully crying. I did my doctorly act and declared the baby born, grabbed a bite to eat, and headed back to work. The other physicians in my office saw the rest of my morning patients, and my afternoon schedule was fast approaching.

I was trying to catch up on charts in my office when my pager blasted an angry beep at me. I looked, and it told me to call Labor and Delivery for a C-Section. "You're popular today, Dr. Rob" the nurse told me on the phone. I guess I had done such a fine job declaring the last baby born that they needed an encore performance. Flustered, I grabbed the keys - still warm from my last use - off of my partner's desk.

sauna I once again maneuvered the sauna-mobile through mid-day traffic and ran up to Labor and Delivery. The Operating Room where the C-Section was to take place was empty. The nurse informed me that Anesthesia was taking a long time to get the epidural in. The C-Section, it turns out, was happening because the baby decided to stick his hand out first. Perhaps that is what his GPS told him to do. Unfortunately, the OB would have to recalculate his course and bring him out through another route.

After a 45 minute wait, the C-Section was on. It went fine, and I once again declared the baby born (to the jubilant cheers of the nurses and obstetricians in the OR), and I left go back to my office.

This whole day had conspired to turn me into a grump. I really had not wanted to be grumpy, but my course could not be recalculated and thus headed straight for Grumpville. My mind was jumbled. I had narrowly avoided death and then had then declared two babies born. I had been face to face with the beginning and end of life. Now there was work to do.

It is hard to reset your brain on a day like this and not wallow in your misery. You want everyone to know how bad your day had been, but as a doctor, you can't do that. The visits are not about you, they are about your patients. They are not there to hear your day was like, they want you to care for them. Taking mind off of yourself on this kind of day takes a whole lot of discipline (and perhaps some mild shock therapy).

And so this grumpy, self-pitying, GPS-hating, car-borrowing, birth-declaring doctor walked into his first patient's room and was greeted by a grin. A baby grin.

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Babies don't care who you are, they just smile. Between two and nine months of age, babies can't help but smile at everyone and everything. Even grumpy doctors; although this doctor had just been cured by a good dose of baby therapy.

Thanks baby.

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Grand Rounds Fiasco, Part 6

hotpotato Welcome to the incredibly confusing Grand-Rounds fiasco. If you have not seen parts 1-5, then you are really missing something! If you are here first, then shame on you. You must be one of those people who read the last chapter of the book before you finish. Shame... Go to Grunt Doc if you want to start at the top. Really, you should.

evel-knievel-crash So GR has crash-landed on my blog. Most unfortunate. I was actually planning on writing a post about mutants, but then suddenly this grand rounds thing shows up on my doorstep. I really didn't expect it. I had prepared so many things for my mutant post, that it really upset me.

But I refuse to let such unexpected turns dissuade me from my mission to educate my readers about mutants. I cannot let down my readers. So I will do my segment of GR in the mutant spirit (the thought brings a tear to my eye). So here it is:

MUTANT GRAND ROUNDS

1. The Danger of Mutants

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It would seem that we all would be afraid of the penetration of mutants into our world. But many don't understand such dangers are here in our midst. Mutant animals pose a terrible danger for the helpless segments of our society, such as children (as displayed on the right - the one without the horns) and elderly.

Just as mutant goats are a danger to our children by trying to beat their brains out, waiting times are an especially bad problem for a medical office. Ian Furst at the Wait Time & Delayed Care Blog (which is kind of like mutant medical care) gives advice for zeroing in on workflow. He does a brilliant analysis of the factors that can lead to patient dissatisfaction. He does not, however, give any advice for self-defense from aggressive goats. Nuts.

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Another great danger is the way in which mutants are infiltrating our society. They are right here among us. I was just walking down my street and snapped this picture as this llama stuck it's head out of the car. What was scarier was the dog driving the car. These unusually intelligent animals are moving right in to our neighborhoods, trying to fit in (like sleeper cells), only to rise up against us when we are least suspecting. This llama tried actually gave me the hoof as he and the dog sped away. It gives me chills to think about it.

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On the same subject is a post by Tara C. Smith of Aetiology (what a fancy way to spell it!) who writes about looking at the synergy of the medical and veterinary professions and the use of this synergy to understand the spread of diseases, etc. Interesting stuff, and useful too. Especially when those sleeper cells awaken. We need all the help we can get.

2. How Big a Problem?

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The question many of you may be asking is: How big of a problem is this mutant situation? Is it just one of those conspiracy-theory things like that whole man-on-the-moon nonsense, or should I really take it seriously? I have to say, I sometimes am skeptical when scare tactics are thrown my direction, but I have to say that this is a huge problem. The dangers these mutants pose are beyond description.

The same can be said for insufficient screening for colon cancer. This is raised in the blog On the Wards. Who is to blame for such poor screening in our society? Katie Couric? Alan Thicke? Nick Genes? No, it is the physician who need to be identifying those at risk and encouraging colonoscopy.

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Yes, this is a picture of Hogzilla, a large pig that was shot in my home state. You may not realize it, but there are probably very large animals in your state. This is terrifying. Imagine having a 600 pound squirrel running on your roof. Imagine a mammoth seagull letting go and hitting your windshield. The scenarios are wholly unnerving.

Dr. Wes asks us to use our imaginations as well, asking us to imagine a world without Medicare. OK, that is not nearly as scary as the mutant animals, as he points out. In fact, it may not be at all a bad thing. It sure would beat being chased by poisonous killer slugs.

3. Not Just Animals

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Reading this, you may think that the problem of mutants is limited to the animal community. No dice. Mutations are happening in all areas of creation. They are a result of genetic experiments of evil scientists funded by the major multi-national corporations like Hasbro and Shop-Vac.

You may be surprised when you see just where the mutations are occurring, like the half man, half vegetable mutant pictured on the right. In this case, the scientists took a human egg and crossed it with a very large asparagus. Just who would allow their child's genes to be mixed together in such a hideous way? It defies the imagination.

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Sandy over at Junkfoood Science shares other scary information on how your genetic information may be used (or mis-used). Do employers have access to your code? Can insurance companies deny coverage be denied due to your genetic risk? Scary stuff.

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Almost as scary as the mutation gone bad of a smurf as pictured above.

HRPufnstufEven those innocent TV characters we all loved as kids are corrupted through evil mutations. This is all reminiscent of the predictions of such writers as Aldous Huxley, who wrote the book Brave New World. It is a brave new world we live in, where children can be attacked by mutant goats or mutant...uh....that thing on the right...I am not sure what it is, but that child does look terrified.

Terrified too we should be of the brave new world of medicine outlined by Henry Stern over at InsureBlog. Are insurers really going to stop paying for all that high-tech medicine? It seems so.

4. A Call to Action

So I ask you to stop hiding from this problem. Mutants are cropping up everywhere. But there is still hope. We can mount up a defense against such a huge threat. We can fight back.

I present to you: Robo-Goat.

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Yes, this creature is only able to eat losing lottery tickets (I wonder what he does with the winning ones), but this is just the start of a robot army we can make to fight the mutants.

JC Jones of Health Observances takes up the call to action in highlighting National Youth Violence Prevention Week. Truly a noble cause: to protect innocent youth from the horrors of violence that is so prevalent in our society.

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Much in the same way this robot Chuck E Cheese is protecting this child.

DSCF0680Huh? Oh, no! There is a scratching sound at my door! I hear mooing...and bleating....and large human vegetable kind of sounds (hard to describe).

I need help in this emergency!

Who can I call?

Where can I turn?

Ahh! I think I smell a giant cucumber about to attack!

I know! I will call Kim at Emergiblog!!! Please follow me over there!

Before it's too late....

Addendum: Yes, this was a fun April Fool's frolic, which included the genius of Grunt Doc, Dr. Val, David Williams, Nick Genes, Dr. Anonymous, Nurse Kim of Emergiblog, and the token fool: me. It was an incredible pleasure to work with these wonderful bloggers.

Hope your 1st of April was foolish.

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Opening Remarks

eeerik_estrada I was never too good at opening lines. "Hey baby, you come here often?" "What's your sign, beautiful?" No, that's not me. Perhaps that is why I didn't date much. Now, however, I must be good at opening lines. My job depends on my ability to talk to my patients and get them to talk to me. Sometimes it goes well, other times it doesn't. For example, sometimes I walk into a room with a person looking ill and out of habit I ask them "how are you doing?" Obviously not well, since they are in my office, right? But out of habit, they usually respond, "Fine, how are you?"

Sometimes it is the patient who initiates. Last week I had several patients say to me, "Doc, you look more stressed out than I am." I really didn't feel that stressed on that day. It made me very self conscious about what non-verbal message I was sending. I try to avoid saying things like, "You look tired today!" I may say it, but only after I have talked to them for a bit.

fatalbert I have also had patients comment on my weight, which has gone up and down. One lady was somewhat rude and said, "My word, Doctor, you look pregnant!" I was so taken back by her forwardness that I had a hard time gathering myself for the conversation. I suppose people feel that I put them on the scale, so I am fair game. I have more than once had some people say that I look like I have gained weight only to have a subsequent room tell me that I must be losing. I try to take it in stride as best as I can.

One of my favorite things people say to me is: "Don't come near me, Doc. You don't want to catch what I have!" I give them a quizzical look and say, "It's really somewhat normal for a doctor to be around sick people." Why would you come to the doctor and then have them stay away? I guess they are being polite, but it is somewhat humorous when that say it.

Another common encounter is with the impatient patient. They are checking their watch and wondering what took me so long. If they confront me as to what took me so long, I usually try to disarm them and say something like, "Well, I was really trying to avoid seeing you. My nurses kept harassing me, however, and I had to give in and see you." I do this if I know the patient well enough. Otherwise I will say, "You got in the slow check-out line in the supermarket. It just happens some days - we can't predict how much time each visit will take, but regardless, I will always give you the time you need." They seem happy with that answer.

e84f96d7d4dbabbfc42c431a31a86491 In general, however, I try to enter with a compliment. If it is a baby I am seeing, I will say something like, "hey there cutie!", or "Hey beautiful!" I also like to say "Hi there, skinny" to the particularly chubby baby. For adults, I will try to find something to compliment. My elderly ladies are very pleased when I compliment what they are wearing. In general, my African-American elderly ladies still believe you should dress up to come to the doctor. I like that.

Some patients have built their world around their medical condition. To them, their way of getting attention is to highlight their problems. To these people, I am always finding something good to dote on before they can complain. If I can give them some attention for reasons other than their sickness, perhaps some day they will come in without complaints. That is my dream for them (albeit far off).

I get about 90% of my information for decision-making from my discussion with my patients. History is always more important than physical. Saying the right things at the start will make that job much easier.

Besides, I don't really want my patients to "come here often." My goal is to keep them out.

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