One day, in a town not far from here, the Urology team were about to perform a radical prostatectomy on a middle aged man. He had a wry smile on his face, as we gassed him down. Must be the midazolam, thought the anaesthetist.

When he was fully asleep, he was stripped bare, but hidden in his jocks was a bit of paper. On that piece of paper there was a poem, which read…

Note to Dick Doc

Hey dear Doc,
I love my cock,
And have a girlfriend
Young and hot.

Now I may not be
The worlds best Bard,
But my girlfriend likes it
When I’m hard.

So I won’t ask
If you can spare a dime,
Perhaps another place,
And another time.

But my sex life
Is on upward curve,
So hey there buddy,
Can you spare a nerve?

This had the whole team in hysterics. The operation proceeded well, and the surgeon, presumably flattered by the effort, and unable to conceal his own aspirations at Shakespearean fame, composed his reply…

Response to Eric

Oh brave patient!
Your wishes are ancient!
With crafty words hidden
Down low, near forbidden.

A reminder to us,
The nerves are a must!
So to protect them for certain,
We raised up a curtain.

Now the Evil is gone,
Your member will live on.
A reminder to all
Who this disease will befall,
That with modern surgical skill,
We are sure to Fulfil!

The Anaesthetist, not to be outdone, composed her own response, although the final word may have been altered to protect the innocent.

Dear Eric

To save your bits,
We did our best!
Mother Nature
Must do the rest.

For your wit,
You do deserve
To keep the power
In the all-important nerve.

With some surgical finesse,
And a bit of luck.
Your lovely girlfriend
Will remain a lucky duck.

The Anaesthetic Registrar, having come back from his 12^th tea break for the morning, was rather proud of his contribution. He wrote…

Ode to Eric

Hi Eric!
You had us in hysterics,
You made us smile,
With your style.

So we shaved you there,
Because we care,
To get it right
Up, without a fight.

We did remember
To spare your member.
And with Viagra,
She’ll want to shag ya!

We wish you luck,
With every… year!

The poems were photocopied onto a double-sided A4 paper, and placed back “down there”.

Eric woke with a smile…

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

A few years ago I was looking after an elderly woman in the emergency department who had suffered a stroke. She was aphasic — unable to understand speech or create comprehensible sentences. I explained to her family what had happened to her. Then her daughter asked me a question for which I hadn’t prepared an answer:

“What does it feel like to have a stroke?”

The answer to this question is not taught in medical school. I could call on a few vague recollections from some of Oliver Sacks‘ books, but the place I directed her to was TED.com and a talk by the neuroscientist Jill Bolte Taylor. Taylor wrote a book titled My Stroke of Insight based on her own experience of a hemorrhagic stroke. The fusion of her objective scientific approach with her personal, subjective internal adventure gives an incredible unique insight into the effect of an intracerebral hemorrhage on the human mind.

Watch, learn and be amazed:

http://www.youtube.com/watch?v=UyyjU8fzEYU

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Treat the patient, not the disease

Care more particularly for the individual patient than for the especial features of the disease.
— William Osler

We enter medical school eager to help the sick and the dying. Over the years this golden objective is transmuted into the base lead of disease-specific diagnostics and therapeutics. Our absorption in the strangeness of the manifestations of a remarkable pathophysiological process may distract us from its impact on the person.

Olser warned us of this danger:

There is a tendency among young men about hospitals to study the cases, not the patients, and in the interest they take in the disease lose sight of the individual. Strive against this.
— William Osler

This tendency is dangerous. Failure to temper it comes with undeniable costs. The elderly may die alone in sterile surroundings rather than a home filled with the memories of loved ones. The symptoms of disease may be replaced with the side-effects of therapy. Autonomy may be sacrificed for dependence at the altar of medical paternalism.

This tendency turns us into misguided Ptolemaic medico-astronomers when we forget that the patient is the center of the medical universe. Perhaps we can be forgiven. After all, we find ourselves buried under mountains and mountains of facts and figures and guidelines and ‘the latest’ in evidence. We are stamped and punched with holes by the grinding and boring down of the ‘health care’ machine. We are worn away by the diminishing returns of circadian disruption won by playing a loaded game of roster roulette. And, perhaps the pill that is hardest to swallow, we sometimes find ourselves the target of vehement violence and abuse by those we try to help. Perhaps we can be forgiven for forgetting just what it is that is the Philosopher’s Stone of our profession.

All the more reason to remember the lessons of Osler.

"Observation, Auscultation, Palpation, and Contemplation" from Library and Archives Canada (Click image for source).

In his or her first days of becoming a doctor, the once and former medical student comes to a deflating realisation. The patients have not read the textbooks or attended the lectures. The child with abdominal pain has pneumonia, the slightly crazy man with all over body ache didn’t even mention chest pain as a symptom of his myocarditis, and the man with the shrinking feet isn’t crazy (even though his feet are not shrinking). Osler reminds us that this state of affairs is nothing new:

Our study is man, as the subject of accidents or disease. Were he always, inside and outside, cast in the same mould, instead of differing from his fellow man as much in constitution and in his reaction to stimulus as in feature, we should ere this have reached some settled principles in our art.
— William Osler, from Teacher and Student, in Aequanimitas.

As doctors our learning is a lifelong task. Everyday we learn new lessons. And who teaches us? Our patients. Everyday I hear the words of one of my own teachers, Prof Koelmeyer, who would admonish us to remember that the patient is “our first, last, and only teacher”.

But what of the difficult patient?

Indeed, difficult patients present great difficulties. They sap our physical and emotional reserves, they disrupt the under-oiled workings of the hospital conveyor belt, they confront us, and may even be a physical threat to us or put the ‘Mark of the Beast‘ upon us. The threat of physical violence towards hospital staff is never to be tolerated, no matter who the patient is. However, sometimes this threat comes from those who know not what they are doing. We must guard against making assumptions and try to help. Aequanimitas cannot always be maintained and, sometimes, ‘Freudian slaps‘ will be proffered.

Yet each difficult patient teaches us a lesson. With each lesson we become better at treating difficult patients. With time some patients that we once considered difficult, no longer merit the disdained classification. They simply become patients.

Every patient you see is a lesson in much more than the malady from which he suffers.
— William Osler, from The Student Life, in Aequanimitas, 406.

But treating the difficult patient is made easier by more than just the fact that they are our teachers. They allow us to prove our humanity and remind us why we do what we do.

To serve the art of medicine as it should be served, one must love his fellow man.
— William Osler

Despite all of medicine’s scientific advances and technological marvels, empathy is still at the heart of our profession. Empathy is a two-way street, there are times when, one way or another, we suffer together with our patients. But what to do when we open the empathy cupboard and find it bare? Sometimes empathy is simply an impossibility, we just have to be professional. But much of the time we just need to think of ourselves — or that still much-loved black sheep among our friends and family — and remember that we also are all too human with our own unique complex of flaws and frailties.

Keep a looking glass in your own heart, and the more carefully you scan your own frailties, the more tender you are for those of your fellow creatures.
— William Osler

Though it may be difficult in this era of ‘four hour rules‘ and the tyranny of QPIs, today as in the past, doctors do well to heed Osler’s wise counsel:

The motto of each of you as you undertake the examination and treatment of a case should be “put yourself in his place: realize, so far as you can, the mental state of the patient, enter into his feelings… Scan gently his faults. The kindly word, the cheerful greeting, the sympathetic look.
— Wiliam Osler

Though it is not always easy, or even possible, there is much to be gained by always striving to treat the patient, not the disease.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The associations that populate our minds are wonderful things. To some degree they make us who we are. To what thoughts does your mind race as you contemplate this banana, I wonder?

Photo by Jason Gulledge

Perhaps some of your evoked associations may not be fit for public dissemination. Fair enough, your privacy should be respected.

Among my own associations I can bring forth the image of a little old lady. I can see her calmly sitting in her hospital bed in the rehab ward. She was afflicted with a lesion to one of her frontal lobes. Her potassium was running a bit low. One of my colleagues was speaking to her.

“Here have an extra banana, it will help boost your potassium levels”, he happily suggested.

The patient appeared nonplussed, her eyes fixed on the banana.

After a brief pause she reached out and took it in her spidery grasp.

Then she spoke to my smiling colleague.

“I’ll tell you what to do with this banana…”, her voice filled with unexpected vitriol, “take it over there, and stick it up your mate’s…”

Startled that the banana was now being directed at me, I failed to register the finer details of the intended location.

Fortunately, I never did find out.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

UCEM‘s PR Supervisor, Assistant Sub-Professor Egerton Yorick Davis IV, has kindly released the new UCEM guideline, ‘Putting Patients at Ease’, to the LitFL team. This marvel of pedagogical pedantry was assembled by a crack team of educators under the direction of the incomparable Professor Harry Stickler. It serves as a guide for MUPPETs to a key Waiting Room medicine competency: the art of instantly and effortlessly putting patients at ease. The guideline adheres to the Sticklerian philosophy that the best way to learn how to do something is to first learn how NOT to do it.

So, without further ado, here are some UCEM-sanctioned pearls for how NOT to put your patient at ease, how NOT to build rapport and how NOT to make the patient think you’re the right doc for the job.

http://www.youtube.com/watch?v=m1IGH-WKW38

While introducing yourself to the patient, say:

• “Oh, you’re not Mr Smith? Whose clinical records are these then?”
• “Are you sure you’re not Mr Smith? Are you in the right cubicle?”
• “Mr Smith, sorry about the delay… I’ve just been examining the wrong patient.”
• “Sorry, my mistake Mrs. Smith, I understand now. You’re not his grand-mother, you’re his wife.”

While examining a patient:

• swing you stethoscope around your neck, such that you hit yourself in the eye and a juicy periorbital hematoma starts to form.
• scream “What the hell is that?!?”
• mention to the patient’s father, “he really doesn’t look anything like you, does he?”
• squeeze the abdomen so hard that the patient lets out an involuntary fart.
• gently pat your non-pregnant patient on the belly and say, “well, you’re sure getting big… Tell me again, when are you due?”

Before a procedure:

• vomit or drip sweat onto the patient.
• start reading a textbook in front of the patient. After 2 minutes turn the book the right way up.
• inquire of the patient, “Are you sure it’s this leg, I mean arm?”
• say to the patient, “I’m feeling a bit shaky, can I have one of your beta-blockers?”
• reassure the patient that “if this doesn’t work out we can always refer you to Plastics.”
• explain to the patient with abdominal pain, “Look we’ve got no idea what’s going on, so we’re going to cut you open. OK?”
• confidently assert, “Don’t worry about a thing, I’m much smarter than I look.”

During a procedure, say:

• to the nurse: “Hmm, have I given the local anesthetic yet?”
• “I wish I’d seen this done before”.
• “Damn it, I should have used my dominant hand for that bit”.
• “You know, maybe we should just start this all over again.”
• “I think its stuck”  (this is especially effective during a speculum exam).
• “Oh, no…”
• “It’s OK, I’ll just hold this here until help arrives.”

After a procedure, say:

• “Wow, that was great – my first one!”
• “Wasn’t there another swab around here somewhere?”
• “Well, at least it went better than the last one I did.”
• “Mr. Smith, it appears that my hand has been glued to your head.”
• “Just remind me, what did I say was wrong with you?”

http://www.youtube.com/watch?v=EYPsCWli-go

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

All doctors find breaking bad news a difficult thing to do. No matter how well prepared you are for your patient’s reactions, the unexpected is always waiting around the corner.

Fortunately, I have yet to encounter this scenario (you may want to turn up the volume):

http://www.youtube.com/watch?v=boyO324pzns

From the film ‘Funny People‘.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Everyone who works in ED or ICU should read Alicia von Stamwitz’s brief but moving account of her father’s last visit to the emergency department:

…

The doctor explains what I already know: my father’s heart is weak, his kidneys are failing and his lungs are filling with fluid. For the second time in six months, he needs to have a tube inserted in his windpipe.

I nod, waiting for him to continue listing procedures and tests. Instead, he takes a small step back from the gurney and asks, “Does your father have a living will?”

I freeze. No emergency room doctor has asked me this before. I answer, evenly, yes. “Do you have durable power of attorney?” Yes.

Visibly relieved, he looks me in the eye and gently but pointedly asks: “Does your father want us to employ extreme measures” — he pauses one heartbeat for emphasis — “knowing that he is not likely to improve?”

…

Read on here.

Being compelled to make a life-or-death decision for a loved one is a nightmare scenario for anyone. As health professionals we may not always agree with the decision of a patient or his or her family – but sometimes it is their decision to make.

It is our job to help and support them regardless.

[Hat tip to Dr. Bearemy's My Emergency Blog]

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Blood slowly dripped from two linear slits on the left side of the man’s chest. He focused on the doctor with a wide eyed stare and spoke in an anxious whisper:

“Doc, don’t let me die… don’t let me die, doc.”

“We won’t let you die”.

The doctor looked up from the patient’s tattooed face to the stony-faced nurses and paramedics, then continued his assessment.

“Tell me what happened to you.”

“I fell on a knife.” he whispered.

“Twice?”

The patient would say nothing more.

The doctor approached the paramedics as they collected their equipment and finished their notes. The taller, red-haired paramedic said:

“As we were driving away from the scene a woman chased after the ambulance waving a large kitchen knife. Just a hunch, but I suspect that she might have something to with this…”

More information came to light from the nurse-in-charge:

“This man isn’t allowed within 200m of the emergency department. He’s been here quite a few times before with a number of badly beaten women and has repeatedly threatened and intimidated the staff.”

The patient didn’t look quite so menacing now – despite the crew cut, the gold teeth, the gang patch and leathers, the missing finger, the tattoos and the countless scars.

The police were standing outside as a nurse left the trauma room.

“Is he going to make it?”

“Looks like it.”

“That is a shame.”

The patient was plumbed with lines and remained stable, so he was taken for a CT scan. Apart from a small amount of blood and air around his left lung, his only serious injury was a difficult-to-spot knife wound to his diaphragm. The lower stab wound had missed his heart by less than a centimetre. He went to theatre to repair the diaphragmatic rupture and to look for other internal injuries. His recovery was uneventful, with the exception of the incident in the intensive care unit.

A woman, sunglasses partially concealing the bruise around her left eye, came to pay him a visit. Soon after she arrived, somehow, despite having been securely sutured in place, the patient’s chest drain mysteriously ‘fell’ out.

http://www.youtube.com/watch?v=_NV45ZuepZo

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The patient’s son and two daughters had said little during the family meeting. The older daughter steadied her sister’s trembling hand while the son stared at the doctor intently.

The doctor felt that he may have said too much, that he may have clouded his message. He decided to sum up the situation, “I’m very sorry but your father’s heart is just too weak. Although we are doing everything we can to help him, I think he is going to die.”

The doctor stopped speaking and turned to the nurse beside him who nodded sadly. He looked at each of the patient’s children, trying to give them enough time to comprehend how negligible their father’s chance of recovery was. He saw mascara and teardrops mix and merge into murky streaks on the women’s cheeks.

Finally the doctor asked, “Do you have any questions for me?”.

The patient’s son stretched his arms above his head and with interlocked fingers cracked his knuckles. He said, “Doc, can you tell me where the cafeteria is? I could murder a burger…”

The now infamous recruitment ad for a NZ burger bar.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The surgical team left the old man’s bedside as the ward-round came to an end.

“That chap’s really not with it is he?”, said the Surgeon to his House Officer. “Perhaps we should get the medics to have a look at him. Do you think his state of confusion is acute or chronic?”.

The House Officer ferreted through a pile of old notes hidden beneath the ward-round trolley while the surgeon checked his watch. The old man’s notes were found and the thick file fell open on a faded clinic note written by a General Surgeon in 1965.

The house officer read the first line aloud, “This man is clearly a mental defective of some description.”

He looked up from the notes and said to the Surgeon,  “I suspect its mostly chronic.”

The Surgeon nodded as he left the ward.

Ed Wynn in "The Perfect Fool," 1959. Photo by Sid Avery.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog