The type of Emergency Medicine story that gets your heart racing. (Also got a nice kick out of him linking to MDCalc for the Parkland Formula .)

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(If you’re squeamish, this isn’t the post for you.) There’s a total RIBBFOMP story and photo over at White Coat Rants , hand versus snowblower. If you’ve always wondered what the tendons look like that allow your fingers to flex and extend, but never wanted to take the anatomy class, there’s a perfect specimen in the post. Wow.

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A good stepwise process, for future reference in residency, from a lecture today in Family Medicine. This applies to both deaths and bad news in terms of studies, lab results, etc. (It’s also often a good idea to have the social worker or chaplain with you if you can.)

1. Make a setting. Don’t do it in a hallway, go find a private, quiet place to sit and talk.
2. Introduce yourself. Often the family has seen a number of different people caring for their loved one–doctors, nurses, techs, etc–so reiterate who you are, especially to the significant other.
3. Ask what they know already. It gives you a sense of their knowledge level, what they might be expecting, what they’re worried about, so you don’t repeat anything or speak above or below their level of understanding and medical knowledge.
4. Make a “preperatory statement.” This readies and focuses the loved ones for what they’re about to hear. A good suggestion from the lecturer: Don’t say “I have some bad news.” Try, “I have something very important I need to tell you right now.”
5. Deliver the news. Be brief, direct, and succinct, 25 words or less.
6. Pause, wait for a response. Be there and be present.
7. Arrange a follow-up for later. A phone call, a card–it doesn’t have to take extraordinary effort.
8. Take care of yourself. It’s emotionally trying and exhausting to do this, so allow yourself to grieve however you may express that, too.

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Shadowfax finds a kidney stone in a “known drug seeker” and treats her with toradol. Success. I had a somewhat similar case with a “known homeless drunk” who had pretty severe electrolyte derangements after I bothered to check, despite nurse balking. Only re-iterates the point: trust no one.

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In two common infections of the vagina, bacterial vaginosis (and sometimes in trichomonas vaginalis) your doctor may do a “whiff” test, where he or she takes some discharge, drops some potassium hydroxide on it (a base, KOH) and smells it for a fishy, foul odor. The base causes some foul-smelling amines to be released: cadaverine and putrescine . What great names.

Interestingly, some women will complain of foul odor after intercourse, and the reaction is the same: semen is basic, and when it mixes with the discharge, you get the same release of cadaverine and putrescine. Cool.

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Flea (RIP) used to talk about the medicalization of childhood –that kids don’t just run the spectrum of normal variation, that everything nowadays has to be a diagnosis or a pathology that requires treatment. I’ve started to come across the same thing in pregnancy.

There’s this strange phenomenon that several of the docs, nurses, and assistants have commented on–that women will come in, having missed their periods, taken several at-home pregnancy tests, all positive, and still want or need the doctor to “deem them” pregnant. (Plus often a number of the pregnancy changes: nausea, vomitting, breast tenderness, bleeding gums, etc.) Just seems strange that in some ways we’re so out of touch with our bodies–or at least the “natural” changes of them–that we need some “authority on bodies” (doctors) to concur with our own diagnosis.

I guess you can take this a step further and apply it to a lot of common complaints: a weird twitch somewhere, a strange sensation. In some ways it makes sense–you see plenty of patients who wait too long before they see a doctor for what turns out to be a heart attack, or cancer, or stroke, or out of control diabetes–and you wonder how they could possibly have waited so long. And on the other hand, you have people coming in for weird aches and feelings that are just typical, natural weirdness of our bodies.

Sometimes I wonder if a lot of the extremes are due to the break up of the extended family, and the more migratory lives of people. Had a newly-pregnant woman been living with her parents or grandparents, the mothers would just immediately recognize, “Duh, you’re pregnant.” Likewise, the guy who looks green and is clutching is chest might be convinced to seek medical care if his family members urge him to.

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Started Family Medicine this week (my last clerkship!) and very much agree with the philosophy, probably more than the Internal Medicine approach: that you must take the patient in context. That much of what we consider “health” doesn’t fit within the conventional boundaries of medicine, and that a person’s environment greatly affects his or her health. A couple of thoughts from the introductory lectures, one by a patient advocate on Advance (not Advanced!) Directives:

• On the term “life support,” as in: We would have to place your dying father on life support or else he will die tonight: We should call it “artificial organ support,” not life support. Life is something that we define as people–and all “life support” does is keep the organs in the body working longer.
• On making sure everyone has an advance directive: Maybe it’s a bit morbid, but what if on Thanksgiving or some family holiday, everyone brought out papers and wrote an AD? Then everyone in the family would have their wishes known, and there’d be less fighting later.
• Did you know you can write people out of an Advance Directive? Say you have a child who hasn’t been around for a long time, or a trouble-maker in the family–you can specifically mention in your directive that you do not want that person to take part in health care decisions for you. (I hadn’t considered this as a possibility.) ( Some info on ADs. )
• On “Do Not Resuscitate”: In Georgia (and it seems, slowly spreading elsewhere), health care may be switching to the term “Allow Natural Death,” trying to make it known that death is a normal part of life, and that it cannot (and perhaps should not) be fought at any cost.

And finally, via the wonderful Gooznews :

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If you ever had any interest in knowing what Violet the Vulva looked like from my standardized patient encounter last month , look no further. Tyra Banks and guest doctor provide said puppet, and an educational lesson to boot!

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My own ED is blogging? How did I not know this? Straight Talk from the Stanford ED : go Cardinal. Maybe people will realize we see more than just horse accidents down at the Farm.

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This is a post about immigration from an obstetric point of view.

I’ve seen (and delivered) a number of 1st generation immigrants over the past several weeks, and come to understand the immigration debate from a totally new point of view: governments, laws, and artificial borders versus the human spirit.

I have no idea if these women I saw were here legally or not–I know that any woman in active labor must be cared for by EMTALA law , but most of the women I saw had some degree of previous prenatal care, even if it was late. I probably used to know the policy and laws of insurance and everything, but my brain had to delete those to make room for the plethora of OB-Gyn facts I’ve been cramming in there recently.

I was most amazed by a woman at 39 weeks who arrived in this country 7 weeks ago from El Salvador. That means at 32 weeks of pregnancy, less than 2 months from delivering, she somehow got here, speaking little to no English. I wanted to ask her how she arrived–plane? boat? bus? pickup truck? walking?–but she was a little too ready to push, we were a little too busy, my Spanish is a little too poor, and it’s really none of my business.

I wondered what would drive these women to take such risks, even if they were here legally–move here while they were gigantically pregnant, picking up and leaving their families, support systems, jobs, houses, clothing, speaking almost no English–and it’s the human spirit and the maternal instinct. It’s the same thing that all of us want for our children and loved ones: a safe, solid place to grow up with access to education, health care, and jobs. It’s done out of love.

So many of our fairy tales, movies, and stories focus on this theme that I find it interesting there’s often such vitriol and hatred in the immigration debate. We love stories where the individual wins, love triumphs, often against all odds, but somehow, these immigrants, who seem to want the same things we all want–are different.

I guess the point of this post is that we can spend waste as much money as we want on borders and laws and regulations and security cameras, but the human spirit is so dedicated–exponentially so when you throw in the maternal instinct–that it seems like we’re almost trying to stop the inevitable.

If we want to prevent people from other countries from coming to ours to make a better life (and most of us “Americans” ended up here because our immigrant ancestors felt the same way), maybe money would be better spent trying to help other countries to better their own citizens’ lives.

(I’m well aware that the immigration debate is a hot topic and incredibly complex; I do not claim to be a scholar on the subject, just one man with a perspective I don’t often hear in the debate.)

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