Monday, 15 February 2016

General

general
/'jen(ə)rəl/
adjective
1. affecting or concerning all or most people, places, or things; widespread.
2. considering or including the main features or elements of something, and disregarding exceptions; overall.
General Electric makes all kinds of electrical things.  General Motors makes all kinds of cars and trucks.  General Mills makes all kinds of breakfast cereals.  General stores sell, well, everything.  General . . .

Uh oh, it looks like Doc had a stroke.  Why the hell is he talking about light bulbs, Cadillacs, and Cheerios?

You know, as usual I had a point before you interrupted.  Now if I might finish, I could perhaps get to that damned point.  "General" is a wastebasket term, and just about anything can fall under the umbrella of "general", just as with general surgery.

Ooooh . . . gotcha.

Yeah, maybe next time you won't be so hasty to jump to conclusions about my mental health, which is, as usual, stellar.

Anyway, the best thing about general surgery, the thing that keeps it interesting, the thing that makes me continue despite the 2 AM appendectomies (it's always 2 AM), is the sheer variety of patients for whom I get consulted.  On any given day I could get a call for a pancreatic mass, a perianal abscess (though I would prefer not), an enlarged lymph node, appendicitis (it's always appendicitis), and anything in between.  And when I'm on trauma call, you can add splenic rupture, compartment syndrome, subarachnoid haemorrhage, and anything in between.

It's that "anything in between" that has the capacity to throw me . . . sometimes.  I'm not a cavalier surgeon.  I know what my limitations are, and when a patient tests (or surpasses) those limits, I call for help.  Arrogant surgeons (the prototypical ones on "Gray's Anatomy" with the god complex) think they can do anything to anyone and get away with it.  When they do that, the patients are the ones who suffer, receiving substandard care from doctors who have no business treating them.  Sometimes these calls can be one of those zebras we hear about, something I'm not equipped to handle on my own and really tests my limits.

Recently Dr. Lee (not his real name™) did test my limits, though not in the way I just described.  Make sense?  No?  Don't worry, just like with the Buicks and Count Chocula, it will.

Dr. Lee is an emergency doc that woke me from a deep slumber just after 1 AM, and the call didn't surprise me one bit.  My phone had been ringing off the hook all day up until midnight when it finally shut the hell up for all of 60 minutes or so.  I figured it would be another appendicitis patient who urgently needed me to save his life but decided to wait until the middle of the night to do so just like all the rest.  Grumble grumble fucking grumble.

"So I have this guy here . . ." Dr. Lee started.

Yeah, you always have a guy.  It's 1 AM, so just get the hell on with it.

"He was in a car accident and has a laceration on his forehead . . ."

Well isn't that dandy, at least it isn't appendicitis.  I can suture a forehead.  But wait, so can Dr. Lee.  So why the hell is he calling me?  What else more serious is going on that I can treat?  Is the laceration deep enough to require a multi-layered repair under anaesthesia?  Does he also have a fractured skull?  A lacerated liver?  A haemothorax?  Bladder laceration?  These are all the thoughts that screamed through my head in approximately 0.192 seconds as I awakened fully and listened intently.

". . . The accident was a week ago . . ."

I started listening somewhat less intently and began grinding my teeth slowly, waiting for the punchline.

". . . and he had stitches put in his forehead, and he needs to have them removed."

He stopped.  I anxiously waited for him to tell me why he was really calling me, because if this was really why he was calling me at 1 o'clock in the goddamned morning, the patient isn't the one who would need a trauma surgeon right about now.  I figured it was obviously just a joke, though I noted to myself that I didn't really know Dr. Lee well enough for him to be trolling me like this in the middle of the night.  All those thoughts had lumbered through my skull in the next 0.294 seconds, until he said,

"So, uh, I was wondering if you could take them out."

I was glad I had the mental fortitude and forethought to mute my phone before letting loose the string of expletives that would have made Quentin Tarantino and Samuel L. Jackson blush.  I finished cursing, composed myself, unmuted my phone, and asked him slowly and carefully if I had seen the patient a week prior and stitched him up.

"No, it was done at another hospital."

Mute.  Expletives.  Unmute.

"Is the wound infected?" I asked him, hoping at least there was something to justify this.  Anything.

"No, it's healed just fine.  The stitches just need to come out."

Mute.  Expletives.  Unmute.

I don't think my voice was nearly as composed as I intended it to be just then as I said in a quavering voice, "Then why are you calling me at 1 AM instead of either A) telling him to see, at a reasonable hour, whoever put them in, or B) taking...the...sutures...out...yourself?"

There was a slight pause before he said (with a baffling amount of confidence that what he was saying made perfect sense), "Because you're listed as being on call for surgery."

At this point I made no effort to conceal my true emotions as I explained to Dr. Lee in no uncertain terms that he, as a fully trained emergency physician, was fully capable of 1) evaluating a wound and 2) removing sutures, especially sutures that were not mine.  I also explained that he was fully capable (maybe) of using his brain to determine if calling me at 1 AM to remove someone else's sutures made any logical sense whatsoever.  I was not entirely convinced that Dr. Lee believed me as he told me he would just send the patient home to follow up with the surgeon he saw initially.

I grumbled (probably . . . I don't remember my exact response), hung up, cursed some more, wondered at what carnival Dr. Lee won his medical degree playing fucking Skee Ball or something, and went back to sleep, visions of giant teddy bears and MD degrees hanging from the ring toss game dancing through my head.  General surgeons are trained and expected to do pretty much anything at any time (within reason, of course), but that conversation strained even my admittedly ample limits.

The patient that actually needed me and was actively dying came in about 3 hours later, but that's a story for another post.

37 comments:

  1. People like this Dr. Lee really make me wonder how the hell they can breathe, as they seem to lack the brain power to do it on their own. I have only had stitches once, and thankfully my family happens to be friends with a doctor. The stitches weren't in any place serious, just my finger, and she was more than capable and willing to take out my stitches herself, in the comfort of my own kitchen. Some tylonal and a painful 15 minutes or so and it was done. (what can i say, it hurt. A lot. But i doubt had i gone to the hospital it would have been any better- heck then my wallet would be hurting also!) And no, we didn't call her over at 2 am, nor did we call her over when the night before I realized it was time to get my stitches out. Why? Just because a doctor is always on call, doesn't mean you should call on them at inconvenient times when its not neccesary, a fact that seems lost on so many people.
    In the case of appendicitis patients, I bet doc the reason why They need surgery at 2am is that throughout the whole day they just think they are in sick or something, and only by late at night do they realize its time to go to the hospital due to it being possibly life threatening. At least THEY (and other people who have organ failure or non injury based needs) have an excuse, those who injure themselves at 2 am doing stupid shit at that hour have none.
    Connor

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    1. I think the 2 AM ones suddenly realize it hurts too much to sleep. to me, the ones who hurt themselves at 2:00 AM and call for help at least have the credit of knowing they need help. the ones who hurt themselves and then wait several hours to call for help show a lack of recognition of their situation.

      but getting stitches out? that can wait until regular hours.

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    2. I was thinking the same thing about the appendicitis situations. Abdominal discomfort can have lots of causes...just plain indigestion and gas, constipation, the onset of a "stomach flu" type virus, or a mild case of food poisoning. Usually we try to treat this at home with the various OTC products available, and hope to feel better as time goes on, rather than rushing off to the ER every time something in the lower midsection seems out of sorts. By the time the patient realizes that the pain is getting worse and nothing is helping, it might well be "after hours."

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    3. Yeah the realization thing was what i was going for. Like (believe it or not) i walked around on a sprained ankle a week before i came to the conclusion it was sprained (it may not have started out as a sprain, as the pain was very mild at the start, to the point im not even sure at what point i injured it, but by the next friday i could barely stand much less walk as it was excruciating.) However, having delt with sprains before many times (and recognizing the source of the pain being a sprain Not a fracture due to all my past experiences) me and my family just got myself a brace and moved along. Didn't go to the ER or anything as the only thing we would get out of the visit was information on how long it would take to heal. 2 weeks later the pain was completely gone. Due to me not doing anything about what to be quite frank i thought felt like simply a bad bruise probably caused that very minor sprain to progress as far as it did.
      Every other time Ive injured myself though? happened around afternoon and sought medical attention within an hour or 2.
      Connor

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    4. @scarab: I was thinking more of injuries than appendicitis with the waiting thing. I do expect internal problems to take a while for the patient to realize this isn't just bad gas.

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    5. I've been to the ER (for myself) three times. once I wasn't consulted (was barely conscious) once I felt like it was so minor it didn't need a full ER visit (three stitches in my lip) and once was a back injury outside of business hours. (don't take chances with your back)

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    6. I had various kinds of abdominal symptoms for 5 days before finally breaking down and going to my doctor's office, because it was Friday and I damn sure wasn't going to keep hurting over the weekend. You might wonder why it took me 5 days to decide that seeing a doctor was a good idea...well, considering that my medical history includes extensive diverticular disease (inherited, alas), a bowel resection due to the above, ovarian cysts that once resulted in spending New Year's Eve in the ER, watching the ball drop on the TV in the ER bay while the doctor was up to his wrist giving me a pelvic exam (you can't make this shit up, kids), a septate uterus, and various other ladypart-type and gastrointestinal issues over the years, I was trying to figure out just what the hell this felt like before I went in to bother the Doc; also, I did the whole "kick your right leg out sharply; if it hurts, it might be appendicitis" test multiple times, and...nothing. Anyway, 7 hours, an ultrasound, and a CT scan later, they decided it was appendicitis, wheeled my not-so-happy ass off to surgery (at 7 p.m.), and took out my badly-infected-and-about-to-blow appendix out; I got to spend an extra day and a half in the hospital on IV antibiotics just to be on the safe side. (The funniest part of the whole adventure involved the two bright-eyed and bushytailed young student nurses who came in, dragging a portable ultrasound machine, and asked if I minded them checking me out for the experience...it's a teaching hospital, sure, what the hell. Got all gooped up, and as they were moving the thingy (sorry, brain fart) over my stomach, they suddenly came to a dead stop right over my uterus as they looked, wide-eyed and a bit freaked out, at the monitor. I figured out immediately what the problem was: "That's probably my Mirena IUD you're looking at there." "OHHHHHHHHH..." It was hard not to laugh, but being in pain helped a bit with that, so if ever there was a silver lining in suffering from appendicitis pain, it's hurting too much to laugh at the poor student nurses, who really and truly meant well and were probably young enough to be my daughters.

      Anyway, this is how people can end up finally realizing that something is wrong at a godawful hour...and at least I went in during the day, even if it was on a Friday in August.

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  2. Oh for fuck's sake! I removed sutures from a healed forehead laceration as a nursing student (under the supervision of my instructor, a fully licensed RN-MSN, of course).

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    1. I was going to say the same thing. Hell, the emergency department at the hospital I work at sends patients home with a kit of sterile supplies and instructions so they can remove sutures or staples themselves at home. We don't want them to come back unless they think the wound is infected. It adds to the patient load of a major city hospital that is already struggling to manage all of the patients who use the ED as their PCP because they can't afford medical treatment otherwise. If nursing students and patients can do it, this guy should have been more than capable. I'm baffled that he thought the best thing to do was page the surgeon on call. I'm wondering how he even managed to graduate from medical school.

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  3. Jesus fuck. *I* can remove a stitch.

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  4. Every single time (aside from casted sutures I couldn't get to) I've had sutures I've removed them myself. Even surgery sutures. It's a no brainer and painless. Of course I sterilized all equipment I needed but easy peasy! I would have made Dr Lee (not his real name) need sutures when I got done with him!

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    1. I concur! The only medical training I have to my name, is a limited number of hours in a first aid course. I have removed plenty of stitches for others, and myself. The doctors here even tell you to go for it to save you a trip. It is easy, and painless. Staples on the other hand suck, and require a specific tool (although I was tempted to use a regular staple remover at one point), but a quick trip to the hospital, during regular hospital hours, with the doctor who put them in, and they were gone in no time.

      That wasn't fair to you, nor your next surgery patient, as it was a waste of well needed rest for yourself. Hopefully next time, the Dr. thinks before he acts, and the patient decides to not waste emergency time, for a non-emergency.

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    2. It kind of helps I do have medical training as a former EMT, and almost more training being a patient having had thousands of sutures in my life.

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    3. I have gone to the hospital to have stitches removed.

      The stitches were from surgery, and they were removed during my follow up appointment. I went there on the day and time they told me to.

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  5. Truly bizarre, on SO many levels. I can't even figure out *why* a patient would go to the ER in the middle of the night just to have stitches removed, and *how* he even got *seen* by the ER doctor.

    In my part of the world, this patient would either have been sent away by the triage nurse (if the ER was busy) and told to see his/her PCP during regular hours, or (if the ER wasn't too hectic) maybe had a nurse come out to the waiting area and take care of this simple task.

    Removing stitches, if the wound or surgical incision has healed OK and there's no other problem, is not "surgery." And, it's not always even necessary to have a "doctor" do the job. Nurses and medical assistants in the doctor's office do a fine job, as do the vet techs at the veterinary clinics when we take the pets for post-surgical checkups.

    I can only hope that I never end up in any ER where "Dr. Lee," or anyone with his mindset, is working. If he can't even take out stitches, what *can* he to do help a patient in a *real* emergency???

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    1. I am now curious if maybe the patient did not HAVE a PCP. not to speculate about where Doc actually is, but in the US, a lot of less wealthy folks never go for medical care except to the ER.

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    2. Good point, Ken. Another situation that overloads our ERs here is the fact that lots of people who have the HMO or similar "managed care" plans have to wait weeks or even months for an appointment. A few of the larger hospitals in my city have added on "urgent care" facilities to supplement their full-service ER operations, so that patients who come in with a non-life-threatening illness or minor injury can be quickly assessed, treated, and sent home. But these aren't available in *all* neighborhoods yet.

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    3. I've seen cases where a patient went by ambulance because they didn't have access to a car. also cases where a patient went by car because they couldn't afford an ambulance. it is kind of distressing when you think about it. a person has a life changing situation, and has to base their decision on finances.

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    4. When I was uninsured I went to an Urgent Care or Walk In clinic. Loads cheaper than the ER. Most will do a sliding scale fee or waive fees all together if it's a "real" reason for going (like strep). The one time I had to ride in an ambulance I had to pay $400+ for it. If I knew it would be that expensive I would have just asked the police officer to give me a ride (although, he was nice enough to give me a ride home).

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    5. police and fire are prohibited from stealing the ambulance's fare. at least in areas where the ambulance is a for-profit company. the only way my department can carry a patient in our apparatus is if the ambulance company requests we do so.

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    6. To play devil's advocate, I do want to point out that some people are day sleepers and night workers. My husband works from mid afternoon to late at night, so 2 am IS his "middle of the day". He also has no PCP because he never goes to the doctor and anything he would need to go for he just hits up the 24 hour Urgent Care, again, because no doctor's office is open at midnight and he will only miss work if he is actively dying or too injured to work. So it's not always because the patient is being cantankerous or difficult, it's just that 2 am is the only time that fits into their life without making things way more complicated than they need to be. (Still think that Dr. Lee was dumb to call you, though.)

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    7. Cassandra - Obviously there are such people. But those vampires all know that being nocturnal is not the norm, and they find times during the day on their days off to do such things.

      At least the ones with IQs higher than a radish do.

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  6. Good grief! Why did you bother to mute the phone? Dr. Lee deserved everything you probably said and then some!

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    1. The only sutures I didn't take out were my brain surgery sutures. Most of them unraveled before my follow up, but the internal ones that held my muscles together inside were just trimmed at the skin level by the PA at my neurosurgeon's office. Finally, they desolved.

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    2. AMEN! Stitch removal is NOT a big deal, says someone who's had it done far too often, and definitely can wait until normal business hours, assuming nothing else is wrong. Remember, kids: just because there's a surgeon on call doesn't mean you have to wake him up for something...

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  7. Seriously? I can and have removed sutures from my animals, my kids and myself. I refuse to remove sutures from my husband because I WANT him to go see his GP every so often. Pain is the only thing that gets him there and he's too big and heavy for me to whack on the back of the head, sling over my shoulders, dump into a car and then persuade a physician to come out and take a look at his prone body. There might be...other phone calls made, instead.

    Carnival prize or box of Cracker Jacks? I lean towards Cracker Jacks because they can be purchased at the store and carnivals are seasonal.

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  8. Why wouldn't he just direct the nurse to take them out if he couldn't?! That's what every other Dr does!

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    1. I think now Dr Lee needs to direct his nurse to put some ice on that burn.

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    2. I think Dr Lee also suffers from Cranial Rectal Inversion Syndrome or CRIS. Seen many cases on this blog.
      Connor

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  9. Doc,

    I am sure your accounts of ER docs' incompetence are true (and rightfully infuriating), but are you not cherry-picking the stories that make them look as foolish as possible? I have a hard time believing that so many physicians within a certain specialty are that much worse than any other type of doc.

    - Not an ER doc

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    1. Derek - Of course I am cherry picking. That's the whole point of this blog - highlighting the stupid, the inane, the ridiculous, the infuriating. There are plenty of good emergency docs out there, but who wants to read a story about a patient who was accurately diagnosed and treated accordingly? I rarely glorify anyone, and if I'm going to do that, it will be me.

      Just kidding.

      Not really.

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    2. Cherry picking makes a story more interesting. For instance on bouron street for mardi gras my sister and her friend both straight girls chose to makeout (well really just rub lips) to get beads for about 4 hours straight. Its made less strange if i mention normally girls show their tits to get beads and do it all day and all night. Persective and context makes a diffeerence. Another example: saying i choppd the top of my index finger (as in opposite to my palm not as in tip. Between the top two joints) with a toilet sounds ridiculous as hell by itself. Doesnt sound very realistic. But it is made very different if i mention my father and i were using hammers to crack them apart to put them in our garbage cans as that was the only way to get them hauled away after they were replaced, and that the sharp porcelain sliced deep and left a huge chunk (pretty close to the bone. Doc said i was lucky to have not severed nerves) hanging off my finger in a bloody mess. Thats what we got for stupidly not wearing gloves. Still both pretty ridiculous stories, but by cherrypicking details here and there the story is made all the more baffling, ridiculous, and funny. Who cares if Doc only tells the interesting stories? That just makes us love his blog more
      Connor

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    3. "I rarely glorify anyone, and if I'm going to do that, it will be me".

      Hahaha, I love dry wit...

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  10. Stories like these give me hope for my own medical dreams; because I may not be terribly smart, but I'm pretty sure I'm not that dumb.

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  11. I'm surprised that you didn't slap him the next time you saw him. And what the hell was up with the patient? I had four stitches in my hand and after the first one fell out 3 weeks into a 4 week heal, I waited a couple of days, went into a walk-in clinic and the doctor had the other 3 out in a few minutes. After seeing how the doctor did it (which was literally snip once and pull each one out), I'm fairly convinced I could have done it myself. Who the hell needs their stitches out at 2am?

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  12. As an ER nurse this story baffled me!!! I cannot imagine an ER doc calling a surgeon for suture removal though the idiocy of it all did make me laugh.

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