ICD-10

Everyone in the medical world knows that medical coding is a pain in the ass.  To anyone not in the medical world, you'll just have to trust me - medical coding is a pain in the ass.  We go by a list of codes called the International Statistical Classification of Diseases and Related Health Problems (no seriously, that's actually what it's called) that is maintained by the World Health Organisation and has been updated periodically since its creation in 1949.  The 9th version contained about 13,000 codes (yes, 13,000) for every diagnosis imaginable.  Well, almost.  Obviously they didn't think 13,000 was quite detailed enough because the 10th version, which was completed in 1992, expanded this to some 68,000 codes.  A total of 27 countries over the flat plane of the Earth use ICD-10: the Czech Republic adopted ICD-10 in 1993, UK in 1995, Canada in 2002, France in 2005, and the USA came in dead last in 2015.

Come on United States, it's like you're not even trying.  Fahrenheit?  Really?  Inches?  Gallons?  Do try to keep up with the rest of the world, America.  I bet even the eels from Ceti Alpha V use metric.

Anyway, some examples of codes that I use are S06.0X1A (Concussion with loss of consciousness of 30 minutes or less), K35.3 (Acute appendicitis with localised peritonitis), and S36.116A (Major laceration of liver).  But while perusing this thoroughly entertaining (not really) book you can also find codes for everything from W55.21XA (Bitten by cow) and W61.33XA (Pecked by a chicken) to Z63.1 (Problems in relationship with in-laws).

Ha ha!  Hilarious!  Pecked by chicken!  Problems in relationship with in-laws!  Don't we all!  Ha ha!  Good one, Doc!

What's that?  This sounds ridiculous and these codes couldn't possibly be real?  You think I made these up?  Then I challenge you to click the links and enjoy now having the knowledge that someone at WHO thought that there was adequate reason for these codes to exist.

Trauma is a bizarre world.  The patients are bizarre, the stories are bizarre, the injuries are bizarre, the situations are bizarre, and nothing seems to fit into any kind of pigeonhole of any kind ever.  Of course I'm exaggerating for the sake of drama and interest, because otherwise who the hell would read this crap.  In reality the majority of my patients are car accident and fall victims who have minor bumps and bruises and go home.  

But we do get the truly strange, the outlandish, the "What The Fuck Happened" cases from time to time, and those are the ones that stand out and are highlighted here.  Obviously.

This one fits.

Alan (not his real name™) was kind enough to relate a story that happened to him and a few friends recently.  I'll preface this by saying that Alan and his friends are university students, and as anyone who ever went to college knows, college students are stupid immature and impulsive, and anything can happen.  Anything.

Hey, Doc, I first heard of you via comments from FML and recently started reading your blog. I've enjoyed it very much and wanted to share with you a story that happened during my freshman year of college. 

My suitemate and I got back to our dorm around 3 AM one morning.  My roommate Brandon (not his real name™) was in my room with two other friends.  When we walked in, Brandon was sitting on his bed, and Aaron was sitting on my bed, talking.  Brandon walked over to us when we came in, and started talking to Mike.  At this point, I had my back to the others, and they filled me in with what happened after. 

Apparently before I got back, Aaron had taken Brandon's can of Febreze and was using it on his shoes (he's a soccer {that's football for the rest of the world} player).  I then hear Aaron say, "Hey, Brandon, look what I have!"  Then Brandon replied, "Give me that back!"  I then heard a thud. 

I turn around and see Brandon lying on the floor face-down.  I initially thought that he was just playing around, as is usual for him.  I said, "Ok, Brandon, get on up."  Upon receiving no response, I shook his shoulder.  "Brandon. Brandon!" Still nothing, so I turned him over, only to see blood coming from his forehead.  "What did you guys do to Brandon?!?" I exclaimed.  Aaron then explained that after Brandon demanded his Febreze can back, he tossed it to him under-handed.  Brandon apparently dove towards him, thinking that Aaron wasn't going to give it to him.  Somehow, the Febreze can connected with his head, and it knocked him out completely.

Try as we might, we couldn't rouse him.  Eventually, a fire EMT crew showed up and managed to wake him momentarily.  Shortly after, a few policemen showed up along with a regular EMT crew.  The police of course were grilling all of us concerning what caused it, repeatedly asking if we were drunk or high (which none of us were, though understandably we had a hard time convincing the officer otherwise).  Brandon ended up being taken to the hospital.  Though I'm not sure where exactly he was hit, apparently according to the ER staff it shouldn't have knocked him out, especially for as long as it did (nearly half an hour), considering what he was hit with, and how weakly it was thrown.  They all had a good laugh when they found out that the object that he was knocked out with was a pink Febreze can.

I diligently searched the approximately 947,502,485,503 ICD-10 codes, but I was unable to find "Concussion due to mildly thrown aerosol can".  What I did find, however, surprised me a bit:

• Y93.D1 Injury while crocheting and/or knitting
• W56.22XA Struck by orca
• W56.11XA Bitten by sea lion
• V97.33XA Sucked into jet engine
• X52.XXXA Prolonged stay in weightless environment
• V95.42XA Forced landing of spacecraft injuring occupant
• W61.11XA Bitten by macaw, {not to be confused with}
• W61.12XA Struck by macaw, {not to be confused with}
• W61.21XA Struck by other psittacines (does anyone other than the ICD-10 authors know what a 'psittacine' is?)
• W22.02XA Walked into lamppost {which is more of a problem in Narnia, I presume}
• Z99.89 Dependence on other enabling machines and devices {which I would like to assume means "Addicted to iPhone" but which actually refers to ventilators}

and my personal favourites:

• R46.1 Bizzare personal appearance
• V91.07XA Burn due to water skis on fire

These codes are 100% real.  I will repeat: "Forced landing of spacecraft injuring occupant" and "Burn due to water skis on fire" are real diagnosis codes.  For the record, I have used exactly -0- of these in my practice and don't expect to use any of them ever.  Although I will confess that I didn't know R46.1 existed until I wrote this post.  

I may have to start using that one now that I think about it.  It may actually come in handy with my idiots.  I mean patients.

No, I meant idiots.

Jahi McMath update...not really

I'll be honest, this isn't much of an update.  Though the case of Jahi McMath has not exactly come to a halt, it is grinding along at what is apparently the normal pace for American legal proceedings.  There have been no real advancements made in the legal trial, though there has been the usual and expected back-and-forth crap that I admittedly do not fully understand.  Demurrers have been submitted and denied by the judge, whatever the hell that means (Scarab?  Help?)  The legal details (including the most recent judgment allowing the family to prove she is "alive") can be found at Professor Thaddeus Pope's Medical Futility Blog here.

The other "development" is the posting online of several supposedly recent pictures of Jahi.  We'll start with these two:

I believe both of these were taken by the woman who has been braiding Jahi's hair (please someone correct me if I'm wrong).  The first thing that struck me is the strategically (and rather obviously) placed "JAHI IS ALIVE" bracelet next to her head.  That bit of propaganda is about as subtle as Donald Trump. 

The next interesting feature is that neither picture is taken head-on.  In both she has her head turned to the side.  That may be telling or it may be completely irrelevant, but it seems to tie into the next thing I noticed.  The final interesting thing was the discoloration on her philtrum (the groove above the upper lip).  At first I thought it was a shadow, but on closer inspection it looks the same in both pictures.  There also appears to be some darkening of her lips, though as we all know her mother Nailah likes to play dress-up and puts makeup on her, so it may just be dark lipstick.  I'm not sure which option is more disturbing.  Regardless if that discoloration is real, it is not a good sign.  The skin of the face has a very rich blood supply, so necrosis of that area would be indicative of something very bad happening, and taking the pictures from that angle would minimise the visual impact.

The other picture making the rounds is this one:

Again, I don't know when this was taken, but to me it looks older.  At least it's a head-on shot.  First of all, notice how her eyes are still closed as they are in every picture taken of her since she died.  Despite the claims that she is getting better, she has clearly not opened her eyes.  If she ever did, I am 100% certain that the pictures would be online instantly.  But what most people are talking about in this picture is the supposed lower lip piercing:

As disturbing as this entire case has been from the very beginning, I highly doubt this is actually a lip piercing.  It looks to me more like a reflection off her lip gloss.  But considering how irrational this family has acted, nothing would surprise me at this point.

Reach

When I started this stupid blog, I could have never imagined the reach it would have.  I'm pretty sure I've said that before, but whenever I try to use my brain to dredge up old memories, something newer and more useful probably gets jettisoned, so I try to do that as little as possible.  While searching the bowels of my memory I may accidentally forget how to take out a spleen or something.

Anyway, when I say "reach", I don't mean geographical reach.  At least not this time.  I've covered that in my hypocritical various milestone posts.  Rather, I mean the impact that it could potentially have in people's lives, beyond trauma, beyond surgery.  But Veronica (not her real name™) kindly emailed me and did the work for me.

Hello Doc.   

I found your blog while looking for information on Jahi McMath.  I kept reading because I found it interesting and educating.  You said you like to get responses, so I am giving you my response. 

I am 50-years old and have had pain in my joints since I was 10.  Diagnoses ranged from "I don't know" to systemic sclerosis.  Every doctor had a different answer.  When I was 40 it was discovered that I have celiac disease.  That made my doctor at the time start looking hard at my immune panel. 

I was sent to a rheumatologist who kept testing me for lupus.  I don't have lupus.  Whenever I questioned a new symptom, he would wave his hand and say it was nothing.  Swollen joint?  It's nothing.  Scaly patches on my leg?  It's nothing.  Scaly patches on my forehead?  It's nothing.  After reading your blog, I went to my primary care physician and requested a referral to a different rheumatologist. 

I saw the new doctor.  She read the entire new patient form and paid special attention to the list of diagnoses and how long I had been complaining of pain.  She *looked* at the swollen joints, all of the scaly patches, and even the severe dandruff.  She said she suspects psoriatic arthritis, and sent me to a dermatologist. 

The dermatologist looked at my skin, took a sample for biopsy, and reassured me that the patches looked nothing like cancer.  The tests he did all came back negative, reinforcing his belief that I have psoriatic patches, which he expects to see on patients with psoriatic arthritis. 

I know that psoriatic arthritis is a painful condition.  I have had pain for 40 years.  I know that the pain will only get worse, that it cannot be stopped.  I am fine with that.  Medicine cannot cure everything yet.  I am disgusted that it took so long for someone to *listen* to me and *look* at me.  My medical history told the new doctor what was wrong.  Now she knows what treatment needs to be done. 

I would still be with the original rheumatologist if I had not read your blog.  If I had not read your words about doctors listening to patients, I would not have requested transfer to a different doctor.  Thank you for that. 

To add to all of that, I have complained about severe pain, numbness, and immobility in my right shoulder for 19 years.  6 doctors in 3 states have seen me for it.  I have had physical therapy, drugs, and even told it was all in my head.  As it turns out, the rotator cuff requires surgery to be repaired.  The new rheumatologist is the only one that ordered tests to actually see what is happening in the joint.  It could have been fixed 19 years ago, but doctors just didn't look or listen. 

Thank you for posting your blog.

While I would never be so arrogant to claim that she's better because of me, I . . . actually, you know what, goddammit yes I will.  For once, I will take credit.  Ok ok, maybe Veronica is not actually better, but at least she now has a diagnosis.  And that's something, right?

What surprises me most about this is that Veronica's first doctor thought it was lupus.  He should have known that it's never lupus.

The Thank You Project

WARNING: Grab a box of tissues or a handkerchief (does anyone use those anymore?) or a towel or something absorbent, because you will cry before the end of this.  You have been warned.

This isn't my story, but I feel like it should be.  Karen (not her real name™) wrote me with a link to a video to me over a year ago, and it has unfortunately been buried under my "stupid patient stories" list until now:

Dear Doc Bastard, 

You write about your important cases and tell such great stories, yet you have mentioned that some patients never even showed up to their post-surgery check-ups.  Has anyone ever come up to you months or even years later to thank you for helping them? How did or would you react?  What's your opinion of patients overall, and do you think many patients realise just how much doctors such as yourself do for them?  

I'd be really interested to know if you've seen this video, and wanted to suggest that you could write a short blog post either about it or at least inspired by it, like about gratitude or something like that.   

Thank you so much for being such an inspiration to so many doctors, aspiring doctors and just generally kind human beings.  It's funny that despite your slightly crude online persona, you still seem like a very kind-hearted man and you inform everyone about important safety issues - I myself have made sure to always wear my seatbelt in the car ever since I read your first post about it. 

I hope Mrs. Bastard and the little bastards I'll admit it feels strange calling them this when they must be such fantastic kids) are doing well and that your work is going smoothly.  With much admiration and the kindest regards, Karen (not my real name™)

It's been on my "Write About This, Dammit" list since then, but I haven't been able to get to it.  But that list has shrunk over the past few weeks, so I finally have the opportunity.  The story went viral back then, getting covered on national television shows and various other news outlets, so I'm way behind the game here.  Nevertheless I still feel like story this deserves to be covered here in case anyone missed it.

I've written before about the impact of saying "Thank you" to your doctor, but this takes that concept to an entirely new level.

In 2004 Kellie Haddock (her real name!) was in a car accident with her husband A.J. and their 14-week-old son Eli in Orlando, Florida.  A.J. tragically died in the accident, and baby Eli was airlifted to Arnold Palmer Hospital for Children with serious injuries, including intracranial bleeding.  Though the paediatric team at the hospital worked tirelessly to treat Eli and his trauma-induced seizures, Kellie was told that even if he recovered he would most likely never walk.

Less than a week later, Kellie took Eli home.

Fast forward 11 years, and Eli has made a full recovery.  He's now a happy, healthy tween, Kellie remarried, and her new husband adopted Eli.  While this may seem like a nice, heartwarming story, it fortunately doesn't end there.  Ten years after the accident, Kellie was inspired to track down every member of the medical team that made Eli's recovery possible - first responders, the flight medic, the respiratory therapist, nurses, doctors . . . everyone - in what she appropriately called the Thank You Project.

In pointing out exactly what's wrong (but what could be right) with the world, Kellie said, "We rarely take the time to notice when people are doing things right.  I want to be a person that points out when someone does something right.  How much better would the world be if we all spent more time focusing on what’s right instead of what’s wrong?"

So Kellie found them all, arranged to meet them, and then threw an elaborate dinner for everyone.  And all of them got to meet Eli, now a very bouncy (and very normal) 11-year old.  Tears flowed, as would be expected.

I feel happy when I get even a simple "Thank you" from a patient or family member, elated when I get a hug, and absolutely on top of the world when I get a card or a fruit basket.  So I cannot even begin to imagine how honoured all these people felt when Kellie found them.  Kellie went way above and beyond as her way of saying "Thanks", but if everyone made even a tiny fraction of the effort that Kellie did, just imagine the possibilities.

Here is the video that Kellie made with the assistance of Strongfilms, a professional video company.



Thank you Karen for sending this to me.  And thank you, Kellie.  Thank you for saying "Thank you."  That means more than you will ever know.