Histories

My favorite histories from the ER today:

"23-year old man who arrived at a party and shot several of the partygoers. The other partygoers responded by assaulting him, beating him about the head, chest and abdomen with hockey sticks and cricket bats."

"36-year old man who was attempting to shoplift some alcohol from a liquor store when another patron tackled him. He presented after he fainted while in police custody."

Yup, those are my patients!

Anti-smoking ads

These are some of the most clever advertisements I have ever seen:

Singing Cowboy

Focus on the Positive

Miscarriages

Hitchhiker

Knife and Gun Club

When I am working in the Emergency Department, I see the CT scans and X-rays of nearly every injury that comes into the hospital. I am getting really discouraged by the superabundance of some specific injuries:

1. Gunshot wounds to the spine. Way too many teenagers and young adults are forever paralyzed from the neck or mid-chest down as a result of careless or, more likely, malicious people shooting them. I'm not sure what these patients were doing to induce others to shoot them, and I really don't care that much. Although I am sure that a significant proportion of those who are shot were engaged in illegal activities at or shortly before the time they were shot, it doesn't make me feel any better about these patients whose lives are now infinitely harder than they would otherwise have been.
   
   To wit, they will, for the rest of their lives, have no bowel or bladder control. They will need surgery to enable them to put catheters into their own bladders or to divert their urine into a hole on their abdomen so that it can be collected in a bag. They will either need surgery to divert their feces into a colostomy or will need their diapers changed for the rest of their lives.
   
   Of course, they also will be unable to move independently for the rest of their lives.
   
   I am further disgusted that these patients are now wards of the state. You and I, the taxpayers, are and will be paying for the lifelong care of these patients - for both the cost of their surgeries and the salaries of those who change their diapers and roll them around in bed. It sickens me that these patients are only unable to care for themselves because some other person made a rash and/or evil decision to pull the trigger of a gun.
   
   
2. Gunshot wounds in general. Way too many people get shot around here. Gunshot wounds are devastating injuries, shattering bones and organs alike, and causing all kinds of mayhem. While many people survive their injuries, those who get shot in the head tend not to.
   
   
3. Motorcycle accidents. These are a touchy subject for many motorcycle aficionados, but let's get real - every day I see horrible injuries sustained by people who are doing innocuous things on a motorcycle. For example, this man was riding his motorcycle at 10 miles per hour.
   
   
   
   He got clipped by a car, which shattered his left foot. He had to have his leg amputated below the knee.
   
   No matter whose fault it is, a motorcycle accident will always leave the motorcyclist in a world of hurt.
   
   
4. Lung Cancer. This is another subject that gets me somewhat upset. Way, way too many people are dying early because of smoking and its deleterious effects. Take, for example, this woman. An ordinary chest CT would have lungs on both sides of the chest, with the heart on the patient's left.
   
   This woman's heart has been displaced into the right side of the chest by this enormous aggressive mass that replaces pretty much her entire left lung.
   
   
   
   It is also making its way out of the chest cavity by bulging out between the ribs. What a crummy way to die.
   
   
   

Anyway, those are four of the most preventable problems in our society, and we see far too much of them. I wish, like Alma, that I could cry repentance with the voice of thunder, that all men everywhere might repent, that there might not be more sorrow upon all the face of the earth.

EtOH

After an experience I had the other day, my conviction that alcohol is not for the body and not good for man is much stronger.

I was reading CT scans from the emergency room, and a young man came in who had been backed over by a slow-moving car. His pelvis was smashed to smithereens, and he suffered facial fractures.

I was chatting with some of my associates about how he could have sustained such an injury, when it occurred to me to ask if his blood alcohol level had been measured when he came to the ER. It was twice the legal driving limit. I am sanguine that the blood alcohol level of the driver that backed over him was also quite high.

The next patient was a man who had fallen off his bicycle while attempting to get on it. Passersby noticed that he was struggling to get up and summoned the police, who brought him to the hospital. His alcohol level was 4 times the legal limit.

The next patient had been assaulted and stabbed. He was also drunk.

For the next several patients, I inquired as to the alcohol level of the patient. Every one of them had been too drunk to legally drive when they arrived in the emergency room - meaning that their blood alcohol level when they were injured was even higher.

Now, there could be a number of confounding factors in this sample; perhaps the emergency room has a lower threshold for ordering CT scans on drunk patients because the physical exam is less reliable, or maybe it was random chance. However, it is clear based on my experience that being drunk is a risk factor for being irradiated if you go to the emergency department. I would also suggest that, based on the mechanisms of the injuries I described above, being drunk is a risk factor for being injured.

So unless you want me to see some really embarrassing pictures of your insides, it's best not to drink alcohol in Sacramento or its environs.

I like the looks of these

bakingsheet: SHF #7: Graham Crackers

Homemade Graham Crackers
1/2 cup all-purpose flour
1 3/4 cups whole-wheat flour
1/2 cup sugar
1 teaspoon baking powder
1/2 teaspoon baking soda
1/2 teaspoon salt
1/4 teaspoon ground cinnamon
1/2 cup cold butter, cut into 1/2 inch cubes
2 tablespoons honey
2 tablespoon molasses
1/4 cup cold water
1 teaspoon vanilla extract

In a food processor, mix together the flours, sugar, baking powder, baking soda, salt, and cinnamon. Add the cold butter and process until the mixture resembles coarse meal, about 30 seconds or so. Add the honey, molasses, water, and vanilla. Mix until the dough startes to come together in a ball, another 30 seconds. Scrape dough out of the mixer.
Between 2 sheets of waxed or parchment paper, roll the dough 1/8-inch thick. Chill for at least 1 hour, until firm (I chilled for several hours).
Preheat oven to 350F. Retrieve dough and roll it a bit more if it is not yet 1/8-inch thick. With a sharp knife or pizza cutter, cut into 2-inch squares. Arrange the crackers on parchment lined baking sheets. With a toothpick, prick several holes in each cracker.
Bake for 15 minutes, until lightly browned at the edges. Remove from the oven and let cool on the pan.
Yield: 48 crackers

Note: If you cut the dough through but leave the squares together, you can break them up after they're baked, just like a store-bought graham!

Literal...

Libby, my oldest, has the tendency all four-year-olds have of taking everything I tell her very literally. This sometimes has untoward consequences. A few weeks ago, we were heading to the library to check out some books and movies. We had not taken the girls in a while, so we were explaining the principles of appropriate library etiquette. Libby asked why we need to be quiet in the library. "Because," I replied, thinking quickly and trying to be clever, "if you aren't quiet the librarians tie you up."

"Why?" - of course, the standard response.

"Because there are people trying to study, and they need it to be quiet."

She nodded slowly, letting this idea sink in.

I forgot all about this conversation until last night, when, in celebration of my birthday, we went out to dinner, shopping, and finally to the library. It was very late (7:00) by the time we got there. The girls are usually being bathed by that time of day, and their ability to cope with stress was at a low ebb. Immediately the girls began fighting over the library computer, shrieking, and generally being naughty. Audrey had to be taken outside for an attitude adjustment within a few minutes, but she returned a tiny bit calmer and quieter.

Libby, not to be outdone, began screaming at the top of her lungs at Audrey a few minutes later. Amy had had it. She took Libby by the arm and marched her for the door. Libby, terrified, began yelling, "No! I don't want to be tied up!"

All heads turned toward Amy as she walked out the door, a determined look on her face, with a terrified, struggling child at her side. "Where on earth did Libby get that idea?" I wondered, still with no recollection of our prior conversation, and mortified that all the library patrons now believe that Amy and I punish our children by tying them up in the basement or something.

 

When we got home, Amy asked Libby why she had said what she did, and she said "Daddy told me they would tie me up." The recollection of our prior conversation came flooding back. Oops.

 

Amy glared at me. "You can't tell them things like that! You need to clear anything you tell the kids with me first."

 

I'm kidding about that last sentence, but I am sure that is what she is thinking.

Guns and coumadin don't mix

This is a patient who came in after reportedly shooting himself in the forehead with a 25-caliber handgun. He was reportedly taking coumadin, an agent that is used to keep the blood from clotting.


Incredibly, when he arrived in the emergency room he was alert and conversant with the ER staff. They saw the entrance wound on his forehead, but couldn't find an exit wound.

The first image they took was an x-ray of the skull.



The white thing just at the level of the nose is the bullet. The little arrow on the forehead is a marker that the emergency room put on the patient to show where the entrance wound was. It also shows the skull fracture that ensued from the bullet wound.

When he became unresponsive, they rushed the patient to the CT scanner to get a better idea of what was going on in his head. This is what they found initially on the "scout radiograph" - the initial image they take to plan where they will take "slices" with the CT scanner.





This is a side view of the skull. Again, the dot on the forehead shows where the bullet entered the head. The bright thing in about the middle of the head is the bullet, which is embedded in the soft tissues at the back of the patient's mouth. The dark oblong shapes in the middle of the head should not be there - those are indicative of air within the space that should be filled with brain or cerebrospinal fluid.




This is a slice through the patient's head at the level of the forehead sloping back just above the ears. The black dots throughout the head are collections of air that are moving around within his shattered skull. The white rounded area near the top of the image is clot and blood within the brain, marking the path the bullet took as it went down through his forehead, through his nasal cavity, and down into the soft tissues at the back of his mouth.





This image shows the exact path that the bullet took. It is a side view through the head showing the wound (at the upper left of the image) with the bone fragments traveling diagonally downward until you get to the bullet (the bright rectangle at the bottom center of the image).

Suffice to say, this was a non-survivable injury and the patient soon succumbed to increased intracranial pressure - probably from bleeding into the space that should be holding his brain. Gross!

So much stuff!

I came home from work the other day and started unloading the pockets of my scrubs onto the kitchen counter. My wife stared as I pulled out more and more things - it was reminiscent of the scene from Mary Poppins when Julie Andrews starts pulling potted plants and hat stands out of her carpet bag. Eventually, my wife shook her head and said, walking away, "you need a purse."

This is a picture of the things I carry on my person at all times. Clockwise from the top: my radiation badge (essentially a piece of Kodak film that gets tested every three months to see how much radiation I have been exposed to), my keys, my ID badge, my wallet, my cell phone, my pager, my little pre-inked stamper to put my name and ID number on orders that I write, and my car keys. In the middle are my iPod and pen.

Valentine's Daddy, part deux

This is the letter I received in response to my last one:

February 20, 2008

On behalf of our President and CEO, thank you for your letter of February 15th regarding your recent shopping experience at our _____ Market on _____ Drive. We are pleased to know that you found the quality and price of your purchases favorable even though your check out experience was less than satisfactory.

We appreciate fully the concerns you expressed regarding the magazine covers displayed at the cash registers. While it is important for us as a retailer to offer a variety of magazines and other publications that represent our customers' diverse interests, it is also important for us to exercise good judgment in our display of such merchandise. As a standard practice, we offer a 'vanity' shield at all magazine display racks and ask our store directors to place the shield over magazines with questionable or prurient covers. Generally, our store directors do a very good job in shielding these covers but, as you know, this can oftentimes be a matter of subjectivity.

Your idea of having a family-friendly checkout aisle is a great one and continues to be an item of discussion in our business. In the meantime, we extend our apologies to you and your daughters and assure you we will ask our store directors to be more attentive to our display of magazines so that a visit to our stores is not an unpleasant one.

Sincerely, etc.

Valentine's Daddy

This is a letter, slightly edited, that I sent to the CEO of one of the grocery stores where I shop regularly. Tell me what you think:

-----
Dear Sir:

I am a regular customer at the _____ store located in the _______ area. Yesterday – Valentine's Day – I went to that same store to purchase some last-minute items for my wife and for my two daughters. A couple of weeks earlier, I had brought my wife some flowers, and my daughters were excited that I might do the same for them.

I found a large and varied display of flowers, and was pleased with their quality and price. After getting a few other items, I went through the checkout stand and noticed, as I have many other times, that there are a number of magazines displayed near each checkout stand. The covers of most of these magazines are plastered with pictures of scantily clad women in alluring poses, many of which are frankly pornographic.

As I went through the checkout aisle, averting my eyes, I thought about an article I had read earlier that day about the harm done to women – particularly young women – when society convinces them that the most important attribute they can possess is "sexiness." I thought about the numerous times that I have brought my girls through those same checkout aisles and been embarrassed to have them see such exploitative photographs.

I hope to raise my girls in such a way that they will know their own inherent worth. It is not easy to teach this concept in any circumstance, but particularly difficult when objectification of women is so prominently – indeed, unavoidably – displayed.

Please make arrangements – such as removing the magazines from at least one checkout aisle in the store – that will make shopping more family-friendly. It occurs to me that having such a family-friendly checkout aisle in every one of your stores would be a valuable advertising advantage.

Sincerely, etc.