The Triumphant Return of Nurse K!

Yes, it is 3 a.m. and Doctor D should be sleeping since he is still getting over his viral infection, but some news just can't wait:

The world's greatest medblogger has returned! Nurse K is blogging again and as brilliant as ever. Who knows how long the cynical goodness will last? So head on over there and laugh till you wet your undergarments!

By the way, this is by no means lessens my endorsement of Tex and Nurse Lee yesterday, but heck, Doctor D would recommend Nurse K over even his own blog.

ER Nursing Blogs (Friday Linkages)

Doctor D actually works in an Emergency Room, but he only rarely tells fun ER stories. He prefers leaving the wild and crayzee emergency stories to the professionals. Nurses always have the best emergency room stories.

With Nurse K still on blogging hiatus the world is a little less fun, but fortunately Doctor D as a little ER joy to share. He has found two ER nurse blogs that never cease to make him smile:

• Nurse Lee is a newcomer to medblogging who blogs at Life in the ER. Doctor D found her when he came across this post and has been enjoying her ever since. She can be a bit silly, and Doctor D has no idea whats up with the glamor shot with a gasmask profile picture. Perhaps her way of preventing airborne illnesses? You should go check Nurse Lee out.

• Another great ER nurseblogger is Tex over at Weird Nursing Tales. He has been serving up wildness from the ER since 2007.
  

Of course, neither Tex or Lee could ever replace good old Nurse K, but reading them will definitely help scratch that ER story itch until K makes her triumphant return.

You can also hang around here with Doctor D (who isn't nearly as funny) to hear more next week about how silly the 1 to 10 painscale is, and to get your doctoring questions answered.

Never Say 10! (How Doctors Interpret the Painscale)

A question from a reader:

My doctors all use that 1 to 10 pain scale. Could you explain why? It seems so crude. Is a doctor equating my "6" to someone else's "6"? I always figure that "10" should be left for when a wolverine is gnawing off my face while my lower extremities are on fire, but other people may use "10" more casually.

The painscale is one of Doctor D's biggest pet peeves! The “powers that be” in medicine prefer looking at data rather than real people. And by data I mean numbers. Academics, researchers, and bureaucrats love numbers! They add them up to make treatment or policy recommendations. I often appreciate these bean counters that help clinical doctors, but it gets problematic when we try to pull hard numbers out of subjective human experience.

Medical people are now all commanded to record a numerical pain level on each patient. 0 means no pain at all and 10 means the greatest pain humanly possible (such as fiery wolverines.) They tell us to record this number like a vital sign, but while a fever of 102° F is the same temperature in every person, 8/10 pain may be a very different experience for different people. And lots of hospitals are making policies like "No one can be sent home from the ER until their pain is less than a 5."

Doctor D sees lots of people every day who claim they feel level 10 pain—the most excruciating agony a human being can experience. 10 is by far the most commonly chosen number on the scale. Doctor D suspects that some people might be exaggerating a bit when they answer “Ten” while texting and complaining about the lack of pretzels in the waiting room vending machine. I've seen a few people I was certain had 10 of 10 pain and it seems like disrespect to those people to classify bruises and upset stomachs in the same category. But pain is subjective, so who is to say a mildly sprained ankle isn't more horrific to this individual than the fires of Hell?

Obviously there are some addicts who lie about pain to get drugs, but I think more commonly people say 10 because they lack the imagination to conceptualize greater pains or they hope that a 10 will cause doctors and nurses to take their discomfort more seriously.

While the painscale is supposed to empower patients to define their own pain, it ends up tricking people into an answer that gets them nowhere. Anyone who says 10, who doctors don't think looks like a 10, is immediately assumed to be full of shit. And anyone who answers 11 or greater must a histrionic drama queen who is both lying and saying something impossible. If pain is a vital sign, then saying your pain is an 11 is like saying your temperature was 200° F.

If you want your pain to be taken seriously never say 10! (Unless you're pushing out a baby without an epidural or you have several broken bones sticking out of you.) If you want a doctor to respect your pain say. “It hurts like hell, but I would give it a 7 or 8.” Your doctor will recognize that if you understand how bad 10 is then your 7 is really horrible, so your doctor will work hard to alleviate your misery.

But trust me, never say 10! Even if it you had to set your self on fire to get the wolverines to stop eating you say 9. Ten on the painscale is a Catch-22; answer “10” and the doctor immediately thinks you are about a level 4.

What is the worst pain you every felt? Doctor D's worst pain of his life was about a 6. Did a doctor believe you went you complained of the pain? Do you think the painscale was helpful for getting your pain treated?

Follow-up post: The Purpose Of Pain: Why the painscale doesn't work

Work Excuse

Doctor D's blogging excuse note:

Sorry to readers for the lack of posts this week. Between weening myself off of coffee and catching a virus from my son, Little D, my free-time productivity has drastically dropped. I'll get a post up answering one of your questions soon. Right now I'm taking another Tylenol.

Are Modern Patients to Blame? (Friday Link)

Doctor D has made his triumphal return from his vacation and is back to working himself to death and blogging.

Today is Friday which means D delivers some exciting links for your weekend reading. Doctor D has an interesting radio piece for you:

National Public Radio did a piece about how educated patients who read about medical care on the internet are costing too much. Doctor D is so relieved! He had been told all along it was doctors who are bankrupting the country. Turns out it's you patients, who all have "medical student syndrome" and think you have every disease you read about. You even made that nice overworked doctor in Virginia cry!

It actually is an interesting use of 8 minutes:

So medical pages like this one are ruining the healthcare system! Too much information and you start demanding tests and treatments you don't need.

Doctor D's theory is that doctor blogs might actually be helpful with this problem. Instead of just giving info on diseases and treatments, medblogs actually give the perspective of healthcare providers. Hopefully patients who read heathcare provider blogs learn not just about diseases and treatments but the mindset of physicians, which includes understanding why over-testing and over-treating is not a wise choice.

Doctor Blogs could save the healthcare system billions! Hopefully the AskAnMD will get a generous government grant to underwrite Doctor D's important work!

So what do you think? Does being an educated, web-savvy patient make you cost the system more? Do you think reading Medblogs make your healthcare cost more or less?

How To Speak Doctor

Question from a reader:

My heart sinks when I realize the vast difference between a detailed medical appreciation of my disease and the incredibly simplified version my doctors tell me. Do doctors feel like they are speaking baby talk to patients? Do patients ever really understand our illnesses, tests, and treatments?

First of all, any doctor who implies they have a full understanding of your body is bullshitting you! Some specialists may know a little more about a particular organ or disease, but in the end your body is a mystery and doctors are all just making educated guesses. Doctors know some useful things, but things we don't understand far outnumber the things we do.

Patients are nervous about doctors working with limited knowledge, so MDs learn to sound more knowledgeable than we really are. One of the easiest ways to sound really knowledgeable is to use a lot of technical jargon. We can really impress non-medical people by throwing out some dense multi-syllabic pseudo-Latin with a lot of acronyms mixed in. It just sounds so darn smart!

Doctors are also used to talking with each other in medical jargon and sometimes forget that patients have no idea what the heck these words mean. It's not that "MI" or "Raynaud's phenomenon" are too difficult to for you comprehend; it's just that they sound really complicated if you don't speak Physician.

If a doctor says something that makes no sense the best strategy is to frankly ask, "What does that mean?" When it comes to understanding your prognosis or making a decision it is important that you understand what is being discussed.

A wise teacher once told Doctor D, "If you think you understand something, but you can't explain it in a simple way you probably don't really understand it." This is true for medical knowledge. Your doctor should be able to explain these things in plain English when you ask for it.

Listening to a simple explanation in plain words it may become obvious that your physician doesn't fully understand everything either. Don't panic! We don't have to understand everything about a body or a disease to treat it well. We may not be good talkers, but we are great guessers!

Have you ever had a doctor that just couldn't speak simple English to explain your condition? Doctor D would love to hear your stories in the comments.

The Instinct To Link (Friday Links)

Since he is on vacation this week, Doctor D hasn't been keeping up with the world of Medblogging, but he does have some links for you:

You can still get your Doctor D fix because he did a Psyche Consult, so you can read his guest-posts over at the Reality of Anxiety Blog!

The first post Stress and The Survival Instinct explains the nature of stress instincts, and the second post on Anxiety Management explains how to take control of the stress instinct.

"For your hunter-gather ancestors violence and danger may have been around every corner, but you do your hunting and gathering at the local grocery with laws in place and police nearby to stop most violence. So why are the safest human beings in history always so stressed?"

Readers of this blog know D loves discussing how instincts that worked well in in the past cause a lot of poof health today from obesity to avoiding exercise. Doctor D hopes that understanding our instincts will lead to healthier living.

What do you think? Do you live better when you understand your body better? Or does understanding that certain instincts like stress instinct and eating instincts are hard wired make them harder to resist?

Doctor D will be returning home late next week after his stress-free vacation and he'll be posting some answers to your questions again soon after.

Doctor D's Disappearing Act

Just to let you know, I am out of town on vacation and I probably won't be answering posting any answers to reader questions for the next week. Doctor D still loves you, but he is really enjoying his family and his rest right now.

But you can still email Doctor D because he loves getting questions from readers and he'll be back to answering questions a soon as he returns. If you want to get the word about Doctor D's return when it happens you can sign on to the Ask An MD Feed or you can follow Doctor D on Twitter. (I will probably Twitter daily even when on vacation.)

I'll still be able to give you some Friday Links tomorrow.

Nurses VS. Residents

Question from a reader:

What is the relationship supposed to be between nurses and residents in a large teaching hospital? During a lengthy stay for a surgery, I noticed a tension between these two groups, especially between junior residents and highly experienced nurses. Perhaps it is inevitable?

It wasn't that long ago that Doctor D was a resident in a teaching hospital and he can still recollect old days of being a young doc fresh out of med school and working beside experienced nurses...

The rules of medicine say that the doctor should call the shots, but this can be problematic when a new doc with no experience is giving orders to nurses who have been taking care of patients for years. There will always be some tension. It's like a captain just out of military academy taking command of a group of battle-hardened veterans. The captain may have an officer's rank and a head full of military theory, but the foot soldiers are the only ones who know what it's like to get shot at.

Ideally, this tension will make the team better. The young doctor learns a lot from working with experienced nurses, and the fresh ideas from the newly-educated residents improves the care the nurses give.

Unfortunately people who should be working together sometimes go to fighting amongst themselves. When inflated egos of new doctors or experienced nurses cause trouble and it is patients who can get hurt. Any doctor who doesn't listen to experienced nurses is headed for disaster, and any nurses who abuse new doctors are harming both patient care and medical education. Once the battle gets going, however, it is hard for either side to back down.

The best strategy is to start out on friendly terms and work to stay there. When Doctor D started residency the first advice his attending gave him was, "Be good to the nurses and you'll do well."

Mutual respect and open-communication works best for everyone, including patients. I can tell you it is hard to be nice when an older nurse is giving you shit just for being young. I'm sure nurses can attest that it's equally difficult to refrain from kicking the ass of a cocky resident with a big god-complex and zero inexperience. I have found, however, that if I bite my tongue and act respectful the obnoxious behavior of insecure nurses and doctors usually subsides to a tolerable level.

If you are a patient in a hospital where the tension between residents and nurses has broken into open warfare this is a bad sign. I would advise you appeal to a higher power to intervene, such as an attending physician or head of nursing. Don't take sides--trust me you don't want a part of that battle. Just tell them that you as a patient are worried by the animosity. Usually the responsible authorities can sort out who needs to have "come to Jesus" talk so that both sides can calm down and start playing nice together.

Have you ever witnessed (or been a part of) an interesting Nurse VS. Resident conflict? How was it resolved? I would love to hear your stories in the comments.

The Curse of Doctor D (Friday Dead Links)

Be afraid! Doctor D is the kiss of death for really great medical blogs!

Just when Doctor D says to himself, "This is my favorite blog on the whole frickin' internet!" the blog suddenly disappears. Not just stops updating, but disappears completely into password protected oblivion!

First came Crass Pollination by Nurse K. Doctor D laughed so hard reading those wild tales from Nurse K's ER! It closed just a few weeks after Doctor D found it. Coincidence?

Then just this week Doctor D was reading Journey to MD and said to himself, "I really enjoy Ella's witty commentary and stories from medical school. I think this is my favorite medblog of all!" And suddenly it's gone... without even a "Hiatus" post!

This is some dangerous stuff! I am desperately trying not to love Dr. Grumpy lest I inadvertently destroy his blog as well. But in case I don't succeed, you should read the post about drunk doctors, the story of Mr. Jackass, and the time Happy Hospitalist got schooled by Grumpy right now!

Doctor D's new found blog-killing power really should be harnessed and used for good! Feel free to let Doctor D know in your comments which medblogs should be spared and which should be destroyed.

Ella and Nurse K if you are out there, please come back! I promise not to annihilate your blogs again.

*UPDATE: So just a few hours after I posted this Ella's Blog reappeared! WTF? Was she just messing with Doctor D to see if he missed her? Welcome back Ella! Now we just need to figure out how to do the same for Nurse K!

Putting Down Pets And People

I read a very poignant post by Neo-Conduit this morning about her terminally-ill friend who considered suicide. I was reminded of a question I have often been asked by patients:

We put down our dying pets humanely. Why can't we be so good to people in the same situation?

It is a good question that needs an answer. Doctor D used to just say, "Doctors shouldn't kill patients," but that really didn't respond to the suffering of people facing terminal illness.

I am glad that euthanasia is illegal where I work. Doctors have the ability to keep a dying person comfortable without putting them down like dogs. Human beings are not dogs. Doctor D was good to his elderly dog when he euthanized her, but there is a huge difference between killing a pet and a person.

The most important approach to suffering people is a deep respect for their value as human beings. That respect motivates me to care for their pain. It motivates me stop treatments when they no longer desire them. It also motives me to never give a deadly medicine—even if it is requested.

The approach of death can be disorienting and terrifying. There is a spiritual suffering that is often greater than any physical pain. In moments of hopelessness ending one's own life may seem like the only escape. A person asks him or herself, "What is the value of this dying thing that is me?"

Doctor D has had many patients nearing the end of life say to him, "I wish I could die now!" I have yet to have a single one be disappointed when I respond, "It is ethically wrong for me to end your life, but I will stay with you till the last breath and make sure you are comfortable and respected."

Suffering and dying people need to know they have some value that is more than the sum of days they have left. The deepest respect of all is reminding them they have the most valuable thing of all: a human soul.

Quality of Life is a subjective judgment. I honor my patients by letting them decide what is a quality life and what is not. Value of a Life is different. The value of every person's life is infinite. I honor that value by never killing a human being for any reason.

I already know Nurse K is going to give me a hard time for such a touchy-feely post. Doctor D promises to get back to some fun shit soon.

...But before we get back to fun questions what do you think of Euthanasia?

Getting To Know Your Body (First Visits)

Now back to a question I only halfway answered before:

One thing I would like to see answered on your blog is, what do you do on a first visit? Especially if you're not sick?

On your first visit with Doctor D:

• First, you and Doctor D size each other up. A doctor-patient relationship can be a complicated thing. You gotta know who you're working with. What is the doctoring style of the physician? What are your wants and needs as a patient? How will the relationship work? It is a lot like a first date. We may not be discussing it directly, but Doctor D and his patients are carefully listening and watching to figure out if we are compatible. If you have strong opinions about your care, you should probably let me know, especially if your expectations are out of the norm: "Doctor D, I want you to take care of me without using any medicines" or "I refuse all preventive care." This helps prevent misunderstandings later.
  

• Second, we go over your medical history. This is when you tell Doctor D all the stuff that has happened to your body in the past. We talk about surgeries, pregnancies, illnesses, drug reactions, as well as any current diseases, symptoms, and medicines. For some of you this will be a short discussion but for those who have been through the ringer in the medical system this could take a while.

• Third, we evaluate your risks. We talk about what might happen with your body in the future. Doctor D will ask about diseases your family members had. He'll ask about your habits (diet, drugs, exercise, sex life, etc.) and do a review of systems to look for symptoms you may not have noticed. Then we talk about how to either prevent diseases or catch them early. Any Primary Care doc who only treats what you have now without preventing future illness isn't doing their job correctly.

• Finally, Doctor D takes a look at your body. I might find some hidden disease on this exam, but I usually don't. The real purpose is so Doctor D knows how your body looks, sounds, and feels when it isn't sick. Diseases change the body; to properly recognize these changes it helps to know how the body looked when well. You may say, "Come on doc, I feel and look great!" Doctor D also suffers from a delusion of physical perfection he developed as a cocky 19 year old, but the fact is that even healthy bodies still have lots of little quirks or abnormalities. If I see you for the first time when ill I might mistake one of these physical quirks for a new problem and misdiagnose you. Similarly I might assume some small abnormality has always been there when it's really an important clue to your problem.

A while back Doctor D was in the ER and a dude comes in with a runny nose and headache--pretty standard viral cold, except that one eye was much bigger than the other. This gets Doctor D thinking about tumors in the eye socket and other scary stuff.

Doctor D asks about the eye and the guy says he's never noticed any between his eyes. Uh-oh! Then Doctor D shows the dude his own face in a mirror and the man is like, "Which eye doc?"

WTF? How does someone totally not notice one eye is fricking huge compared to the other? We doctors are trained to notice physical weirdness you stopped paying attention to when your mom taught you not to stare, so maybe this dude never noticed his funny eye? So Doctor D calls the family from the waiting room and they say he looks normal. Dr. D points out the eye and they are all like, "Well, what do you know? It is bigger!" Nobody knows how long it's been this way.

Luckily somebody had a childhood picture of this dude, and D discovered one eye has always been bigger. Apparently this guy has had a odd eye his whole life and nobody noticed! Stuff like this happens more often than you think. A lot of times this dude would have gotten his head pumped full of radiation in a big workup just because he was born funny looking.

It is really important that you have a doctor that knows you and your body well. First visits take a while even if you are healthy, but they are really important so don't skip out on them.

Incidentally Doctor D has his first visit with his new Primary Care doctor next month. What is the weirdest thing that ever happened to you on a first doctor's visit? Doctor D would love to hear your stories in the comments.

How I Learned To Stop Worrying And Love The Healthcare System (Friday Links)

Only an hour left in Friday but Doctor D still has a link for you!

Healthcare is a weird world. Those of us that work here get used to the absurdity of it all. A great article to remind us of how FUBAR all this is:

What If Air Travel Worked Like Health Care?

It is both funny and sad, because it's true.

So Doctor D's been doing Friday links for a few weeks now. Should Friday Links stay or go? Dr. D reads a lot of crazy medical stuff online. Should he continue sharing it or just stick to answering questions? Let Doctor D know in your comments!