A couple of weeks ago we had an afternoon lecture/demonstration with an ENT (Ear, Nose, & Throat) surgeon. I walked in late and they were doing laryngoscopes (looking at the voice box through the nose) and I asked him how bad my deviated septum was. He asked me to plug my right nostril and try to breath in through my left nostril. Nothing. No air movement at all. He took a look at my nose and about 30-45 seconds later he was on his phone with his nurse setting me up for surgery.
As an aside, I haven't been able to breathe right out of my left nostril for probably 15-20 years. Likely this is from some bonehead move when I was in high school or college. Now, this is nothing that I would pay out-of-pocket for, but if my insurance will cover it and we've already met our deductible and a surgeon is offering it to me...I'm gonna take it.
There are some interesting things about being a doctor and seeing what happens on the other end of surgery. We don't really get called until the patient in on the OR table and getting ready so when the surgeon comes in the room they are ready to cut. That means that I got to the hospital 2 hours early, proceeded to tell each nurse that came in the room that I was a doctor so they could skip all the inane questions (I didn't really say that last part, but wanted to). That means that I got to sit in a very small and flimsy hospital gown nearly naked for 2 hours and read my book that I had the foresight to bring.
We then went down to the OR and I remember moving to the operating table (and probably mooning a couple people in the process), lying down, feeling something cold go in my IV, look back at the anesthesiologist who told me it was Versed and then...nothing. I honestly don't remember a thing. Very weird. Who knows what gibberish I might have been spouting off. That happens to be one of the properties of Versed...amnesia, not spouting off.
The post-op for me was actually pretty uneventful. I was wondering what it would be like to take narcotics, but I didn't really need any, so I didn't get to find out. Alas. For just a septoplasty the recovery entails some pink/red nasal drainage like you have a runny nose and a sensation of TONS of sinus pressure from these small plastic splints they had shoved up my nose. A part of me (a small part of me) wishes that it would have been more involved so I could get a real sense of what surgery is like for my patients, but I'll take the glimpse that I got and be glad for the easier breathing.
Friday, December 30, 2011
Sunday, December 11, 2011
Old School Medicine
Much of modern medicine now relies on tests. When someone comes into the ER they almost always get blood work to one degree or another and then if the diagnosis isn't clear, they get some imagining (CT scan, Ultrasound, etc). Often the physical exam portion of the interactions is perfunctory and really only done for billing reasons. That being said, there are some times when something on the physical exam is more important than imaging and blood work.
I had a patient come in to the ER the other night and we were called down to admit her to the hospital for abdominal pain. Abdominal pain is really difficult to work with because there are some many causes for it. You have the pancreas, stomach, small intestines, large intestines, liver, gall bladder, and appendix. If you're a woman then you also have the ovaries and uterus as well as pregnancy that could be involved in the list of things we need to look at. This lady was a 22 year old lady who was pregnant, had a previous C-section (meaning she had abdominal scarring added to the list), and had a previous umbilical hernia (more scarring). Added to the mix is that she lives at the Salvation Army with her husband and child, is adopted from Vietnam and still speaks with an accent. She has been seen a LOT of times in the last year by both the ER, Obstetrics, and our Residency Clinic.
Anyway, I get down to the ER and start talking to her. She has a very very strange style of interaction. She would just sit there and look straight ahead and mumble answers. Her husband would answer some of the questions, but she just wouldn't make eye contact and just gave off a weird vibe. But one thing I learned from my public speaking class is that people are very uncomfortable with silence. So I would ask her a question and then just wait for her to answer. 30-40 seconds doesn't sounds like a long time, but try sitting in a small room at 10:30PM staring face to face with a doctor answering questions and it becomes a very long time. After a couple of questions and some very long pauses she eventually broke down and started talking with me. Essentially she has had this pain prior to her C-section and Hernia repair (hence not scar tissue, and the duration points away from it being her organs as they usually present more acutely) and although heating pads have helped somewhat, mostly just not using her abdomen has been the most helpful. She said it was worse with movement. All of her lab work was perfectly normal as was her baby.
Still confusing.
However, on physical exam I had her lie down on her back and then do a straight leg lift while I tried to push her feet down. This was very painful for her and perfectly elicited the pain she has been complaining about. Eureka! My conclusion was that it was some abdominal muscle strain that hasn't resolved because she has continued to use it with her job. She needs some Physical Therapy and a little bit of strengthening exercises and she should be good to go.
Most of what I do that is particularly memorable usually involves some sort of tragedy. It was really nice to finally do some sleuthing that changed course from what could have been a big work-up and potential surgery to something simple and easily fixable all because of a simple physical exam.
I had a patient come in to the ER the other night and we were called down to admit her to the hospital for abdominal pain. Abdominal pain is really difficult to work with because there are some many causes for it. You have the pancreas, stomach, small intestines, large intestines, liver, gall bladder, and appendix. If you're a woman then you also have the ovaries and uterus as well as pregnancy that could be involved in the list of things we need to look at. This lady was a 22 year old lady who was pregnant, had a previous C-section (meaning she had abdominal scarring added to the list), and had a previous umbilical hernia (more scarring). Added to the mix is that she lives at the Salvation Army with her husband and child, is adopted from Vietnam and still speaks with an accent. She has been seen a LOT of times in the last year by both the ER, Obstetrics, and our Residency Clinic.
Anyway, I get down to the ER and start talking to her. She has a very very strange style of interaction. She would just sit there and look straight ahead and mumble answers. Her husband would answer some of the questions, but she just wouldn't make eye contact and just gave off a weird vibe. But one thing I learned from my public speaking class is that people are very uncomfortable with silence. So I would ask her a question and then just wait for her to answer. 30-40 seconds doesn't sounds like a long time, but try sitting in a small room at 10:30PM staring face to face with a doctor answering questions and it becomes a very long time. After a couple of questions and some very long pauses she eventually broke down and started talking with me. Essentially she has had this pain prior to her C-section and Hernia repair (hence not scar tissue, and the duration points away from it being her organs as they usually present more acutely) and although heating pads have helped somewhat, mostly just not using her abdomen has been the most helpful. She said it was worse with movement. All of her lab work was perfectly normal as was her baby.
Still confusing.
However, on physical exam I had her lie down on her back and then do a straight leg lift while I tried to push her feet down. This was very painful for her and perfectly elicited the pain she has been complaining about. Eureka! My conclusion was that it was some abdominal muscle strain that hasn't resolved because she has continued to use it with her job. She needs some Physical Therapy and a little bit of strengthening exercises and she should be good to go.
Most of what I do that is particularly memorable usually involves some sort of tragedy. It was really nice to finally do some sleuthing that changed course from what could have been a big work-up and potential surgery to something simple and easily fixable all because of a simple physical exam.
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