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Sunday, November 22, 2015

To practice medicine is to appreciate the richness of its history, especially when it comes to the physician names that are sprinkled liberally in the language of the profession. While some names originate in ancient Greek times, think Achilles, a hero of the Trojan War whose tendon is routinely injured in NFL wars, many terms have their origins in the last couple centuries. New England Patriot’s receiver, Julian Edelman broke the proximal fifth metatarsal in his foot but every medical student has to learn that it is a Jones Fracture, named after Sir Robert Jones, who in 1902 described 11 patients with similar fractures of the foot, including his own.

Medical speak is littered with eponyms that honor the people who first discovered their piece of medical knowledge. Some names are almost never heard while others have become part of the language.

  • In 1953 Dr. Virginia Apgar, an obstetrical anesthesiologist developed a scoring system, the APGAR score, to help determine how well newborn babies were coping with the world outside the uterus just after their birth. She used scores for the baby’s Appearance (color), Pulse rate, Grimace (irritability), Activity and Respirations to predict whether they needed emergent care in the delivery suite. It was fortuitous that her name and the scoring system where the same.
  • In 1963, two pediatric orthopedic doctors, devised the Salter-Harris system to classify children’s fractures based upon the involvement of a bone’s growth plates. Medical students routinely have to Google the classification system but it’s important to know because in orthopedics, it’s all about understanding where the bones are in relationship to each other; plus bones tend to break in similar ways, so the first doctor to describe the injury pattern gets to name it…or at least publish the scientific article and have colleagues bestow the eponym.
  • Sometimes there is sadness about how a disease is named. In 1872, George Huntington wrote of the genetic disease that bears his name. He described the symptoms of the degenerative brain disease that led to the gradual decline in the physical and mental function of both his father and grandfather. He would also develop Huntington’s Disease, but continued to document the progression of his symptoms.
  • Englishman, Thomas Addison wrote about adrenal insufficiency in 1855. The general public learned about Addison’s Disease only after President Kennedy was elected in 1960. His family and advisors were able to hide this disease from the electorate, as well as his hypothyroidism, even though he had collapsed at an election rally and his opponents tried to use his Addison’s diagnosis as a political weapon.

No matter how hard doctors try to speak regular English, even to each other, the eponyms have a way of creeping into the conversation. From surgeons who talk about McBirnie’s point, where abdominal tenderness in appendicitis is often located, to cardiologists and their Beck’s triad, whose symptoms often make the diagnosis of cardiac tamponade, the names become medical shorthand.

While there is nothing special about using an eponym, there is a certain satisfaction in knowing that learning and practicing medicine is based on one doctor caring for one patients only to recognize enough similarities with others to describe a physical symptom or an illness or injury, and be lucky enough to have their name memorialized. It’s also a reminder that when a doctor gets lucky enough to find an interesting patient, perhaps that patient isn’t so lucky to have that injury or disease.

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waiting to be seen

Sunday, November 15, 2015

Making the decision to visit the ER is never taken lightly. Aside from obvious injuries that need attention, think lacerations or broken bones, most other illnesses have the undercurrent of disaster. Is the chest pain a heart attack? Does my child have appendicitis? Is a tumor causing my headache? And worse yet, it’s the waiting, first in the waiting room and then finally being placed in an actual exam room, only to wait again. And then disaster strikes, but you don’t know about it.

Most hospital ERs, are staffed with doctors, nurses, lab and x-ray technicians, housekeeping and cleaning people, for the expected rush of patients that happens at different times of the day and different days of the week. Planning for the surge of patients on a weekend evening shift is no different that retail stores who prepare for Black Friday or Christmas Eve, expecting more customers. Hopefully, in the ER, the number of people working is enough to care for the number of patients walking in the door.

All that planning goes away when disaster strikes. In the Paris terrorist attacks, 129 people died (at the time of this column) and more than 350 people injured with almost 100 critically. These victims needed emergent care and many needed the services of a trauma team to provide care. But think of that number of patients. There are 13 hospitals in Paris, according to the Paris Tourism Office. Not all are capable of caring for these victims, but if each hospital took their fair share,  the “regular” emergency patients would be bumped and their wait to be seen extended. To be fair, hospitals have disaster plans and their whole staff would be mobilized to care for patients, both from the disaster and for those “routine” patients whose emergency visit was unlucky enough to happen at that same time.

People are very tolerant of waiting when a disaster happens. They see the carnage and they hear the news. Patients are less tolerant when waiting happens and they don’t know why. Many hospitals have waiting rooms that cannot see the ambulance bay and the steady stream of patients being dropped off. That said, arriving by ambulance does not necessarily let a patient jump the queue. Triage happens every time a patient gets touched, whether it is the person who walks in the ER door, or who arrives by ambulance, or who is found to be sicker than initially thought. First come, first serve is not the ER mantra.

A rush of patients doesn’t need to be the cause of the patient flow in the ER coming to a halt. It may be that the inpatient beds in the hospital are full and patients who need to be admitted from the ER have no place to go. They may be boarded in their ER bed, causing a logjam and the next patient up in the waiting room has no place to be seen. Or it may be there is one significantly ill patient that takes the time of many of the ER staff, leaving others to wait. Or it may be that a death has caused a doctor and nurse to spend time with a grieving family. Or that death caused the same doctor and nurse to take a few minutes to regroup emotionally for the next patient.

There is some sadness when hospital administration decides to use waiting times to lure patient to the ER by posting “real-time” waits on billboards or websites, or promising a patient will be seen within a certain amount of minutes. All those promises go away when a chest pain patient arrives at the door. To meet national standards of care, an EKG needs to happen within 10 minutes and if a heart attack (myocardial infarction) is happening, they need to be in the heart cath lab in less than an hour. If a stroke patient presents, they have less than 4 1/2 hours from onset of symptoms to get treatment and save their brain. Children with suspected meningitis need antibiotics immediately. A trauma patient who is in shock gets bumped to the head of the line. The waiting time listed on a website is old news if a disaster arrives before you do.

Waiting to be seen is difficult in the ER because of lack of control. There is the worry of the unknown about a headache or belly pain. There is the lack of choice as to what doctor or nurse will be providing care. And there is often a lack of information provided as to why the wait is happening in the first place. It is of little consolation to hear that somebody else is more sick or injured; there can be some perverse comfort in knowing that somebody else has it worse, but in the end, there is no joy in waiting.

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