Minnesota Antique - Fair?

Dear Paw Paw:

I am an 86 year old widow. After our weekly canasta party, I started feeling short of breath. Thelma and Louise insisted I needed to see a doctor so they drove me to the emergency room. Once there the doctor and nurse asked me all kinds of questions. They said it was necessary to know about any illnesses I had. So I told them about the high blood pressure and diabetes. They did a lot of annoying tests on me. All I wanted to do was go home, watch TV and see that cute Walter Brennan on reruns of “The Real McCoy’s”. After a while the doctor came back and said my EKG and blood tests did not show any sign of a heart attack. But the doctor was worried and wanted me in the hospital for more tests. Hey, I might be old, but I am not stupid! If everything was ‘ok’, why did this doctor say I needed to be in the hospital for more tests? Are they crazy or just interested in running up my bill?
Ann Teek, Geezerville, Minnesota


Dear Antique:

The ghost of my dear wife, Maw Maw, visited me in my dreams last night and said that since you seem to be a sweet old lady, I need to be kind. So despite my strong urge to humiliate and insult you, I will be gentle. No your doctor is not crazy. Actually they are smart and being very careful. Your doctor does not want something bad to happen to you in the next few days, like a heart attack or even dying. Look sweetie britches even though your tests do not show a myocardial infarction (MI), you are at high risk. This is why they wanted you in the hospital for more tests.

In the National Registry of Myocardial Infarction 2 study (NRMI-2 for short) one third of patients with proven MI did not have any chest pain when they came to the hospital. Those people with an MI who are more likely to not have chest pain are: diabetics, women, people over 85 and those who are not of the white race. The most common non-chest pain symptom is shortness of breath. You certainly qualify as one at high risk.

These non-chest pain symptoms are often called angina equivalents. In other words, they should raise as much concern as chest pain. Some of these angina equivalents are: weakness, fatigue, cold sweats, syncope, confusion and dizziness. Actually the older you are, the more likely you are to present with an angina equivalent.

Also you may not realize it but nearly 7% of people with an MI have a normal EKG at first. So even though your initial tests are ‘ok’, your doctor is looking out for you by telling you to have more studies. Yes it is true, doctors love to do tests, but in this case they really are helpful.

They also are concerned you are having an acute coronary syndrome (ACS). In other words, symptoms from your heart, but no damage to the heart muscle yet. People with ACS are in danger and need further testing and treatment. Often they need to have a cardiac catheterization and have their blood vessels opened up (angioplasty).

These are the kind of things doctors worry about all the time. Sending someone home and then having them come back with an MI or having their family find them at home dead, is not what your doctor or nurse want. If you don’t think doctors and nurses worry about their patients you are mistaken. They worry all the time. It gives them sweats, high blood pressure, insomnia, ulcers and turns their hair white or even worse makes them bald.

If it doesn’t seem that your doctor worries or cares about you, I suggest you get their DNA tested to make sure they are human. Then again, maybe you should just find another doctor. After all caring about people is the first step in caring for people. And caring is what it means to be a doctor.


By the way, next time maybe you should get different drivers. These two seem a little ‘over the edge’ to me.
Paw Paw

Food For Thought

July 15, 2007

Dear Paw Paw:

Recently an 8 year old girl presented in DKA. She was not known to be a diabetic. Her serum glucose was 540. The rest of her labs were: Na=119, K=3.1, CO2=12 and a BUN of 35. Her venous blood gases showed a pH of 7.2 and pCO2 of 31. She was tachycardic, tachypneic and nauseated. Naturally I wanted to get her glucose down fast, and correct her acidosis. So I gave her an ampule of bicarbonate IV, started NS IV at 1 liter/hour, gave an insulin bolus of 0.1unit/kg, and then started an insulin drip at 0.1units/kg/hour.

Within an hour or so, she developed lethargy and headache, and then became hard to arouse. Shortly thereafter she began posturing and became unstable. She was admitted to the ICU. The Pediatric Intensivist said she developed cerebral edema.

Although I know I did my part as quickly as I could, I feel bad that her family waited too long before they brought her to the ED. Now if she survives at all, she will be neurologically impaired for the rest of her life. What should I say to them to relieve them of the guilt they must feel?
Dr. Charles Wezz, Frogbottom, Georgia

Dear Dr. Cheese Whiz:

You get the King Pyrrhus Award for 2007. Yep you won the battle, but unfortunately lost the war. Using what few functioning neurons you have, you may remember that Pyrrhus was a cousin of Alexander the Great and an outstanding military leader. He was a strong opponent of Rome. In the battle of Asculum in 279 BC he lost irreplaceable losses in his ‘victory’ over the Romans. Hence the term Pyrrhic victory, but I digress.

More to the point, cerebral edema (CE) can be seen in DKA, especially in children. OK it only happens about 1% of the time. But the mortality is reported as anywhere between 40 – 90 %! It should be anticipated and at the first signs, it must be treated aggressively. The thoughts about why this happens are more complex and numerous than JFK Conspiracy Theories.

Factors that are suspected to predispose to CE are: use of bicarbonate, low pCO2, preexisting hyponatremia, high BUN, overaggressive fluid resuscitation, use of insulin bolus, and lowering of glucose too quickly.

This girl had hyponatremia, even after corrected for the elevated glucose. The formula is: corrected Na = measured Na + ([1.6 x (glucose – 100)] ÷ 100). Her corrected Na is 126. He BUN was high, her pCO2 was low. She was definitely at risk. The bicarbonate and bolus insulin are now “no - no’s”.

You do get a few “ata boys” for using a venous blood gas to check her acid base balance. Remember you are doing this for acid base reasons not to check her oxygenation. The pCO2 on the venous side is not significantly different than on the arterial side and a VBG is a heck of a lot easier to obtain than an ABG, especially on a kid.

Unfortunately it sounds like her brain has been turned into the neurologic equivalent of a bowl of Lime Jell-O. And despite what Bill Cosby says, Lime Jell-O is not acceptable to anyone anymore.


Often the initial symptoms are subtle: irritablitity, lethargy, head ache. You have to know about it to think of it. You have to think of it to recognize it. And you have to recognize it to treat it. Get it?

If you start to see any signs it is imperative to stop the insulin, decrease the fluids and treat as you would any other episode of cerebral edema. Early treatment with Mannitol is advised. Some recommend taping a dose to the head of the bed and giving as soon as you suspect CE. Early aggressive treatment is the only chance for an acceptable outcome.
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This young girl’s family did nothing wrong and they have nothing for which they should feel guilty. You on the other hand are another story.

Now go in peace my son. Your penance is to recite “I Will Not Be an Idiot” three times while genuflecting in front of the statue of Sir William Osler, and promise to never sin again.

By the way you may find these articles of interest:
1. Risk Factors for Cerebral Edema in Children with DKA – NEJM, January 25, 2001; Volume 344, Number 4, Pages: 264-269.
http://content.nejm.org/cgi/content/full/344/4/264
2. Diabetic Ketoacidosis and Cerebral Edema by Elliot Krane, MD
http://pedsccm.org/FILE-CABINET/Metab/DKA-CEdema.html

Then again, maybe you should do your own damn Google search!

Paw Paw

Lazy & Sorry

Dear Paw Paw:

The Director of our EMS got mad at me and my partner the other day. We picked up an old lady who was unresponsive, sweating, cold and breathing funny. Family claims they told us she was a diabetic on insulin, but I couldn’t hear them too good above my Sony Walkman. Our Director got really huffy and said we were a bunch of slackers for not checking her glucose, starting an iv line and giving her some D50. We were only 9 miles away from the hospital, so we just loaded her up and took her to the ED. After all, we needed to get back to the station for dinner and to watch America’s Funniest Home Videos. Besides they can do all that and check her vital signs once she gets to the ED just as well as we can.
Lazy and Sorry from Wyoming


Dear Lazy and Sorry:

Are you guys serious? You need an I-Pod! Walkmans are so “last year”. I agree with your Director, if you can’t upgrade your music listening accessories and start stealing songs off the Internet, you obviously don’t have enough ambition in life. You should be fired immediately.

Oh, by the way, expect a call from this poor old lady’s attorney. You can look forward to hours of depositions, and weeks of rest and relaxation in your county courthouse explaining yourself to 12 of your friends and neighbors. They will actually expect that you do your job which is to provide emergency medical service. After all you are part of the Emergency Medical Service aren’t you? Isn’t that why they call it EMS?

Hypoglycemia is an emergency. It should always be considered in unresponsive patients and treated promptly. Glucose is the sole energy source for the brain. And so the longer the brain goes without an adequate level, the greater the risk of neurological problems. Hypoglycemia can mimic strokes, TIA’s, seizures, and psychotic episodes. Be wary and check finger stick blood sugars.

If patients are awake enough to take food or liquids orally, that should be the method used to treat low blood sugar. Sometimes giving something sweet to rapidly elevate the glucose can be given. But to achieve sustained elevations food in the form of complex carbohydrates and protein should be given, like a sandwich or real food.

Hypoglycemia is a common problem in patients on insulin, but it can occur with oral hypoglycemics such as the sulfonylureas like Diabinedse (chlorpropamide) and other conditions as well. Sulfonylureas can cause prolonged hypoglycemia, and patients who have overdoses on sulfonyureas usually should be admitted as recurrent hypoglycemia is common. Insulinomas are unique pancreatic tumors that secrete insulin and cause frequent hypoglycemic episodes. , The diagnosis is made when the c-peptide fragment of insulin is elevated coincident with a low blood sugar. Measuring the c-peptide fragment distinguishes endogenous insulin from exogenous which has no measurable c-peptide fragment.

Malnourished alcoholics or small infants commonly suffer from hypoglycemia. Intravenous dextrose D50 is often used, but because of irritation of the veins, D25 is used in children and D10 in neonates. Glucagon, which can be given intramuscularly, causes conversion of glycogen to glucose. But in alcoholics, the malnourished and infants, glycogen stores in the liver are often depleted and glucagon may not work. The dose is 1 – 2 mg im or iv.

The usual dose for iv dextrose is 0.5 – 1 gram/kg. D 50 has 0.5 gram / ml, D 25 has 0.25 gram/ml and D10 has 0.10 gram/ml. High concentrations can cause pain, phlebitis and tissue necrosis if extravasated. Also D 25 and D50 are hyperosmolar. It is for these reasons that D 10 is used in infants and neonates.

You guys need to decide if you want to do your job or not. If you merely want to drive a meat wagon and not care for patients, then go immediately to the nearest Oscar Mayer plant and see if there is an opening. You two should be hired on the spot since you are both full of baloney.

Paw Paw

Frustrated Fashion Freedom Nurse in Frisco

May 25th, 2007

Dear Paw Paw:

The CEO of our hospital recently adopted a policy that all of the ED Doctors and Nurses had to abide by a Dress Code. He wants the Nurses to all wear the same colored uniforms and the Physicians to wear dress clothes and a white coat. I and the rest of the girls think this is a violation of our Civil Rights and we should have the freedom to express ourselves. Do you know a good lawyer who can sue and get us a lot of money?
Frustrated Fashion Freedom Nurse in Frisco

Dear Frustrated:

Babycakes, I think all Nurses should get their uniforms at Hooters and I could give a dead goat’s tail about what them snooty doctors wear. Frankly I don’t know why the nurses should look any different than Housekeeping, Lab, Xray, Doctors or the Registration Clerks. Yep I think they should all look like clones of that Brittney Spears chick. Let’s keep everyone guessing.

So what if patients find your nose ring, bling, tattoos and see through T-shirt from Lizard Larry’s Lounge less than professional. If you want to look like an incompetent Bozo, that is your God given right. Besides if they can’t understand you when you are doing your assessment just because you like to chew bubble gum, talk on your cell phone and play with your tongue piercing simultaneously, then that is their problem. Maybe they need to talk to Oprah or Dr. Phil and just get over it.

Of course most so called experts on customer service disagree, but what the goat dung do they know! They’ll tell you that everyone needs to look clean, well groomed, and professional. That each department should have a unique uniform that easily differentiates them from others. They have the gall to suggest that physicians should wear professional dress and a white coat. They will lead you to believe that patients actually have certain preconceived notions of what the doctor and nurse should look like. And that if you fail to meet their expectations they may feel you are less than professional in your care of them as well.

Yep your CEO is definitely an old fart with an idea that is not politically correct. You should send him off to Prison for “re-education” and collect a huge settlement from the hospital. I can’t get over the nerve of some people. I suppose he thinks you are there to satisfy patients. What a cretin. Call Sleazy Slim’s Legal and Waste Management Services at 800-555-2727 and tell Slim I sent you. Now, how about a lap dance Sweetie and can I get 10% of the cash you get from your lawsuit?
Paw Paw

Clueless In Colorado

May 9th, 2007


Dear Paw Paw:


The other night I saw a diabetic dialysis patient who had drunk a lot of hooch and popped some kind of pills to try to get high. My professional diagnosis was that he was Really Sick. I called the Hospitalist who asked me for his anion gap. I didn’t know what he was talking about and he got frustrated with me. He said something to me about mudpiles, but I don’t know how playing in the dirt has anything to do with taking care of patients. Should I complain about him?

Dr. Clueless in Coloarado

Dear Dr. Clueless:


Oh this goes way off the scale on my Stupid O Meter. He should complain about you! Anion Gap is not where the pioneers crossed over the Appalachian Mts. on their journey to the West. It is a way to characterize patients with metabolic acidosis and help identify the causes. Metabolic acidosis can be associated with low, normal or elevated Anion Gap. Mudpiles is a mnemonic for the causes of elevated anion gap acidosis:


M Methanol
U Uremia
D DKA, AKA or starvation ketosis
P Paraldehyde, Phenformin (Metformin)
I Iron, INH
L Lactic Acidosis
E Ethylene glycol
S Salicylates

The anion gap can be calculated by the formula: Na – (Cl + CO2). Normally, it is less than or equal to 12. If it is more than 12 it is elevated. Low anion gap acidosis is really weird and we won’t go into that now. Normal Anion Gap acidosis has the mnemonic “HARD UP” which you obviously are. Hard Up stands for:

H Hypoaldosteronism
A Acetazolamide
R Renal Tubular Acidosis
D Diarrhea
U Uretero-sigmoidostomy
P Pancreatic fistula

Now go and read about Acid – Base Disorders and try to be a real doctor.
Paw Paw

From Nervous in Nebraska

May 5, 2007

Dear Paw Paw:

Last week a 28 year old woman who is G8, P7 at 39 6/7 weeks gestation presented to our ED saying she was in labor. Her water broke at home and she was having contractions every 4 minutes. Dr. Dorch examined her and told her, “You are only 6 cm dilated. I don’t do Obstetrics and you need to go somewhere else.” He discharged her from our ED and told her to go to one of the large hospitals about 45 minutes away. She was quite dismayed, but got into her Gremlin with her husband and 7 children and drove away. I and the rest of the nurses thought this might be an EMTALA violation. What should we have done?
Nervous in Nebraska

Dear Nervous:

Next time Dr. Dork tries to pull a stunt like this take a metal bedpan and whack him over the head until his toes bleed. Of course this is an EMTALA violation. What does he think EMTALA is? Something you get at Taco Bell? He ain’t Prissy from GWTW and he needs to know ‘somethin bout birthin babies’ if he is going to work in the ED!

EMTALA is a law and violations are crimes. This means he could face the following penalties:

1. Termination from Medicare and Medicaid
2. Fines of up to $50,000 per violation
3. Criminal prosecution or lawsuit under the Civil Rights Act if a patient says that the EMTALA
violation was based on discrimination
4. Suspension of Medical Staff privileges
5. He could be reported to the State Medical Board and NPDB
6. Investigated by State PRO or Licensure Board for questions about his quality of care

In short, his career, livelihood, and finances would be toast. No his liability insurance will not pay or provide him with legal assistance. The hospital can be fined and lose ability to see Medicare patients too. If that were to happen the hospital is essentially out of business. The hospital could seek to collect damages from him as a result of his violations.

For patients in labor, EMATLA requires that he perform a screening exam, provide treatment and meet all transfer requirements. Usually the patient(s) needs to be stabilized which means delivery of the infant. CMS has decided that all emergency departments are capable of delivering full term uncomplicated deliveries, whether the hospital provides obstetric services or not. If the hospital does not offer obstetric services transfer may be an option, but only if it can be done safely and properly. A Gremlin is not a proper mode of transport for anyone, a Porsche maybe, but a Gremlin never. This woman deserves a medal for being able to fit herself, hubby and 7 kids into one.

The transfer form must state why the patient needs more advanced services. Transfer of women in labor may be acceptable only if she requests the transfer or if the physician certifies that the benefits outweigh the risks. What you describe is one of the more common EMTALA violations. It often results in citations. You can not discharge a patient (any patient) and tell them to go to another hospital for care.

Next time refuse to discharge the lady, and call someone with at least ½ an ounce of sense to come and take care of the woman. If necessary call your ED Nurse Manager, DON, ED Medical Director or the largest employee in the hospital to come and sit on Dr. Dork while you and the rest of your team do his job for him.
Paw Paw

Ask Paw Paw - First of a million dribbles

Get to Know Your New Advice Columnist

Demetrious S. Rogers will answer your questions in his column “Ask Paw Paw” beginning with next month’s issue.

My name is John Rogers and I am an Emergency Room Physician. Often I receive questions from people seeking answers to problems and issues they have as Emergency Care Professionals. My Great Great Grandfather has consistently been a source of wisdom and knowledge. I share with him these letters and he always seems to have the right answer. It will be his pleasure and mine to provide you his insight and advice. Please send your questions for Paw Paw to me at my email address: jrogers@usaem.org

Demetrious Snuffleuppleoppagogalous was the 11th child born to a simple goat herder and cheese farmer in the mountains of Greece. When he was a teen, there was a big war between the Turks and Greeks over who invented Feta Cheese. Paw Paw’s sweetheart told him that he should be careful because it was well known that all the Turks had bigger swords than he did. Unable to recover from this insult to his manhood he decided to move to California so he could star in Babe Watch and see Pam Anderson’s Hooters up close.

He signed on with Lt. Columbo and his merry men who were off to find the New World, because apparently it had been lost, and Lt. Columbo always loved a good mystery. Columbo’s three ships the Santa Claus, El Nino and the Pinto set sail from Aristotle Onassis’s shipyard. They decided to go to Plymouth because they heard that those Pilgrim chicks really knew how to party. Paw Paw was quite distressed when the local natives dropped in unexpectedly for dinner demanding roast turkey, cranberry sauce, pumpkin pie, sweet potato soufflé and a couple of kegs of beer before their big game of ‘Moccasin Ball’ with a rolled up Pigskin. Not only that, he was disappointed to learn that in Plymouth all they had was a Rock but no Roll.

Rumor had it that some dude in the West was looking for help, so he joined Col. Custer as a Scout. Somewhere in the Dakota Territory he came upon the SueEm Indians and over heard them talking. One Indian named Tiny Timmy Leary was passing around some funny weeds and smoking them in his cracked pipe. Paw Paw actually liked the Indians. His companion Dick Clark asked him what he thought of their War Song and Paw Paw told him it had a good beat and he could dance to it.

After Tiny Timmy got Chief Squatting Bear totally lit, the Big Chief gave instructions to let some Crazy Horse turn the Colonel into a pin cushion. Naturally Paw Paw tried to warn Ol’ George but the Col. was too busy trying to decide if Brad Pitt was handsome enough to portray him in his upcoming biographical movie. Paw Paw told George he needed to run down to the store for a pack of cigarettes and never went back.

He made his way to Wisconsin where he spent all his money on Schnapps and sauerkraut. There he met the girl of his dreams, married, settled down to a nice cozy life and waited for Ed McMahon to deliver his $10 Million sweepstakes award. One day while sitting in the local Roy Rogers Restaurant chomping down on his Trigger Burger with Horseradish, he turned to Maw Maw and said “Nelly Belle, why don’t we change our last name and become more American? And I can’t think of a more American last name than Rogers.” Maw Maw chugged her Sasparilla Margarita and said, “Dude, That’s Hot!”

Paw Paw was udderly flabbergasted when he discovered that these Wisconsin Moo-Men did not have adequate health care. He realized he could make a fortune selling them health insurance at exorbitant prices and then telling them to take two aspirin, call him in the morning and that if it was an emergency to either call 911 or go to the nearest emergency room. His career as a Farmerologist was long and prosperous. His paper, ’Cheeseball Aerobics’ was the sensation of the age. I guess it was hard for him to get the cheese out of his genes. His lawsuit against Jane Fonda and Denise Austin for violating his intellectual property rights has yet to be settled.

However he did cause quite a stink when he tried to sell his Limburger and Roquefort Poultices as a cure-all for impotence, acne and baldness. A gaggle of Product Liability Lawyers were out to lynch him because it was found that his Poultices actually caused impotence, acne and baldness.
He and Maw Maw escaped to Iowa to avoid prosecution, and helped my parents raise me.

After Maw Maw died he came to live with me in Georgia. Recently it has become difficult for me to care for him myself, and I reluctantly placed him in the ‘Georgia Home for Geezers Who Just Won’t Die’. I see him when I deliver his monthly shipment of 6 gallons of Jack Daniels, a case of Marlboros and his bottle of 300 Viagra pills. Paw Paw tells me he looks forward to your questions and that I need to pull his finger.