Richard M. Ratzan

The blue scrotum sign of Bryant: A diagnostic clue to ruptured abdominal aortic aneurysm

A 73-year-old man presented to the emergency department twice with nonspecific abdominal pain. He was diagnosed as having mild diverticulitis and was discharged. Four days later he presented to the emergency department in severe abdominal pain with scrotal and penile ecchymoses. After an initial urologic consultation the correct diagnosis of ruptured abdominal aortic aneurysm was made. We discuss the pathogenesis of the genital discoloration and make the correct historical attribution of this sign to John Henry Bryant, a turn-of-the-century physician at Guys Hospital.

Using pharmacists to optimize patient outcomes and costs in the ED.

Participation of hospital clinical pharmacists in the care of inpatients is widespread, often encouraged by the dicta promulgated by regulatory bodies. For years, clinical pharmacists have ventured out of the pharmacy to participate in rounds and, otherwise, in the care of patients on hospital floors and in intensive care units. In fact, it has been well documented in many research studies published in the last 20 years that having pharmacists prospectively involved with orders generates significant cost savings for the hospital and benefit to patients. Until recently, the emergency department (ED) seemed to be a hectic environment that would be inhospitable to the careful, meticulous, and usually deliberate process of many clinical pharmacists. The potential benefits were recognized, but the pace and costs seemed prohibitive. The addition of pharmacists in the ED has reduced medication errors and provided numerous other benefits that will be discussed in this article. We will show that recent data indicate that using an ED clinical pharmacist promotes patient safety and is cost-effective.

Winged words and chief complaints: medical case histories and the Parry-Lord oral-formulaic tradition.

Imagine the following story: A very young man who is a renowned warrior enlists with the Greek army attacking Troy. This warrior has been told by his divine mother that he has one of two fates in store for him—either a very long, peaceful life or one shortened by death in battle but lengthened by immortal glory. The commander-in-chief publicly insults and humiliates the warrior by stripping him of a slave girl the warrior has rightfully won as part of his spoils from the ongoing war. The warrior retreats to his camp, depriving the commander-in-chief not

Communication and Informed Consent in Clinical Geriatrics

Obtaining a valid informed consent from an elderly person, especially with possible senile dementia of the Alzheimers type (SDAT), first may involve solving the practical problems of effective communication. Perceptual constraints that frequently occur in the elderly and that may interfere with communication, i.e., the sharing of information, are auditory and/or visual. The most common auditory obstacle, presbycusis (the hearing loss for pure tones due to normal aging) and other hearing impairments, may make the communication of any information about a proposed research project difficult, if not impossible, when not suspected and successfully overcome. Speech and language impediments, whether as a result of stroke or SDAT, are also common and need to be addressed if the person is to communicate his or her concerns and questions effectively with the researcher. Included in such constraints are the misunderstandings that arise from the use of confusing vocabulary, especially “medicalese.” Presbyopia, cataract, and glaucoma are some of the visual constraints that may play an important role in making it difficult for the person to read the informed consent form. This article discusses these and other impediments to effective communication with SDAT elderly and makes suggestions how to obviate them.

Defining a rational back-up policy for emergency departments.

All emergency departments face the possibility of having insufficient personnel to provide adequate care for patients. Such occasions may present an emergency department with several severely injured patients or merely an unusually large number of that emergency departments usual patient profile. When such staffing inadequacies occur, emergency department directors must respond with additional personnel. Since there is no national standard for back-up policies for emergency departments, emergency medicine has a responsibility to examine this question in order to arrive at some possible solutions. In addition, emergency department directors have an obligation to consider their particular staffing and usage patterns in order to try to devise the most efficient back-up policy prior to need. Finally, assessment of the success with which such back-up policies are used is discussed.

A NEAR MISS

This essay is about loss. Yesterday night, while on duty, I sat on a patient with pneumococcal meningitis for six hours before tapping him. He’s ok, but I (and he) had a near miss. As physicians we all have near misses from time to time. Some are our doing (“fault” is so harsh, so Old Testament). Some aren’t. Near misses serve a purpose, if you look at them right. They’re like messengers from the gods: “Stop driving so fast!” “ Stop flirting with-. Leave your marriage alone!” “ Stop working so hard!” I’m still not sure what this messenger is trying to tell me. I think it has something to do with loss, but I’m not sure. I plan to think aloud about it for a few paragraphs. The man was nineteen and sitting in a wheelchair. His father and mother brought him in about one AM, saying that he hadn’t walked or eaten for four days. I looked at him sitting in the admitting area and was impressed with how strange he was acting. He was reserved, not talking, and had a glassy look in his eyes that smacked of drugs or psychosis. When I entered his room a few minutes later, his chart told me that his vital signs were normal, that he had “NKA” (no known allergies), and that he was on ear drops. I looked at him. He lay screaming and writhing on the bed complaining of leg cramps. He begged me to give him something for pain. His father sternly but lovingly told him to behave, that the doctor was trying to help him, reminding me of the patient-family-physician interactions in William Carlos Williams’s “The Use of Force.“’ John did very little talking, even when he wasn’t

The bright balloons of medicine.

On my desk is a photograph of my two oldest children, 4 and 3 years old at the time, each holding a balloon aloft in a hand pudgy with babyfat. Each is happy. Each is looking up at his balloon. David, on the left, is holding a purple balloon. Will is smiling up at a green one. We had just come from a parade and I caught them, backlighted but properly exposed, just right. Those balloons represent, to me, the humanities-what we all took at some point in college, even the most die-hard pre-med of us. In a New York Times Magazine article about the same time as the photograph (approximately six years ago), a writer compared the humanities to the bright balloons of human study. History, literature, philosophy-these embody the values people have cherished, warred over, and celebrated. Like balloons, they soar, are bouyant, lift the spirits of the observer. Reading Shakespeare, listening to Bach or Scarlatti, pondering the incredible beauty of an illuminated manuscript. These are noble works of man and elevate, like balloons, anyone holding on at the time. I think one reason I find the simile of balloons and humanities so appealing is that it carries even more ballast for me as a scientist than perhaps it did for the New York Times writer. As someone interested in the medical humanities, ie, the relationships between history and medicine, literature and medicine, art and medicine, I not only think of the brightness of the balloons and their lofty aspirations, I also think of Boyle’s law and how it contributes to the shape of the balloon, of Avogadro’s number, a number I always felt I had to believe in, like the Trinity, or Washington and the cherry tree. I think too of gravity and Newton and Galileo. Bright balloons symbolize for me not only the art of flight and the human values that the humanities parade: love, fidelity, courage, jealousy (yes, the humanities also have much to tell us about not so lofty values), the same bright balloons also embody the fact that science has its truths, its processes, its form. The relationship between science and the humanities has, of course, been problematic of late and much discussed. Since the rift between the education of practi-

Keep in touch

“You must never again set your anger upon a patient. You were tired, you said, and therefore it happened.“’ Thus begins “Brute,” by Richard Selzer, a writer who recently retired from surgery to pursue writing full time. “Brute” is a confessional gem of a piece, barely four pages long. Yet it tells the tale of a doctor who lost control. Even while realizing it, he maliciously took advantage of a patient he was ostensibly helping. As with all of Selzer’s stories, it’s even more complicated than that. It’s 25 years ago. The doctor has been summoned to the emergency room at 2 AM to sew up a “hugely drunk” hulk of a man with a laceration in his forehead, “deep to the bone.” The man struggles like Samson to get free and will not cooperate. Restraints are applied. As the doctor begins to clean the wound, the man struggles even more. “Lie still,” Dr Selzer petulantly tells him, enraging him further. The man curses at him, angering the doctor. “Suddenly, I am in the fury with him. Somehow he has managed to capture me, to pull me inside his cage. Now we are two brutes hissing and batting at each other. But I do not fight fairly.” Doctor Selzer proceeds to sew the huge man’s ear lobes to the mattress with heavy silk (one imagines it to be 2-O), wipes the clots from his eyes so the man can see, taunts him with the same curse the man just hurled at him, and grins “the cruelest grin of my life. Torturers must grin like that, beheaders and operators of racks.” He finishes the job while the man, sensing defeat, holds still. “How sorry I will always be,” Selzer writes 25 years later “not being able to make it up to him for that grin.” There are many issues here: The rnost immediate is the “need” to use of force as opposed to other options (not discussed or tried in the story), for example, a sedative or waiting for sobriety or recruiting another health care worker with more rapport. Or Selzer could have elected not to sew the patient up at all. On a somewhat deeper and more interesting (intellectually, that is) level is the realization at the time that he was doing something wrong and enjoying it but not stopping. There is also