Dear American Academy of Pediatrics:

I think there is a mistake.  Kids started coming into the office recently with forms for sports physicals, and the form is different.  See Below:

Someone added stuff to the form!  Not only do we have to continue the inexplicable obsession with the hernia check (for maximum humiliation of boys, we try to use only female examiners for this), there’s a bunch of new stuff.  I do understand why we need to check for heart problems, with the risk of hypertrophic cardiomyopathy that can kill previously healthy kids.  But what’s this with the femoral and radial pulses?  Yes, I know it is a screening test for coarctation of the aorta, but so is a simple pedal pulse check.  Plus, checking a femoral pulse on kids is almost as bad as a hernia check.

Then there’s the “functional” part of the exam.  The kids all think this is hilarious, but we were quite confused.  I never was taught in medical school or residency what a “Duck-walk” was.  I did a Google search and found that it is a brand of wine, but I don’t think that’s appropriate for a sports physical (you know, with underage drinking being such a problem).

Google also had lots of pictures of Chuck Berry.  I assume his walk in a squat position is referred to as a “duck walk.”  So are we supposed to have them do air guitar and pretend to be Chuck Berry?

Would the Chicken Dance be OK?  Most of the kids these days have never heard of Chuck Berry.

Then finally, there’s the hopping on one leg thing.  Why would hopping on one leg include or exclude a child from sports participation?  Wouldn’t a child who couldn’t hop on one leg have a low likelihood of making the team in the first place?  What exactly are we looking for?  I guess if we gave them some of that Duck Walk merlot, they pretty much would do anything.  Come to think of it, I wonder if they were drinking merlot when they made this form.

I wanted to bring this to your attention because it’s caused quite a stir among the teens.  They apparently are swapping stories about doing duck walks and are very disappointed with having to do the Chicken Dance.  Somebody thought that hernia checks were not humiliating enough and wanted to share the love with girls as well.

I hope you fix this problem as soon as possible.

Sincerely,

Dr. Rob

It’s time we get away from all of that serious nonsense, and back to something I am far more comfortable with: taking otherwise useful information and twisting it into utter nonsense.  Yes, it’s time to journey back to the wonderful world of the physical exam. My ongoing mission is to explore the human body from my unique (albeit moderately unstable) perspective. For an overview of my previous posts on the physical exam see this post which features Dick Chaney on a Segway (reason enough to click on the link).  Please visit a psychiatry blog to aid in recovery once you have done so.

My most recent post in this fine series covered the topic of psychics and about the examination of the hand.  It was mainly about psychics examining the hand, but I did slip in a little doctor stuff to keep the cops off of me.  But then I got a call from the department of homeland security and they said that if I didn’t shape up, I’d no longer be able to use the picture of Dick Cheney on the Segway.  It’s hard to resist such harsh tactics.

Today I’ll take the high road.  The really high road.

You see, the hand is not only celebrated by doctors on blogs, it is also a subject of divine consequence.  The above picture is, of course, a representation of the most famous utterance of the words: “pull my finger.”

OK, I guess I can’t stay on the high road for long.  I don’t think many of you would read this blog in the first place if I did.

Now that we’ve gotten that out of the way, let’s get back to the subject at hand (har, har): the physical exam.  As I said previously, the hand exam is done usually in response to complaints about the hand.  There are a few common hand problems I am able to diagnose through the physical exam.

The Snuff Box

As a medical student, you are taught a whole lot of information that you wonder if you will ever use.  Why, for example, did we have to use up valuable grey mater to learn about the Kreb’s cycle, that the spot where you most commonly hurt with appendicitis is called McBurney’s Point, that chickens have something called the Bursa of Fabricius (from which the B-Cell is named), and about the spot on the base of the thumb called the anatomical snuff box. Considering the amount of time spent on the anatomical snuff box, you would think it was a window to the soul or a portal to the demonic realm.  I was skeptical about its significance.  But my neurons were relieved to find out that the anatomical snuff box had significance (other than as a place powdered tobacco could be put before snorting it into the nose).

Photographic evidence of the usefulness of the snuff box by Dutch men in hats (credit).

So what exactly is the anatomical snuff box?  It’s a depression just above the wrist and right below the thumb that is formed by the space between two thumb tendons.

Technically it’s not a box, but the term anatomical snuff depression wouldn’t fly with anatomy profs (although I don’t think Dutch guys would mind).  The significance of the snuff box for me (I swear, I didn’t inhale) is that two conditions make the bones under it hurt.  (Note that the above picture uses the term “snuffbox” instead of “snuff box,” which shows which side of the healthcare debate it supports).

Scaphoid Fracture

The first is a fracture of the scaphoid bone.

In this illustration, the scaphoid bone is pink, and has the letter “A” on it.  Scientists are not certain of the significance of the big letters, but some have claimed this as evidence of an intelligent creator.  Opponents of this theory point out that the giant number “3″ is actually pointing at 5 bones, which makes the intelligence of this so-called creator suspect.  The debate rages on.

The scaphoid bone can be fractured when a person falls on an outstretched hand.  I broke mine when I was running backwards and was tripped by some microorganisms who jumped up and grabbed my ankles.  I swear that’s how it happened.  Normal wrist x-rays can miss a scaphoid fracture, but the astute clinician suspects it when the patient jumps, screams in pain, and threatens a curse on the doctor’s descendants when the doctor presses on the anatomical snuff box.

Day-Something Teno-Something

The second condition involving the anatomical snuff box is called De Quervain’s Tenosinovitis.  This condition was first described by a Swiss doctor who was unfortunate enough to be named Fritz De Quervain, a name that has baffled doctors and patients ever since Fritz did his discovering.  How do you pronounce the dang name?  Is it “Dee-Kwer-Vain,” as it appears, is it “Duh-Kare-Vahs,” as the Mayo Clinic suggests, or is it “Deh-Ker-Vehs,” as Miriam Webster suggests?  I suggest it be pronounced “Dang-my-thumb-hurts,” but this pronunciation hasn’t gained widespread acceptance.

The basic problem happens when the tendons (tough fibrous tissue that connects muscle to bone, allowing the muscle to move the bone from a remote location) that straighten out the thumb become inflamed due to repetitive use of said thumb.

Fritz noticed the orange irregular outline, and decided to investigate.  The rest is history. (Credit)

On exam, the person hurts at or near our old pal, the anatomical snuff box, when it is pressed while the person moves the thumb across the palm.  This condition is treated by cortisone injection and a period of torture by a physical therapist.

There is another way to diagnose this condition – a maneuver called the “Finkelstein Test.”  The test is named after De Quervain’s arch rival, the evil Baron Von Finkelstein.  This test is performed by making a fist with the thumb tucked under the other fingers and the wrist is flexed toward the pinkie.

From Mayoclinic.com

When this procedure is performed, two things happen: the wrist hurts in the region of the snuff box, and it glows an eerie red.  There are three reasons I don’t perform this test:

1. Neither the patients nor me want anything to do with the evil Baron Von Finkelstein.
2. The eerie red light freaks people out.
3. The patient is simultaneously in pain and making a fist – a situation most doctors try to avoid.

Well now I have burdened your neurons with more information about the anatomical snuff box than you could ever wish to know.  But there is one more thing I would like to mention about this critical part of the body.

These amazing pictures from the wonderful world of reflexology show that the snuff box is really a mirror to the top of the right leg.  Now that’s information you’d never get on Kevin, MD!  I’d better keep quiet about that, however, because he may just flip me the spleen.

It’s been a very long time since I did an Ask Dr. Rob post.  It’s also been a long time since I shot a spitball out of a straw and hit someone behind the ear during social studies class.  I realize that just because it’s been a long time since I’ve done something, it doesn’t mean the world is better off with me doing it again.

Credit

Still, there have been some interesting questions that have come up and I think it’s time they should be answered.  They are both along the same line:

Question 1: What is the difference between health care and healthcare? I see that you contribute to the Health Care Blog, but you write about healthcare all of the time.  What’s the deal?

Question 2: What is the difference between EMR and EHR?  It seems that some people feel that it is vile and uncouth to call it “EMR”, only accepting people who call it “EHR” into their secret societies of people who are smarter than everyone else.  What’s the deal?

To Space or notto Space

These two questions focus on a very important issue in our society: the place of grammatical elitism in modern society.  You see, the folks who write “health care” are very suspicious of those who write “healthcare,” as they feel that they wantonly leave out spaces betweenwords and endanger the very fabric of the spacetime continuum by doingso.  The “healthcare” camp, on the other hand, thinks that the “health care” crew is just dealing with pent-up frustration from being pottytrained (potty trained) too late and becoming the laughingstock (laughing stock) of the daycare (day care) center.

Back and forth the sides go, the one saying that the misuse of spaces between (be tween) words will open up a wormhole (worm hole) in the Internet (inter net) causing Twitter messages to be reduced to 30 characters (soyouwouldhavetoleaveoutspaces), and for every common expression to be reduced to abbreviations like LOL, ROFL, and ROTC.  Doing so would kill all human life, leaving only cats to LOL away their days in blissful laughter.  But there would be nobody there to laugh.

This makes them very FATFOH (fearful about the fate of humanity).

The “healthcare” crew takes exception to this portrayal of their space usage as being the same malignant disease that created BFF’s, the CIA, and LSD.  They cite the frequent shortening of words in the medical field as their precedent for the omission of the space, such as PMR (polymyalgia rheumatica), “A Fib” for atrial fibrillation, and the original LOL (Little Old Lady).  They also argue the importance of conservation in these days of global warming (GW), oil spills (BP), and Dancing With the Stars (DWTS).  All of these are portents of darker days ahead, and so we should be conserving all of the space on the Internet possible to deal with these terrible threats.  Clearly the medical field needs to lead the battle against this, not a bunch of cats getting sucked into vacuum cleaners.

Who is right in this battle?  I have put myself into the “healthcare” camp, but with reservations.  I do wonder about worm holes eating up the inter net.  I do fear the final domination of the world by cats getting sucked into vacuum cleaners and the disappearance of my BFF’s.  But being proactive I comedown on the sideof the ones who wantto take action.  I don’t think weshould just sitthere and donithing except argue about the useofspaces.

ThatswhereIstand.

Evolution of Electronic Records

So what about the whole EMR/EHR debate?

You can see that these folks are in the “healthcare” camp, with the use of the abbreviation.  But within the camp of those who would shorten things there has formed a rift that may bring down any constructive work the leavingout of spaces accomplishes.  Unlike the “health care” vs “healthcare” debate, the fighting hasn’t spilled out to violence on the streets, but it has caused some nominees for CMS to get OTD PDQ before they ended up MIA.

As many of you know, the term “EMR” stands for “Electronic Medical Record,” while “EHR” stands for “Electronic Health Record.”  The difference is not in the E or the R, it is in what lies between.

The original computerized records were called “CPR,” which stands for “Computerized Patient Record.”  This was all fine and good, and there was little dissent among the three doctors who used it at that time.  But an astute medical student noted that CPR also stands for “Cardiopulmonary Resuscitation,” as well as for “Colorado Public Radio.”  The confusion over these abbreviation caused dying patients to have “All Things Considered” given STAT, caused Ira Glass to be stalked by people wearing scrubs, and caused doctors to pause for 30 minutes of every hour to beg patients for money.

So with the urging of the patients not wanting to buy a copy of the musical “CATS” for $50, the families of resuscitated patients lamenting the now liberal bent of their saved loved-ones, and Ira Glass doing a “This American Life” episode on the fact that he was alive and his heart was beating just fine, the convention of “EMR” was adopted.

All things were quiet in the world of EMR, and, despite the fact that EMR also stands for “Emotionally Mentally Retarded,” “Electromagnetic Radiation,” and “Enormously Magnificent Radishes,” the adoption rate skyrocketed to a whopping 20 doctors.

The Power of Oprah

But this all changed with the advent of the PC movement, which originated in the bastion of evil liberals, Madison, Wisconsin.  By “PC,” I am not referring to the “Personal Computer,” which originated in the bastion of blue screens of death, Redmond, Washington.  I am also not referring to “Processed Cheese,” which was an attempt by the AARP to slow down “all of those young whipper-snappers” by making all children severely constipated.

I am referring to the “Politically Correct” movement that exists with a single purpose in mind: to make us feel guilty for calling anyone by their race, sex, physical defect, or occupation.  They made it impossible to classify people at all, instead preferring that everyone be called sexually non-specific names, such as “Pat,” “Jean,” “Taylor,” and “Hillary.”  The inevitable infiltration by this movement into the medical field occurred after the failure of the Clinton Health Reform bill (hardly a coincidence).  Their damage includes:

• The use of the word “provider” instead of “doctor.”
• The use of the word “inadequacy” instead of “disease.”
• The use of the phrase “conspiracy to poison us all” instead of the word “medication.”
• The use of the phrase, “the one who really runs the show” instead of the word “nurse.”

They also felt that the word “medicine” might cause people to believe that the pharmaceutical industry actually did something good, rather than their known practice of stealing money out of our pockets while they poison us.  They convened a summit, which included such luminaries as Oprah Winfrey, Donald Trump, and Sanjay Gupta, ending with the substitution of the word “medicine” with the word “health.”  Oprah suggested that use of the word “health” would result in people having a more positive attitude and perhaps encourage them to get a makeover (make over).  Trump and Gupta were just bent on world domination (unlike Oprah, who is just so darn nice).

Feeling the pressure, the Health Information Management Systems Society (HIMSS) suggested changing the abbreviation of EMR to EHR.  They did this because their abbreviation clearly was shaky from a PC standpoint.  They had already changed their letterhead (letter head) from MIMSS to HIMSS, and didn’t want to cave to the pressure from Oprah once more.  So now the battle rages among those who feel it’s OK for the pharmaceutical industry to poison us all while taking our money, and those who think we should listen to Dr. Oz and take better gosh-darn care of ourselves.

Where do I stand on this issue?  I was trained to call it EMR, but feel guilty at times and call it EHR.  The problem is that when I type EHR on any Microsoft product, it changes it automatically to HER, which makes me wonder if Oprah has more influence than I ever knew.

Final Questions

Before closing, there are a couple of questions I want answered:

1. Why do Emergency Physicians insist on calling their workplace (work place) an ED, instead of an ER.  Is this pressure from the pharmaceutical industry to increase the use of Viagra in an emergency setting?
2. Why is PMS being changed to PMDD?  Clearly there is an additional letter in that abbreviation, so it is not in the wordshortening camp.  Is it because PMS can be confused with the phrase “Pass My Shotgun?”

Thanks for reading thisedition of ADR on MOADM.

Back to the subject at hand.

To those who are relatively new to this blog, one of the most popular…uh…tolerated series of posts has been my series on the physical exam.  If you haven’t done so already, you may want to go back and read the posts to get in the proper mindset (or destroy enough brain cells).

Astute readers will note that doctors are not the only professionals to examine the hand.

Long before we knew anything about carpal tunnel syndrome or the thenar eminence, we had Madam Linda and her cohorts looking at the hand for signs of what the future will bring for the individual that happens to be connected to the hand in question.  Just as stars and planets can have a peculiar interest as to whether a person will run into money, the lines on a person’s hand can foreshadow a person’s future.

I took an interest into why this would be the case.  What would it be that could make the creases in a person’s hand have such predictive powers?  The classic palm-reading guide looks like this:

So, having the scientific curiosity I have, I wondered about my hand:

Looking at my own hand, I noticed the following:

1. My hand is at a 90 degree angle when compared to the typical hand.  I don’t know if this has an influence on my future; perhaps it means that I will fall over a lot or get lots of sleep.  I couldn’t determine that from my research.
2. The lines on my hand are lavender instead of red.  From my research, this seems to indicate that, while I do like spicy foods, “atomic” chicken wings are not in my future.  It also means that I should watch out for garden tools and hamsters, as they may cause me significant harm.
3. I have a very long “fame” line, but my “head” line is not very long.  So, I suspect that while the rest of my body becomes famous, my head will be left out from the acclaim.
4. My “marriage” lines are shorter than my “travel” lines.  This means that I don’t go on enough trips with my wife.  She agrees with this assessment and now is a believer in palm reading (although I am not sure why she had all those lavender markers).

Some sources suggest an alternative guide to palm-reading:

The best evidence for this interpretation is the fact that Steve Jobs has a very big line 7.  I disagree with this interpretation, as my lines 1 and 6 are quite long and I…uh….

So what about the other professionals who examine the hand…you know, doctors?  Well, we docs have our own mad skilz when it comes to examining the hand.  Here is what the typical hand exam entails:

• Inspection of the muscles of the hand, as smaller (atrophied) muscles can indicate nerve damage.
• Inspection of the joints, as big bumps on them can signify certain types of arthritis.
• Checking the strength and movement of all of the joints.
• Doing special tests that look for certain conditions.

I’m going to ignore the 1st one, because it’s hard to explain briefly (it’s also hard to explain while only wearing briefs).  So let’s move on to the other parts of the exam (and let’s also get some clothes on, because it’s getting a little chilly in here).

Bumps

There are two problems that cause bumps on the joints of the fingers: osteoarthritis and rheumatoid arthritis.  Osteoarthritis causes harder bumps that happen on the two joints furthest down the finger (called PIP and DIP, for proximal interphalangial and distal interphalangial joints).  These bumps have names that are basically meaningless, but are asked a lot on tests in medical school:

I think that Bouchard and Heberden probably donated a lot to some doctor charity or threw some great parties, and so got part of the body named after them.  I don’t see any other reason medical students are forced to learn them.

Rheumatoid arthritis (which is a much nastier disease) causes swelling of the joints at the base of the fingers (called MCP joints, for metacarpal phalange joint) as well as sometimes the PIP joint.  The swelling happens in the capsule around the joint, so it is usually softer than osteoarthritis’ bony bumps.

“Affected synovium” is the doctor way of saying: “bump on joint that is squishy.”

Hand Movements

The movements of the hands are best appreciated with a flashlight shining on the side of a tent.  The patient is told to make the shape of a pterodactyl and scare the sissy kids in the tent.  If they do so successfully their hands are fine (and they get a lot of laughs).  Most exam rooms, however, don’t have tents in them (you see why our healthcare system is such a mess), so doctors instead have the person clench a fist and open their hands back up.  If the patient cannot bring the fingers to a clenched position, then the there is a problem with the muscles, joints, or tendons that help the hand close.  If they can’t straighten the finger(s), then the muscles, joints, and tendons that do that job are messed up.  If the patient clenches the fist and leaves it closed, it signifies that the person is angry about their bill.

The tendons in the hands are line marionette strings that pull the fingers into a fist (flexion) or to straighten them (extension).  The muscles that control the tendons are in the forearm, which is a good arrangement, as having the muscles in the hand would add too much bulk to the fingers and get in the way of their function.  Breaking one or more of these tendons causes several common deformities.  The first is the “mallet finger” deformity, where the tendon that straightens out the tip of the finger is broken.

Credit

These injuries are not usually serious, and are treated by splinting the finger for a few weeks.

The second deformity is called the  ”boutonniere deformity.”  It happens when the tendon extending the middle joint of the finger gets severed while the last joint extension tendon remains intact.

Credit

This most commonly happens when someone jams their finger, but my wife had it happen when she cut it in the kitchen with a Ginsu knife.  I am kidding, it wasn’t Ginsu.  If this finger deformity is a complete severing of the tendon, it can be surgically repaired.  If it is not a complete injury or if it is not seen fairly soon after it happens, it can be splinted with a fairly good outcome.

What?

Is that you, Madam Linda?

What are you trying to tell me from the great beyond?

Ah, the future will hold another post about the exam of the hand because this one is going too long.  Ah, I see.  Thank you, Madam Linda.

What?

My What?

It is not big!  I swear, I’ve been on a diet and it is much better!  I don’t care what that stupid line says.

So you wanted more “Ask Dr. Rob.”  Next you are going to be asking for a colonoscopy.

Well, I guess I can do it.  It has been a long time since I have done one of these.  I thought I was being merciful.  Whatever.

Here’s a question from a moderately fictional person named Mike:

Dr. Rob:

What’s the deal with physics?  I heard that you have to take physics class to get into medical school.  As a doctor, do you ever use physics?

Sincerely,

Moderately Fictional Mike.

Wow, what a coincidence!  That’s the question I would have chosen had I written it myself!  What’s the chance of that?

To answer your question: yes, I do use physics quite a bit.  It’s a good thing, because my dad is a physicist.  This is a physical world we live in, with irresistible forces impersonally shoving us around without getting permission.  My father never told me about this dark side of the forces.

Force #1: Gravity

The first example of these forces at work is the ingrown toenail.  Toenails ingrow for one reason: they can’t grow out.  Instead of sticking out the front of the toe like any self-respecting toenail would do, they grow into the toe.  Why do they do this?  What causes some toenails to grow in while the others behave respectably?

Gravity.

Ever since Sir Isaac Newton suffered a head injury, gravity was felt to be related to the mass of an object.  The bigger the object, the bigger the gravity.  But then came Albert Einstein, and the trouble began.  Einstein’s theory of general relativity put forth the idea that gravity wasn’t even a force, but instead a curvature of the spacetime continuum.  Wikipedia explains:

Einstein discovered the field equations of general relativity, which relate the presence of matter and the curvature of spacetime and are named after him. The Einstein field equations are a set of 10 simultaneous, non-linear, differential equations. The solutions of the field equations are the components of the metric tensor of spacetime. A metric tensor describes a geometry of spacetime. The geodesic paths for a spacetime are calculated from the metric tensor.

Confused?  Yeah, well so is everyone else including the toes. What started out with a simple equation in Newtonian Physics:

became 10 simultaneous, nonlinear, differential equations! Yuck!!

Despite his lifelong battle with fruit, Newton remained
a gentle soul.

To get back at Einstein, the toes decided to take advantage of these changes.  Using a loophole in this new law, they increased the local gravity in his big toes, pulling the nail down into the flesh part, giving Albert the first ingrown nail in recorded history.  In foot-wracking pain, Einstein tried to recant his theory, but the damage was done.  This is why the presence of an ingrown toenail, which is evidence of a hyper-gravitational podiatric state, is invariably accompanied by the following:

• People step on them – scientists have proven that a foot with an ingrown nail is 10 times more likely to be stepped on than those without.
• Heavy objects are kicked – careful analysis has shown that objects such as coffee tables, lamps, and even large appliances move into the path of a person with an ingrown nail.

Why do these things happen?  Gravity.  Thanks a lot, Albert!

Einstein, on the other hand, was left embittered by
his chronic foot pain

Force #2: Opposing Forces

Following his head injury, Sir Isaac Newton (yeah, him again) decided to take the law into his own hands.   The result of this was the creation of Newton’s Laws of Motion.  His design was to prevent future fruit-related head injuries, and he was largely successful (except for one unfortunate Kumquat encounter).

Kumquats can be dangerous

Newton clearly had a lot more sense than Einstein, and he kept his toenails happier as well.  Take it from me: always keep your toenails happy.  The three laws that Newton made were about moving objects, the most famous of which was the 2nd law, with the formula:

Translated: Force = Mass x Acceleration.  This is a great formula because it is so simple (as opposed to Einstein’s ten differential equations), but sadly, it doesn’t apply in the doctor’s office.  The third law (the law of reciprocal actions) however, applies very nicely:

Which translates: “any force that is applied to object 1 due to the action of object 2 is automatically accompanied by a force applied to object 2 due to the action of object 1.” (1)

The application in medicine is not in the clinical realm, but in the interaction between doctors and nurses.  Since both doctors and nurses are important cogs in the machine of medicine, they commonly have significant effects on each other.  Believe it or not, they don’t always agree.  I am sorry if I shattered anyone’s image of a blissful cooperation and camaraderie.  That is true most of the time (if by “most” you mean “almost never”).   The Law of Medical Opposing Forces goes like this:

Any force that is applied on a nurse by a doctor is automatically accompanied by an opposing force applied by the nurse on the doctor.

The best example goes something like this:

Nurse: Doctor, Mr. Tucker’s wife wants to talk to you about the side effects of all of the 29 medications you prescribed.  I told her you were on the floor, so she’s expecting you

Doctor: Fine, nurse, I’ll do that.  Let me first write these three orders for enemas and the order to discontinue the sedative for the screaming lady in room 244.

Nurse: That’s nice.  Did I tell you that the Mr. Wafter has a large abscess that started draining?  I left it alone after explaining to him that you are an expert at wounds like that.  His roommate had to be moved, though, because he couldn’t take the smell.

Doctor: Wonderful.  I forgot to mention that I can’t discharge Mr. Whiner or Mrs. Screamer today.  I just want to wait another day to make sure they are stable.

Nurse: I’ll be sure to have the night shift nurses call you hourly through the night to give you updates.

These two children are in training.
This picture was taken before the hand-to-hand combat

This is a very important law to understand, especially for doctors in their residency.  Most residents assume that they are in charge since they have those letters after their name, but what they don’t realize is that they are weak forces.  Nearly all forces exerted by a resident on a nurse are met with much stronger opposing forces.

There are other opposing forces in healthcare, including surgical vs medical doctors, doctors and nurses vs hospital administrators, members of congress vs. people who don’t get money from drug companies, and insurance companies against anyone trying to get money from them.  Anyone dealing with healthcare needs to understand this very important law of physics.

Conclusion

I am just scratching the surface (which, of course, involves the force of friction), but the spacetime continuum is putting force on me.  But the bottom line (x-axis) is that physics is at the center of the medical universe.

Here’s to you, Dad.  May the force be with you.

Top 10 lists are back!

I forgot about this kind of post, and a reminder by a reader is bringing them back.  They are really a fun and easy kind of post to write, so you may see a fair number of them (read: Rob is getting lazy).  I thought I’d start back with some suggestions for disgruntled patients (or grutled ones, for that matter) to make their doctor’s day much worse.

1.  Require the doctor to keep things secret from your child or your elderly parent. Insist that they can’t know about their cancer, depression, ADD, or foot fungus.  Call the medication the doctor prescribes “vitamins.”  Alternatively, you can threaten your child by saying that if they don’t behave better, the doctor will give them a shot.

2.  Disguise the real reason for your visit with something simple. For example, if you have depression or chest pain, set up an appointment for a sore throat.  Make sure you leave all of the office staff in the dark as long as possible.  It’s a bonus if you end the office visit asking them to check your hemorrhoids or help with a certain discharge you have been having.

3.  Call your children nicknames that have nothing to do with their real names. Let’s say you have a son named “James Wadkins Smith”; you should call them “Trent” or “Flippy.”  A daughter named “Anna Rose Jones” can go by “Jenny” or “Eva Marie.”  You get extra points if you change what you call them every few months.

4.  Smoke a pack of cigarettes or several cigars just before going to the doctor’s office. Then when you are asked if you smoke, say you don’t.

5.  Ask for doctor’s notes for anything. If your car doesn’t start and you miss work, call to get a doctor’s note.  If you don’t like fluorescent lighting and want incandescent lights at work/school, ask your doctor to write a letter stating that this is a medical necessity.  Asking for a few days off of work because of “stress” is sure to have the desired effect.

6.  If you are an employer or school district, make your employees or students get documentation for every single sick day. Make the docs fill out FMLA paperwork for sinus infections, and disability forms if it lasts more than 2 days.  School districts should require a detailed asthma management plan on all patients with asthma.

7.  Call frequently stating that you have a personal issue you need to discuss with the doctor, refusing to talk to anyone else. It’s best to call the office acting like you know the doctor well, referring to them by their first name.  When you do get the doctor on the phone, start talking about your anxiety, depression, or bowel problems.

8. Send your teenage son or elderly parent with dementia to the office alone. Make sure you don’t leave any contact numbers and don’t tell the boy what you are sending him to the doctor for.

9. Invite friends and family. Having as many people in the examination room as possible is the goal.  Having young children with ADHD is the ideal.  Think clowns in a Volkswagen.

10. Bring your spouse or child to the office so the doctor will convince them that you are right. Open hostile arguments are important for the doctor to see just how wrong they are.  Make it clear to your family member that the doctor is against them.

PLACE OF OCCURRENCE, HOME ICD-E849.0

6:00 AM

Alarm goes off.  Hit snooze button. CIRCADIAN RHYTHM SLEEP D/O IRREG SLEEPWAKE TYPE ICD-327.33

6:30

• Alarm goes off for third time.  Ready to hit snooze button, but knee in ribs from wife prevents more snooze button procrastination.  CONTUSION OF CHEST WALL ICD-922.1, ADULT MALTREATMENT UNSPECIFIED NEC ICD-995.8
• Feeling tired, go to make a pot of coffee. CAFFEINE ADDICTION ICD-304.40
• Fill bowl with Lucky Charms and start eating. UNSPECIFIED NUTRITIONAL DEFICIENCY ICD-269.9, HYPERGLYCEMIA ICD-790.29

6:45

• Realize that coffee pot needs to be turned on for it to make coffee. ATTENTION DEFICIT DISORDER, ADULT ICD-314.00, LISTLESSNESS ICD-780.79
• Turn coffee pot on and wander to check email, blog, Twitter, Facebook, etc. OBSESSION ICD-300.3
• Daughter wanders in with dazed expression and blanket draping shoulders.  STUPOR ICD-780.09
• Speaks only in soft, irritated grunts. SELECTIVE MUTISM ICD-313.23, E/M 99212 ENCOUNTER, ESTABLISHED, BRIEF

7:00

• Bring cup of coffee to wife in bed.  She moans when she looks at the clock.  Another morning headache.  E/M 99215, ENCOUNTER, ESTABLISHED, HIGH COMPLEXITY; OTHER COMPLICATED HEADACHE SYNDROME ICD-339.44, OTHER SPEC MENOPAUSAL&POSTMENOPAUSAL DISORDER ICD-627.8
• Wake up other children who return evil glares for gentle nudging.  CHILD EMOTIONAL/PSYCHOLOGICAL ABUSE ICD-995.51; E/M 99214, ENCOUNTER, ESTABLISHED, MODERATE COMPLEXITY
• Walk to shower and get frustrated at towels not hung up. ANGER ICD-312.00

7:25

• Shower, shave, and get dressed.  LACERATION, FACE ICD-873.40
• Walk downstairs to find kids sulking and wife frustrated.  UNDERSOCIALIZED CONDUCT D/O UNAGRESSIVE UNSPEC ICD-312.10
• Try to give her advice.  COUNSELING FOR PARENT-CHILD PROBLEM UNSPECIFIED ICD-V61.20
• Wife glowers.  MARITAL&PARTNER PROBLEMS UNSPECIFIED ICD-V61.10
• Say: “We have to leave in five minutes!” in an angry voice.  PROBLEMS WITH COMMUNICATION ICD-V40.1
• Children glower. FAMILY DISRUPTION D/T PARENT-CHILD ESTRANGEMENT ICD-V61.04
• Wife sighs and chides for the tone of voice.  COUNSELING FOR PARENT-BIOLOGICAL CHILD PROBLEM V61.23; E/M 99215, ENCOUNTER, ESTABLISHED, HIGH COMPLEXITY

PLACE OF OCCURRENCE STREET AND HIGHWAY ICD-E849.5

7:40

• Finally in car with daughter, driving to school.  CRITICAL CARE INTERFACILITY TRANSPORT EA 30 MIN CPT-99467
• Daughter still not talking more than mumbles.  OBSERVATION CHILDHOOD/ADOLES ANTISOCIAL BEHAVIOR ICD-V71.02
• Turn on iPod and play music daughter doesn’t like.  PASSIVE-AGGRESSIVE PERSONALITY DISORDER ICD-301.84

7:55

• Daughter dropped off, running frantically to not be tardy.  Angry that “we are always late.”  UNSPEC EMOTIONAL DISTURBANCE CHLD/ADOLESCENCE ICD-319.3
• Don’t attempt to explain that it is seldom the chauffeur’s fault.  HEARTBURN ICD-787.1
• Nod and smile.  FEAR OF WOMEN ICD-300.29
• Drive to work.  AGGRESSION ICD-312.00

OTHER SPECIFIED PLACE OF OCCURRENCE ICD-E849.8

8:15

• Arrive at work, greeted by a long list of unsigned charts that materialized mysteriously overnight.  DEPRESSION, SITUATIONAL, ICD-300.4
• Go to kitchen and pour another cup of coffee – mega jumbo size.  CAFFEINE EXCESS ICD-305.90
• First patient status is “arrived” even though appointment is for 8:45.  Sigh loudly.  AVOIDANT PERSONALITY DISORDER ICD-301.82
• Check email, blog hits.  DEPENDENCE ON OTHER ENABLING MACHINE ICD-V46.8

8:45-12:00

• See patients, answer phone messages, assess lab and x-ray results, and periodically check email, blog, etc. ADVERSE EFFECTS OF WORK ENVIRONMENT ICD-V62.1,
• Talk with drug reps who explain advantages of drugs which have been out for many years. AMNESIA, PSYCHOGENIC ICD-300.12; E/M 99213 ENCOUNTER, ESTABLISHED, LOW COMPLEXITY
• Get another mega jumbo cup of coffee. PREMATURE ATRIAL CONTRACTIONS ICD-427.61;  POISONING BY CAFFEINE ICD-969.71; EROSIVE GASTRITIS ICD-535.40

Note: This is a caricature, not my real life.  My wife and kids are generally very nice to me and I do like my work.

You may have noticed that there is a lot of interest in two issues these days: the woes of the healthcare system and the economy.  We in the south have especially felt the sting of this with the aggressive anti-smoking tactics taken by the government.

After being sent the following picture from an astute reader, I realized we may have a solution to both problems:

The use of enemas has dwindled in the mainstream of medicine, and I think it is high time we looked again at the practice.  I did some more research into tobacco enemas and found the following uses:

• Resuscitation of drowning victims.  I am not sure how it worked in this capacity – perhaps if you squeeze the bellows really hard.
• It can serve as a means of artificial respiration.  No more having to put your mouth on the nasty lips of a person in respiratory failure; just insert the bellows, light the tobacco, and presto!
• Treatment of constipation.  Even if it stays in there, it may smell better.
• Treatment of cholera.  In this case, the risk to the one administering the enema is substantial.
• Treatment of convulsions.  Not sure how you could hit your target, though.

Wow!  You can do all that, and you can save the tobacco industry all in one magic puff on the bellows!  Are you listening, Mr. Obama??

Then I started thinking about industries that could be saved through the increased use of enemas.  Well, luck would have it that I happened on to the incredible website, Natural Cure through Enema.  The author lists the following types of enemas:

• Coffee Enemas – Make sure you use regular coffee instead of instant.  It detoxifies the liver.  I hate it when my liver gets toxic!  I suppose if you have a problem with bad-smelling flatus, you can use hazelnut coffee.  Your friends will be thrilled.
• Lemon Juice Enemas – Just gets the poop out, but makes it smell lemony fresh.
• Yogurt Enemas – helps replace the harmful bacteria and replaces it with good bacteria, and can prevent cancer.  No more yucky and expensive colonoscopy.  It also can give a wide range of flatus smells, ranging from strawberry banana, to coconut cream pie.  You’ll be the hit of the party and make Jamie Lee Curtis happy while you are at it!
• Garlic Epsom Salt Enemas – For those out there who don’t want to smell fruity, this enema gives people two reasons to avoid you.  You can’t blame it on your dog, but you can blame it on Tony Panini in the cubicle next to you.
• Milk Enemas – I can just picture a whole new set of “Got Milk” ads!

I also found mentions of:

• Cold Enemas – Can help treat fever as well as ulcerative colitis.  This doesn’t support an industry, but it may be fun to pick up as a hobby.
• Herbal Enemas – I found one product called Colonix that boasted 40 different herbs.  This made me wonder if anyone had tried a KFC enema.  I couldn’t find any references, but I sure would like to support the Colonel.
• Bentonite – Another product called the Almighty Cleanse boasted the presence of bentonite.  I wondered if this would perhaps be a bad idea if you were a super hero, but they didn’t mention anything about it negating super powers.  With a name like Almighty Cleanse, it would tend to attract the superhero type.

So look at all the good you can do the economy while making sure your liver doesn’t have any of those pesky toxins!  I think it’s a way to pass out of this economic hole we are in.  We can purge our economy of all the toxic fear and unemployment.  Let’s start a new movement.

So listen up, all you who criticize the alternate medicine purveyors!  They are doing more for the economy than we are and they have way less liver toxins to boot!  We should be ashamed.

Heck, I even saw that Dr. Oz has his own enema system.  That should make Oprah happy; and you know how important that is to me.

——–

Readers please note that this is entirely “tongue in cheek.”  Bad choice of words.  I DO NOT recommend any of these enemas.

Today has been dull.

At one point I started Googling various words looking for stuff to blog about.  I struck gold.

A search for the word “llama” led me to the following webpage: Captured Bat and a Llama on the Lam.  I was intrigued.  How could I resist this kind of website?  What I found when I clicked on the link was not only madcap tales of llamas and bats; it was a window into the lives of perhaps the most bored law enforcement officers and newspaper reporters on this blue planet.

I had stumbled upon the Flathead Beacon. What, you ask, is the Flathead Beacon?  Let their own words answer this question:

OUR MISSION
To publish a multimedia-driven and truly independent news source; a medium where everyone who wants a voice, has one. To approach journalism armed with curiosity and even hands, reflecting the values ingrained in Western Montana.

The Flathead Beacon is devoted to delivering thought-provoking news and commentary to the greater Flathead Valley. Printed every week in tabloid form and updated daily at flatheadbeacon.com, the Beacon encourages its readers to participate in discussions about their valley. 

The Beacon is a news source, in the traditional sense. Yet our seasoned journalists are asked to turn the prism when a story breaks, look at another angle and write stories that provide answers instead of pose questions.

Where, you ask, is the Flathead Valley?   It’s actually probably quite beautiful – as it is right on the edge of Glacier National Park in Montana.

Its biggest city is the sprawling megalopolis of Kalispell.

And has been the home of TV personality Maurie Povich.

But nothing compares to the incredible tales woven by the Flathead Beacon (funded, incidentally, by Mr. Povich), especially the section called “Police Blotter.” This is where the lives of bats, llamas, and drunks unwinds into a sordid tale of woe; held at bay only by the untiring efforts of the Flathead Valley Sheriff’s office.

Here is what I uncovered:

Thursday 7/16

6:33 a.m. On Riverside Drive, a tree fell on top of some important wires and blew an electrical transformer.

6:57 a.m. A husband and wife duo argued loudly in Bigfork. The male party was gone when authorities arrived.

7:43 a.m. Three horses ran amok on Middle Trap Road. One was brown, another white with dark spots and the other dark-colored.

8:16 a.m. Someone decided to drive on the lawn at a local private school. This detracted from the lawn’s aesthetic appearance.

Oh, the tales of woe!  I am heartbroken by the assault on the aesthetics of the lawn.  And that is only the beginning!  On that very same day the following incidents occurred:

12:45 p.m. On Highway 2, someone spotted a big brown llama eluding captivity. The creature was gone when authorities arrived.

4:13 p.m. An individual seen near Hungry Horse Reservoir may have had mental health issues. Forest Service officials were notified.

4:24 p.m. Several horses and mules looked particularly thin on Highway 2. They were in actuality normal-sized.

Whoa.  This llama, described as being “big” and “brown,” seems to be a suspicious character.  I wonder if he will show up later.  I wonder why they don’t talk about whether it is “particularly thin.”

Then I asked myself: “What about the Bat?”  It didn’t take long to find out:

5:15 p.m. A young child captured a bat at an education center on North Fork Road. The family was advised to bring the bat in for disease testing. 

5:17 p.m. A dog on South Cedar Drive got out of its fence, inspiring a neighbor to shoot it with a pellet gun. 

6:54 p.m. At a local grocery store, someone recognized a dog in an unfamiliar car as their own. The dog was returned and all was well.

7:08 p.m. Numerous bicyclists occupied both lanes of the North Fork Road. This behavior perturbed passing motorists.

I want to emphasize that this all happened on the very same day! Children capture bats, people are inspired by dogs to use pellet guns, other dogs get in unfamiliar cars, and motorists are perturbed!  It’s non-stop action!  I couldn’t wait for more!  My suspicion is that the llama was the one who moved the dog to the other car.

11:49 p.m. A daughter and her parents argued in Martin City. The issue was resolved and all parties went to bed.

2:33 a.m. A gentleman hanging around a local eatery claims that he is with the FBI. He is in reality not with the FBI.

I can now see why Mr. Povich doesn’t live in this den of iniquity.  A daughter agued with her parents??  A man pretends to be from the FBI??  I was struck with the non-stop pace of the day (as well as the poetic writing of the journalist), and wondered if this was a typical day in the Flathead Valley.

Here’s what the next day brought:

10:40 a.m. A resident of Plentywood Drive discovered that an empty trailer down the road contained a gaggle of transients. The individuals were asked to move along.

11:12 a.m. Someone removed a table and chair from a Bigfork restaurant. 

11:26 a.m. A 16-year-old girl had no interest in returning to her Columbia Falls home. She was found and counseled.

12:27 p.m. Someone on Kokanee Bend claims that a neighbor’s horse is standing in a pasture with no access to shade. Authorities responded and found that the horse did indeed have shade available but had chosen to stand in the sun.

1:02 p.m. A young boy was spotted crouching in a field along Reserve Drive, holding what appeared to be a rifle and pointing it at passing cars. The reporting party then called again to mention that the boy was holding a “duck call.” It was later found that he was merely shooting gophers with a BB gun.

1:33 p.m. While it appeared that a pit bull on Killdeer Lane had no access to shade or water, the creature did indeed have water and liked to lie in the sun.

2:30 p.m. Dogs on Mountain View Lane were lying in the sun. Authorities gave the owner suggestions for keeping them in the shade.

It seems that someone has a thing about animals standing in the shade.  I suspect the llama stole the table and chair from the Bigfork restaurant, but the police haven’t yet seen it from this angle.  I think the police were finding a shady spot to stand in.

The second day of drama concludes:

6:23 p.m. A handful of youths on Bootjack Lake were burning a recreational fire and perhaps shooting into the air. The party-goers were doing nothing illegal but simply having a good time.

6:38 p.m. Two young kids looked like they might attempt to cross Main Street near a local shopping mall. The two were holding hands.

7:29 p.m. A 38-year-old male driver hit a cow on Lost Prairie Road. His teeth were knocked out on impact.

8:01 p.m. A 20-year-old male fell out of his boat on Echo Lake.

9:02 p.m. Someone created speed bumps on Blackhawk Lane in Evergreen. This irritates several drivers in the area.

9:56 p.m. Someone was bitten on the nose by a spider at a Hungry Horse bar. He became very ill and began to shake.

So there you go.  I this excitement doesn’t make it hard to sleep.  This is just the tip of the iceberg!  There are other tales of llamas, drunk people arguing, mailboxes being uprooted, and of animals who are felt to be thin, but are actually normal in size.

I am pinching myself.

Yes, it’s time for another installment of my series on the physical exam.  The goals of this series are:

1. To educate my readers on the intricacies of the physical exam.
2. To teach the anatomy and physiology as it relates to different parts of the human body.
3. To delight my readers with my wit and fine prose.
4. World peace.

So you see, through my hard work and persistence (writing almost 30,000 words about the physical exam so far), I have come nowhere near any of these goals.  In fact, I have made absolutely no progress toward world peace.  I think I’ve been banned in Iran for using the word “Shuttlecraft” too many times.

Maybe I just need some new goals.  How about these:

1. To irritate my high school English teachers.
2. To cause at least 200 people to waste time that they could have spent watching Oprah.
3. To make sure Canada stays north of us and does not sneak to Florida.
4. To put those pesky French people in their place.

Yes, I think those are much better goals.

Extremely Upper

Our journey over the human body has now led us to the long things that stick out of the top of your torso that have those grabby things on the ends.  We doctors call these things arms. There are some hoity-toity doctors who call them the upper extremities. These are the doctors you don’t want to invite to dinner, as they will probably tell you disgusting scientific facts about the food you are eating.  Consider yourself warned.

The exam of the arms is usually only referred to vaguely during routine exams.  Most docs don’t deal with the arms unless they pick up subtle clues that are discovered only by trained professionals, like when the patient says “I’m having problem with my arms”.  We doctors are proud of our mad skills.

What I am driving at is that the arm exam is a problem-oriented exam.  If you have a boo-boo, the doctor looks at it and sees if a kiss will make it better.  If a kiss doesn’t work, usually an anti-inflammatory will (but we’ll get to that later).  And boo-boos problems with the arm are usually specific to the longitude and latitude on the body.  So today we will discuss the shoulder.

The Shoulder

The shoulder is a joint – meaning, it is a place where your body bends.  Without joints, your arms would be unwieldy and you’d whack everyone who came near to you.  Not only that; it would also make it impossible to put on deodorant.  So between whacking people and offending them with your odor, a jointless existence would truly be a hard one.  We all should thank our joints more often.

There is not a more complex joint in your body than your shoulder.  Here are some amazing facts about the shoulder:

• There are three bones that are involved in different types of movement: the collarbone (clavicle), shoulder blade (scapula), and humerus (not humorous).
• There are at least 18 muscles that are involved in shoulder movement.  Two of them have the word “rhomboid” in them.  I like the word “rhomboid.”
• When people say the word “shoulder,” they may be referring to the joint, and they could be referring to the top part of their torso – between their neck and shoulder joints.  This is a sad testimony to the English language and just serves to make the jobs of medical professional all the harder.
• The word “shoulder” rhymes with a lot of of words and so is very useful in poetry.  For instance:

You shouldn’t have told her that she’s looking older
She wants you to hold her with arm on her shoulder
And go get the folder that llamas once sold her
But there on the boulder the weather is colder.
A fine Jell-O mould or perhaps something bolder
Has rocked her and rolled her but never controlled her
So anger may smolder at cellular slime mold or
Other thingies, sort of.

See?  Pretty amazing, isn’t it?  Try doing that with “elbow!”  Perhaps Dino could write a haiku about it.

So it should not be seen as a coincidence that the shoulder has by far the largest range of motion of any of the joints in the body.  This makes things very confusing for medical students when they have to describe the motion, as the joint doesn’t follow any of the rules the other joints have agreed upon.  Most joints can be bent (flexed) and straightened (extended).  Some joints (like the wrist) can be hyperextended and rotated as well.  All the other joints are content with these motions.  Is this good enough for the shoulder?  Not even close.

Here are the basic movements of the shoulder:

1.  Flexion – moving the arm forward toward the chest.

2.  Extension – moving the arm toward your back.

3.  Abduction – Being picked up by aliens and brought to their mother ship.  (This also refers to lifting your arms up from your sides).

4.  Adduction – Bringing your arms down back to your sides

5.  Rotation – Turning the arm around the axis of the humerus bone.

I have suggested a few more motions that may be added to the roster:

6.  Subflaxion – What you have to do to your shoulder to get your elbow in your ear.

7.  Soufflétion – When your shoulder is mixed with eggs and baked at 400 degrees.

8.  Mallardduction – When your shoulder gets down.

So far the shoulder committee hasn’t answered my mail.  I’m not sure why.

But really, the shoulder is very confusing to many medical professionals.  The range of motion is so great that it blurs the lines between the typical movements.  For instance, adduction is supposed to be when the limb is moved toward the body’s midline.  The shoulder makes this difficult.  When you put your arm by your side and when you raise it over your head, you move it toward midline.  Both could be considered adduction.  The same is true with flexion and extension – when is the shoulder joint opened up and when is it closed?

Really, in this modern time we should give up this archaic nomenclature and instead use a GPS device to determine shoulder position.

Wow.  1000 words already and I haven’t gotten to the actual exam.  I’ll give it a rest now and let you ruminate on words that rhyme with “elbow.”

I probably should sober up as well.