Wednesday, April 28, 2010

Double Crack

There are occasions, in the midst of examining a patient, when I am caught off guard by some meaningless observation or physical finding.

For example, I never would have guessed that an 80 year-old grandmother named Bertha would have a tramp stamp. But, a few weeks ago, there it was, a four-leaf clover tattooed right on the small of grandma's back. It distracted me from appreciating her diamond-studded nose-ring, I'll tell you. A few days later, I treated a very pretty college student who made me wince when she shook my introduction hand within her own man-hand. And, on the same shift, I treated a college guy who didn't have one hair on his entire body, thanks to an overactive Gillette razor. Not one. Heck, even the 50 year-old conservative business man surprised me with his bilateral nipple piercings (I am thinking "ouch" even as I type that). Impressive what a double-breasted suit can hide.

These physical findings rarely play any part in treating a patient or making a diagnosis. They are simply observations that happen to be noticed during the course of a thorough physical exam. Nothing judgemental. No prejudices. Just an aspect of a patient's physicality that jumps out at you when you aren't expecting it. To each their own, I say. Whatever makes you happy and isn't harming the next fellow human being.

I think anyone who does a patient exam can relate to these surprises, though. If nothing else, these findings keep me on my toes. If truth be told, I like these unexpected discoveries--these little secret gems that a patient would probably not commonly share with his fellow man. Seriously.

Picture it. "Um, yeah, Darryl," I imagine a patient confessing at a tavern, an empty pitcher of Guinness sitting between him and his good friend, "I need to tell you something. I have seven toes on my right foot. And, I have your wife's initials trimmed in my chest hairs." Yeah...I don't think so. Lucky me, though--I get to discover those initials when I auscultate this patient's heart.

The other day, I was privy to one of my more favorite observations. Like a rare bird, the sighting of one of these is few and far between. In fact, I can count on two hands how many times I've seen this characteristic in my career. It was very exciting.

I can just picture you now, sitting on the edge of your seat, saying to yourself, "What is it? What did he see?"

Okay. I'll spill. It was the famous (drum roll, please)... "double crack."

Walking into Room 31, I had no reason to suspect that I would, in a few short minutes, be giddy over seeing another double crack. It had been a few years, easy, since my last sighting. And, to be honest, this patient did not fit my usual perception as to who would possess the double crack.

I introduced myself to this patient. A very nice person who had been suffering with some dizzy spells and a chronic cough. Nothing major, but just enough of an annoyance that, after a few weeks, he wanted to be "checked out." After a satisfactory interview, we moved on to the physical exam. Vitals were reviewed. An HEENT exam was normal. Throat and neck, good. The heart, steady and strong with a regular rhythm and no murmurs appreciated.

And then...the spotting of the double crack.

After listening to the patient's heart, I had the patient, who was in a gown, sit up in his cot, leaning forward so that I could auscultate his lungs from a posterior approach.

I had my stethoscope in my ears, listening as I had the patient take several deep breaths in and out, when I casually glanced down along the patient's mid and lower back. And there it was, the double crack, staring back at me, waiting for me to discover it's existence.

To explain the double crack, I am taken back to the first time I had to explain to my giggling kids, at a local zoo, why the baboons' bottoms were bright red. You know that color--the inflamed, captivating shade of a deep, rich sunset. "It's just part of being a baboon," I told them. No other explanation, really, was needed. The baboons' bottoms were what they were. And, as I told my kids, I don't even know if the baboon knew his own bottom makes a bright-red firetruck look dull.

Note to self--don't forget to do a google search on the baboon's red ass.

But, just like the baboon's ass, it is very hard for me to take my eyes from the double crack. And to explain why it exists? I can't. It just does.

So, as I tracked along this patient's vertebrae with my eyes, I spotted his double crack in the lumbar region. Whether it was the way this patient's skin folded, or the way the patient sat, or the way his supporting muscles ran longitudinally along his spinal column, or just where his body decided to deposit some extra fat, I really couldn't tell you. But, when I had this patient sit up in his cot, the sides of his lower back tissue folded up to meet at the mid line, creating a perfect replica of an ass crack.

I kid you not.

Starting around the upper lumbar area, the deep fold ran the length of the lower back, ending just before the tailbone region. There, a gap of about two inches of regular anatomy existed, giving good pause between the impostor crack and the beginnings of the patient's real buttock's crack. Yep, the real crack poked out of this patient's droopy underwear, challenging the impostor crack to a face-off. I couldn't have picked the better crack. Deeply creased and pressed together, that impostor crack looked like the real thing. Perfection, almost.

Thus, the double crack.

I had the patient take a few extra breaths, relishing my sighting while I made sure the patient had good air movement within his lungs.

Like the baboon and his fiery red ass, I don't think this patient knew what he was in possession of. Maybe a good thing, really. I sure wasn't going to tell him.

Could I even bill for that diagnosis? Any coders out there? Acute double crackitis. Code 191.22.3?

I came home that night and looked at my lower back in the mirror. I sat down. I stood up. I rotated. I side-bended. Nope, no double crack on me. I even made my wife look, but she couldn't spot one, either. Darn it. I secretly wanted my own double crack.

"Sorry, Jim," she said, laughing, "you'll just have to suffer through life with one crack."

I guess I'll just have to make myself an appointment to get a tramp stamp.

As always, big thanks for reading (and in this case, tolerating my silly, indecent humor). The well ran dry from a busy weekend, so I took Monday off. Thanks for understanding. See you Friday...


coulrophobic agnostic said...

I had no idea such a thing ever existed. The things you learn in the medical field...

Gia's Spot said...

I bet I could have gone my whole life and not missed knowing this... now I will be forever vig1lant in my search on beaches and bar stools for that elusive double crack! Thanks Doc!! ((Gia smiles))

Chrysalis Angel said...

You had me chuckling. For a minute there, I thought I was reading someone else. I was thinking...what the heck is he talking about! Too funny.

Empress Bee (of the High Sea) said...

doc could you please start taking photos for us? i mean we sit here and read and then have to conjure up our own images??? i mean really... ha ha ha

oh, and i had to google tramp stamp too. ewww.

smiles, bee

Katie said...

I'm really not sure how to respond to this. Maybe with a half-a-smile and a shake of the head.

Oh, and I'm only moderately offended by the fact that "pretty college students" can't have strong handshakes. I've been dragged halfway across church by shockingly strong elderly man enough times to know that wet fish just aren't going to cut it.

Have a great day!
<>< Katie

Stephany said...

This just reminds everyone to be ready for full disclosure if you ever land in the ER!

LOL, I bet everyone reading this has their hand running down their backs checking!

Pissed Off Patient said...

Well, it's good to have aspirations in life.

I knew someone whose goal was to have enough butt hair for a crack comb over. Not sure if he ever met his goal or not.


Heather said...

I think buttocks is 680.5! ;) Look it up. (

You're welcome...carbuncle and fruncle anyone?

911RN said...

YOU ARE NOOOOT RIGHT! I'm with Chrysalis Angel...I was thinking you had a ghost writer, "gone" on vacation, under an IVC or were just plain off your rocker and nobody knew(?). What is he talking about???

Have seen way more butts and backs than is even decent to talk about,
after 20+ years in nursing, but still not sure if I have ever seen a double crack or know what you are talking about? Maybe, I've seen one of what you describe?? Big, hairy, fat guy. YUCK!! I did NOT want to gander longer and make him take extra breaths. Rather, hurried to cover him back up!

Great writing:) I read, incredulously, at your twisted, off beat observations.

Careful, doc. Somebody may want to order a UDS after that post.Know there is a code for that;)

The well may have run dry on Monday but this one was a doozy...I'll be forewarned next time... expect extreme, comic relief after a day off. Think you took even the seasoned ER crowd, by surprise, on this one.

Thanks for the laughs!

Karen said...

I guess I'd need to see a picture because I can't for the life of me imagine this. On second thought, I'll just try to forget the whole thing. LOL

medrecgal said...

Wow, that's interesting...there isn't a specific ICD-9 code for this particular anomaly; it would probably be coded to something like 756.19 (other congenital anomaly of spine) or 757.8 (if it was merely a skin cleft, which would code to other anomalies of integument). You'd think with all the codes that exist out there it would have something specific, but you'd be surprised how many times we have to use something that says "NOS" or "NEC" or "other". The story made the wannabe physician in me wish I'd been there to actually see this anomaly. I'm still weird like that even though I never came close to medical school.

Anonymous said...

Good thing you weren't doing a rectal exam... oh geez.

ACZ said...

What, you couldn't sneak a picture with your cell phone of the double crack to share with us, your loyal readers?

When I first started reading this entry, I thought you might be heading to the A&P freak zone, but alas, it was an impostor!

Smalltown RN said...

Oh goodness doc....I think I would be in stiches. Like you I have seen my share of tats, piercings, scars and extra this and thats...and like you just when you think you have seen it all....along comes a surprise...of course the whole time you must maintain your professional manner all the while your insides are splitting and you just want to wave your colleagues in to share your discovery.

Ah yes....Have to tell you doc I have never seen a double crack...and I hope to never see one...

HalfCrazy said...

Hi there!

Wow, those things you've mentioned, they are surprising indeed, LOL! It is exciting indeed to discover something! Damn, when I become a Psychologist someday, every person who comes to me I will find interesting because I get to find out what's different about them.

I really can't picture the existence of double cracks on one's body. LOL!

Cathy said...

Well this takes the cake. LOL...I never heard of such a thing. God, I hope I don't have one. Going to go stand in front of mirror and check out my lower back.

t. said...

A tramp stamp, huh, Doc? Really... I'd say go for the nipple piercings: the pain is over a lot faster. Or, you could forgo the pain altogether and just shave all your body hair off...

Tanya said...

Wow-I'm truly impressed that you spotted a double crack-I want to see one, and I'm a bit disturbed by what that says about me...

AtYourCervix said...

You crack me up!

(Oh my, I think I just made a funny!)

kristi said...

LOL, my sister had a c-section where she was cut up and down. She has a butt in the front...LOL!

Anonymous said...

mwahahaha! I was wondering where you were going with that "double crack" innuendo. Now I know! The next time I see a case of double crackitis, I will think of you Doc.

what about those 80 yr old ladies with breast implants? blows my mind every time...

SeaSpray said...

This is another first for me!

Never heard if this double crack you speak of.

How will I sleep now? ;)

Thanks for the laugh.

SeaSpray said...

This is so weird. I know I left a comment about double crack last nite. I could've sworn I put it in here. ??

Anyway ..funny post and I never heard of it either. Still trying to picture ..or not picture it.

Confusing concept but a pic would be worth a thousand words. :)

Heather said...

holy crack, that's hilarious!!... and a little disconcerting, given how much time i spend in emerg with my son... good thing he's skinny, so no double crack on him... but now i'm self-conscious. thanks. LMAO