Shared ED

Two more Cases of Takotsubo Stress Cardiomyopathy

2010-12-21T00:02:00.001-08:00

Two more Cases of Takotsubo Stress Cardiomyopathy

Case 1.

This is the ECG of a 50 yo old woman who collapsed, was found to have a pulse, but then found to be in ventricular tachycardia. She was shocked into sinus rhythm. She presented to the ED comatose.
There is marked ST elevation especially in leads V3 to V6, as will as limb leads I and II, with no reciprocal ST depression. The cath lab was activated for STEMI, but the patient had clean coronaries. Before initiating therapeutic hypothermia, a head CT was done and showed fatal subarachnoid hemorrhage.
Case 2.

This 81 yo was found comatose.
.

There is ST elevation in V1-V3 with hyperacute T-waves and Q-waves in V2 and V3. This is highly suspicious for acute anterior STEMI. However, she was found to have a fatal pontine hemorrhage and had a maximum troponin I, at 12 hours after presentation, of 2.0 ng/ml. Echocardiogram showed an anteroapical wall motion abnormality. In this case, since no angiogram was done, it is not proven that she did not have a simultaneous anterior STEMI, but with a low maximum troponin and alternative explanation, it is highly unlikely.
.

These cases demonstrate that SCM can present with STEMI pseudoinfarction patterns.

Takostubo Stress Cardiomyopathy, with Echocardiogram

2010-12-21T00:01:00.000-08:00

Takostubo Stress Cardiomyopathy, with Echocardiogram

This case was posted on the www.hqmeded.com ultrasound site, of which this ECG blog is a part. However, only the first ECG was shown, and it was recorded before the patient became ill.

I refer you to the video case presentation by one of my colleagues, Dr. Rob Reardon (who has, by the way, a fantastic collection of ED ultrasound cases).
http://www.hqmeded.com/node/107

Briefly, this woman without significant cardiac history went into pulmonary edema with respiratory failure. Her ED echo is diagnostic of apical ballooning, also known as "stress cardiomyopathy" (SCM) or "takostubo cardiomyopathy" (because the heart, with its apical ballooning, resembles the Japanese octopus trap called a "takostubo"). The contraction at the base of the heart remains intact, while contraction of the distal or apex is very poor.

Here is the first ECG after the patient became ill.

There is sinus tach with some anterior ST elevation, however not an alarming amount.

Several hours later, she had this ECG recorded:Theere is anterior T-wave inversion and very long QTc (680 ms). These are classic SCM findings after the hyperacute phase.

This ECG was recorded the following day:

The QTc is even longer now, at > 700 ms. T-waves are bizarre.

The coronaries were clean, the troponin had a small bump, and the patient recovered. The apparent trigger was stress from losing custody of children.

SCM may happen from a wide variety of psychological or physiological stresses, including respiratory failure (although in this case a psychological stress led to poor myocardial function and then pulmonary edema, then respiratory failure) and intracranial bleeding.

In this case, the ECG never mimicked a STEMI. I will proceed to post a couple cases in which SCM does mimic STEMI.

Cardiac Arrest, widespread ST depression, but NOT due to ACS

2010-10-17T21:11:00.000-07:00

Cardiac Arrest, widespread ST depression, but NOT due to ACS

by Steve Smith

This young male had ventricular fibrillation during a triathlon. He was resuscitated with chest compressions and defibrillation and 1 mg of epinephrine. On his bib it stated that he had a congenital heart disorder. He arrived in the emergency department hemodynamically stable. His initial ECG is shown here.
There is widespread ST depression. However, note that wherever there is ST depression, it is associated with a very high voltage R-wave. There is profound LVH. Such widespread ST depression maybe secondary to LVH, or due to ischemia, or to both. When there is widespread ST depression do to acute coronary syndrome, it is usually due to three-vessel disease or left main disease. This would be highly unusual in a young athlete. Therefore, one must conclude that the ST depression is either do to LVH or to demand ischemia, or both.

A bedside echo performed by the emergency physician showed no wall motion abnormality and confirmed LVH. A repeat ECG shown.

Now, there is less ST depression. The troponin returned positive, and the maximum troponin was 3.8 ng/ml. Thus, the ST depression was at least in part due to ischemia. This confirms a "Type II" myocardial infarction; that is to say, it is not due to ACS but rather to demand ischemia.
The next day, and angiogram showed normal coronary arteries. An echocardiogram confirmed aortic stenosis with a large pressure gradient. The stress of the triathlon cause demand ischemia and ventricular fibrillation

BRUGADA SYNDROME

2010-10-17T20:48:00.001-07:00

Pseudoinfarction patterns: there are many and this is one: what is it?

by Steve Smith

This is courtesy of Mohammed S. Alo, who kindly let me reproduce a case from his blog (Mohammed Alo's blog).

This is a 40 year old male with chest pain. The cardiologist was called for management of a STEMI:

It is sinus rhythm, and there is slightly wide and abnormal appearing QRS, with an rSR' (though I don't think the duration is long enough to be RBBB, but that is a bit hard to read). There is significant ST elevation in V2 and some in V3. However, it just does not have the appearance of anterior STEMI. First, when assessing any ST-T abnormalities, one must determine if they are "primary" (due to pathology such as ischemia or hypokalemia, etc.) or "secondary" to an abnormal QRS. And here the QRS is abnormal. Then, think if it conforms to any known pathologic morphology. If you do, and you are aware of the 3 forms of Brugada syndrome, you will see that this is very similar to Type II Brugada.
Here are the 3 types:
Type I) ("Coved type") V1 has an incomplete RBBB, a wide R' wave, a downsloping ST segment, and in inverted T-wave, like this (I am sorry that due to a defect with the blogger software, this cannot be enlarged):
Types II and III) These have a saddle back ST-T wave, as in the case presented. The ST segment is at least 1 mm in Type II and less than 1 mm in Type III
There are also variants of early repolarization that can mimic Brugada. Here is one that mimics type III Brugada (again, sorry it cannot be enlarged):

Case conclusion: the man did indeed have Type II Brugada, not Anterior MI.

Risk Assessment: Minor Head Injury in Infants and Children in the Emergency Department

2010-10-04T21:42:00.000-07:00

http://www.thennt.com/minor-head-injury-in-infants-and-children

This is a best estimate, folks. We've presented what we think is the closest thing to the truth about this intervention, but our data is only as good as the studies that underlie it — and often, the studies aren't as complete or as good as we'd like, and in some cases the data have not been validated. We present one number here for the NNB, but please realize this is an estimate and there is a range for actual risk in a given person. That range will depend upon the person's demographic, their subtype of possible disease, the setting of the risk assessment, their general health, and literally thousands of other variables. Using these numbers in practice means taking a number of large leaps about all of these variables, and also about the veracity of the underlying research. Therefore, as with any 'high quality' data, the application of data requires a doctor's expertise and deliberate consideration.

disclaimer

In Summary, if you meet the below criteria for this assessment:

At initial examination:
- 99.1% will not require (or undergo) neurosurgery
- 0.9% will undergo neurosurgery*
After 4-6 hours have elapsed from the injury:
- 99.8% will not require (or undergo) neurosurgery
- 0.2% will undergo neurosurgery or deteriorate
*There were no fatalities in the cohorts reported for this group

In Other Words:

At initial examination, the risk of an injury requiring neurosurgery is 1 in 110
After 4-6 hours have elapsed from the injury, the risk of an injury requiring neurosurgery is 1 in 500

Criteria:

Head injury being seen in an emergency department, and GCS=14 or 15
Excluded: Ground level falls, and running or walking into a stationary object, where the only visible trauma includes abrasions or lacerations (but no hematoma) were considered 'trivial' and were therefore excluded

Where We Get The Numbers:

Source: 1) Kupperman N, et al. Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet 2009; 374: 1160–70

2) Reilly PL, et al. Patients with head injury who talk and die. Lancet, 1975; 306 (7931): 375 - 377

3) Galbraith S. Misdiagnosis and delayed diagnosis in traumatic intracranial haematoma. BMJ. 1976; 1: 1438.

4) Jennett et al. Severe head injuries in thre countries. J Neurol Neurosurg Psychiatry 1977 40: 291-298

5) Rose J, et al. Avoidable factors contributing to death after head injury. BMJ. 1977; 2 : 615

6) DaceyRG, et al Neurosurgical complications after apparently minor head injury. J Neurosurg. 1986; 65: 203-210.

7) RockswoldGL, et al. Analysis of management in thirty-three closed head iniury patients who "talked and deteriorated." Neurosurgery 1987; 21: 51-55

8) Rosckwold GL, et al. Patients who talk and deteriorate. Ann Emerg Med. 1993; 22(6): 1004-7
Harm Endpoints: Badness endpoints: Neurosurgery, death, intubation
Narrative: Minor head injury is an extremely common problem experienced by children everywhere and seen by physicians everywhere.

A small proportion of patients who appear to be neurologically normal will go on to have intracranial bleeding that will typically be treated with neurosurgery, but reliably predicting which children will have these outcomes without over-treating and over-testing has been difficult. This review examines the highest quality data available from a huge, multi-center emergency department study examining the evaluation of children with minor head injuries.(1)

The decision aids that the study presents are excellent, and present precise risk estimates in the setting of children with specific findings. Children who are under age 2 who are acting normally, do not have signs of skull fracture or a scalp hematoma (frontal hematomas are allowed), did not lose consciousness for >5 seconds, and did not have a 'severe mechanism'* have a risk of <1 in 5000 of having a major neurosurgical injury. For those over age 2 if they are neurologically normal, and have no severe mechanism*, severe headache, signs of skull fracture, or vomiting, their risk is <1 in 2000.

This is important information but should not be taken to mean that anyone with these factors is 'high risk'. Even among those children who appear to have a decreased level of consciousness (GCS of 14) or a skull fracture, 23 out of 24 children will not have a clinically important brain injury. Parents and physicians should know this information before moving to expensive radiographic imaging that carries risks and may require sedation to complete.

As with adults, when minor head injury children do have major problems such as neurologic deterioration it typically occurs in the first few hours. Rarely, it occurs beyond this time period, and a substantial body of case series literature suggests that when delayed major problems occur they occur in approximately 20% of bad outcome cases, and they occur after 4-6 hours.(2,3,4,5,6,7,8) In many cases these occur more than 12-24 hours later, making them quite delayed and in some cases detectable neither through a full day of observation nor with an immediate CT scan. Delayed hemorrhages do occur and are not always detectable with immediate imaging or observation.
Caveats: These data are from studies of head injured children being evaluated in ED's. This will not apply to many minor head injuries for whom risk is lower. In addition, enrolled children are in a subset of minor head injuries that is at higher risk than average because of the typical selection bias that comes with study enrollment (study subjects are usually higher risk than those who do not get enrolled in such studies). Therefore these risk estimates are likely to be high when applied to a general minor head injury population of children.

Alternately, the reported cohorts here were evaluated thoroughly by physicians for signs of skull fractures, neurologic abnormalities, and other signs and symptoms of brain injury. Therefore in the absence of this thorough physician evaluation it is not possible to know whether or not a specific patient is appropriately classified as a minor head injury meeting the above criteria.

Unlike data used in our review of adult minor head injury the data from the PECARN study of children that we cite (1) have not been validated. While they have been 'statistically' validated, the decision aid has not been applied to children in the clinical environment to determine how well it performs as a tool in this setting. Therefore while it is a large and excellent dataset, and it may even work better than unstructured physician judgment, this remains untested.

Finally, the above estimates of risk of delayed deterioration are based on extrapolation from case series' of patients, some of whom are pediatric and many of whom are adult, and these data are combined with the data from this large pediatric head injury study. They are not an observed set of outcomes, but rather a statistical speculation about the likelihood of delayed events after an initial 4-6 hours of normal neurologic findings in children.

*severe mechanism: car accident with ejection or fatality or rollover, pedestrian or non-helmeted bicyclist hit by a car, falls of more than 3 feet for <2 y/o and 5 feet for >2 y/o, or head struck by a high-impact object (e.g. baseball bat)
Author: David Newman, MD
Published/Updated: September 19, 2010

Risk Assessment: Minor Head Injury in Adults in the Emergency Department

2010-10-04T21:38:00.000-07:00

http://www.thennt.com/minor-head-injury-in-adults

disclaimer

In Summary, if you meet the below criteria for this assessment:

At initial examination:
- 99.6% will not require (or undergo) neurosurgery
- 0.4% will undergo neurosurgery*
After 4-6 hours have elapsed from the injury:
- 99.92% will not require (or undergo) neurosurgery
- 0.08% will undergo neurosurgery or deteriorate
*There were no fatalities or intubations in the cohorts reported for this group

In Other Words:

At initial examination, the risk of an injury requiring neurosurgery is 1 in 250
After 4-6 hours have elapsed from the injury, the risk of an injury requiring neurosurgery is 1 in 1250

Criteria:

Probable or definite loss of consciousness at initial injury, or memory lapse during examination
Neurologically normal on physician examination (other than memory loss)
Glasgow Coma Scale of 15 (out of 15 potential points)

Where We Get The Numbers:

Source: Stiell IG, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001; 357: 1391-1396.

Stiell IG, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA.2005;294:1511-1518

Smits M, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005; 294: 1519-1525.

Reilly PL, et al. Patients with head injury who talk and die. Lancet, 1975; 306 (7931): 375 - 377.

Galbraith S. Misdiagnosis and delayed diagnosis in traumatic intracranial haematoma. BMJ. 1976; 1: 1438.

Jennett et al. Severe head injuries in three countries. J Neurol Neurosurg Psychiatry 1977 40: 291-298

Rose J, et al. Avoidable factors contributing to death after head injury. BMJ. 1977; 2 : 615.

Dacey RG, et al Neurosurgical complications after apparently minor head injury. J Neurosurg. 1986; 65: 203-210.

Rockswold GL, et al. Analysis of management in thirty-three closed head iniury patients who "talked and deteriorated." Neurosurgery 1987; 21: 51-55.

Rosckwold GL, et al. Patients who talk and deteriorate. Ann Emerg Med. 1993; 22(6): 1004-7.
Harm Endpoints: Neurosurgery, death, intubation
Narrative: Minor head injury is an extremely common problem experienced by people everywhere and seen by physicians everywhere.
A small proportion of patients who appear to be neurologically normal will go on to have intracranial bleeding that will typically be treated with neurosurgery, but reliably forecasting these outcomes without over-treating (or over-testing) an unacceptable proportion has been difficult. This review examines the highest quality data available from emergency department evaluation of patients with minor head injuries, and concludes that untoward outcomes appear to occur at a consistent percentage (0.4%) across multiple minor head injury study populations.1 2 3 4

Decision aids such as the Canadian CT Head decision aid are also useful.3 4 The aid suggests that neurologically normal patients who do not have signs of fracture on examination, who are under age 65, and who have not vomited 2 times or more will not require neurosurgery at any point. This is important information but should not be taken to mean that anyone with vomiting or over age 65, for instance, is likely to require neurosurgery. The data suggest, in fact, that neurologically normal patients over age 65 still have a 99% chance of requiring no further intervention, and physicians and their patients should be aware of these risks.

When minor head injury patients do have major problems such as neurologic deterioration it typically occurs in the first few hours. Rarely, it occurs beyond this time period. A substantial body of case series literature suggests that when delayed major problems occur they occur approximately in 20% of bad outcome cases and they occur after 4-6 hours.5 6 7 8 9 10 11 In many cases they occur more than 12-24 hours later, making them quite delayed and in some cases detectable neither through a full day of observation nor with an immediate CT scan.
Caveats: These data are from studies of head injured patients being evaluated in ED's. This will not apply to many minor head injuries for whom risk is lower as their condition did not prompt them to seek care. In addition, many enrolled patients are in a subset of minor head injuries that is at higher risk than average because of their loss of consciousness, and the typical selection bias that comes with study enrollment (study subjects are usually higher risk than those who do not get enrolled in such studies). Therefore these risk estimates are likely to be high when applied to a general minor head injury population.

Alternately, the reported cohorts here were evaluated thoroughly by physicians for signs of skull fractures, neurologic abnormalities, and other signs and symptoms of brain injury. Therefore in the absence of this thorough physician evaluation it is not possible to know whether or not a specific patient is appropriately classified as a minor head injury meeting the above criteria.

Finally, the above estimates of risk of delayed deterioration (the 'talk and deteriorate' or 'talk and die' syndrome) are based on extrapolation from case series' of these patients, combined with the data from major minor head injury studies. They are not an observed set of outcomes, but rather a statistical speculation about the likelihood of delayed events after an initial 4-6 hours of normal neurologic findings.
Author: David Newman, MD
Published/Updated: September 21, 2010

Stiell IG, et al. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001; 357: 1391-1396.

Stiell IG, et al. Comparison of the Canadian CT Head Rule and the New Orleans Criteria in patients with minor head injury. JAMA.2005;294:1511-1518

Smits M, et al. External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor head injury. JAMA. 2005; 294: 1519-1525.

Reilly PL, et al. Patients with head injury who talk and die. Lancet, 1975; 306 (7931): 375 - 377.

Galbraith S. Misdiagnosis and delayed diagnosis in traumatic intracranial haematoma. BMJ. 1976; 1: 1438.

Jennett et al. Severe head injuries in three countries. J Neurol Neurosurg Psychiatry 1977 40: 291-298

Rose J, et al. Avoidable factors contributing to death after head injury. BMJ. 1977; 2 : 615.

Dacey RG, et al Neurosurgical complications after apparently minor head injury. J Neurosurg. 1986; 65: 203-210.

Rockswold GL, et al. Analysis of management in thirty-three closed head iniury patients who "talked and deteriorated." Neurosurgery 1987; 21: 51-55.

Rosckwold GL, et al. Patients who talk and deteriorate. Ann Emerg Med. 1993; 22(6): 1004-7.

Telling A Patient "I Don't Know" Takes Years of Practice.

2010-09-29T19:49:00.001-07:00

Telling A Patient "I Don't Know" Takes Years of Practice.

by The Happy Hospitalist

Physicians don't know everything. You may or may not have been raised to believe that physicians will always have the answers to all your questions. They don't. Not even the subspecialists whom patients believe are supposed to know everything. They don't.

For many physicians, one of the hardest things to learn is how to tell the patient "I don't know". Medical school and residency offers no curriculum that teaches your doctor how to tell you "I don't know". For many doctors, admitting failure to the patient is a form of torture.

Telling patients "I don't know" takes practice. Actually, it takes a lot of practice. You wouldn't think so, but for many new physicians, admitting their lack of knowledge about the science of your disease process is not easy.

I remember how hard it was to get through complete history and physical examinations during my early years as a third year medical student and then having to tell the patient I didn't know what was going on. Telling a patient you don't know is hard. Some doctors will never get comfortable with saying it.

As a resident, physicians are expected to engage in a greater sense involvement with their patient's care plan. They are also expected to know more and more as the years progress. But rarely does one show up in morning report with the right answer being "I don't know". Not knowing is never an acceptable answer during the grueling physician training process. And many physicians train to accept that as the truth once they leave their academic training centers and enter the real world.

I remember fielding hundreds of "That's the first time anyone has ever asked me that" type questions in my resident clinic. I always seemed to have an answer even if it wasn't the right answer. I remember how hard it was to sit there, face to face, with a patient asking what may or may not have seemed at the time to be simple, easy and straight forward questions. I remember thinking to myself that I should know this, but I don't.

After seven years as a hospitalist and thousands of patients later, I find telling patients "I don't know" to be one of the easiest parts of my job as a physician. If I don't know an answer, I don't hesitate. I just tell the patient up front that I don't know. And when I don't have an answer, often times the reason is because there is no answer, at least not the answer the patient is looking for. In my clinical practice one of the most common indications I have found for telling patients "I don't know" comes in patients with chronic pain of unexplainable etiology that only responds to that drug that starts with a D.

Happy: Ma'am, I understand you're having 12/10 abdominal pain, I have concerns about pursuing further evaluation given the dangers of CT scan radiation exposure we are learning more and more about every day. I think I am comforted by the fact you have had twelve CT scans, four ultrasounds, an exploratory surgery and hundreds of esoteric labs drawn in the last year, all of which have been normal. I am also comforted by your ability to keep down the Big Mac your boyfriend brought you an hour ago. I see you have previously been referred to the outpatient pain clinic but refused to take the Elavil they recommended. I have previously discussed my concerns with you regarding your body's evidence of tolerance and dependence to narcotics, but you declined further evalutaion of this care modality.  I don't know why you're having abdominal pain for the last three years that only responds to dilaudid, but I have nothing further to offer you in your hospital care. I'm going to discharge you to home today.
Patient: I can't go. I'm having too much pain.
Happy:  I'm sorry ma'am.  I don't know what's going on, but I have nothing further to offer you in the hospital. I'll fill out your paperwork for dismissal.
Patient: You're going to fill my dee-luu-ded aren't you?
Happy:  No ma'am. I have a personal policy of not prescribing narcotics for unexplained chronic pain that only responds to dilaudid. You'll have to talk to your primary care physician about long term management.
Patient: F**k you.
Happy:  I don't know what to say to that.

See how easy it is? It gets easier every year. Do you find it hard to tell a patient, "I don't know?"

Trick of the trade: Single digital block

2010-09-29T16:54:00.000-07:00

Trick of the trade: Single digital block

by Stella Yiu

Your next ED chart: Finger injury

The finger needs to be anesthetized.

Patient: "I have had this freezing before. The needles really hurt! Is there anything else less painful? "
Trick of the Trade:
A single, subcutaneous, volar-approach digital block

The traditional ring block involves two injections at the base of the finger (and a third injection if anesthetizing the thumbs and toes). A recent article adds to the literature on a non-traditional approach to the digital block - thesingle subcutaneous method.

Where do we inject?

Midpoint of the crease where the finger joins the palm, on the volar side.
How deep is the injection?
Subcutaneously. The anesthetic will deposit on top of the tendon sheath and infiltrate to where the digital nerves are.
How much volume?
About 2-3 cc.

Study results

How effective is this volar subcutaneous approach?
It is just as good as the traditional multiple-stick, dorsal approach. In this study at 5 minutes, 76% (28/37) patients in the single injection group were adequately anesthetised compared to 65% (22/34) patients in the traditional block (p=0.436, no statistically significant difference).

Also there were no differences in anesthesia at 10 minutes.
Is this less painful?
The self reported pain score was less, but again the difference was NOT statistically significant.
Do clinicians like this better?
Yes, the difference in Clinician Satisfaction score WAS statistically significant. In fact, many study clinicians adopted the single injection method, making recruitment of the trial subjects difficult.
What is my experience?
I really like this method since patients seem to tolerate this better. However, it does not work as well for the thumb, probably due to the dorsal branches of its digital nerves.

Other techniques described involve infiltrating the area 1-2 cm proximal to the digital-palmar crease similarly. I find they all work well for me.
What are others' experiences?
Converts swear by this. Some even use this to anesthetise toes!
Bottom line:
A single volar subcutaneous injection is efficacious and may be less painful for finger anesthesia.
Reference:
Cannon B, Chan L, Rowlinson JS, Baker M, Clancy M (2010). Digital anaesthesia: one injection or two?Emergency medicine journal: EMJ, 27 (7), 533-6 PMID: 20360491

You Know You Work for an A&E When

2010-09-23T20:56:00.001-07:00

You Know You Work for an A&E When

You Know You Work for an A&E When:

1. You find yourself regularly asking people “Now, what part of this complaint fits into the Accident part or the Emergency part of A and E? Because, sorry, I really do need it to fit into one of those categories to let you see a Doctor…”

2. You see any person with a welfare card as your “employer”

3.You and all your friends work for an emergency service or a hospital

4.You marry an Ambo, Nurse or Doctor (sometimes if you want to step outside of this routine you may marry a Cop)

5.It drives you absolutely nuts when someone asks you if you ever think about going to university so that you can make medical decisions on your own.

6.You know that when a kid has been injured the person who will take up most of your time managing at the scene will be the parent, regardless of how sick or injured the child is

7.When a patient arrive at your ED and your first impression is, Umm why have you come here?

8.You thrive on serious trauma (and no, a paper cut doesn’t count a serious trauma people!)

9.You know that Full Moon = Insanity.

10.When you’re always checking out peoples’ veins for IV access.

11.Unconscious = cooperative.

12.You’re up at 2:00 am on Facebook, all in a day’s work.

13.Random phones and buzzers send your heart into VF

14.You get back pain just looking at really fat people!

15.Your dinner conversations often migrate toward that really messy trauma or explosive diarrhea call and you won’t lose your appetite.

16.If you’ve ever conducted a practical joke using oxygen tubing.

17.If you have use lignocaine gel on people’s phones, car handles or any door handle

18.If you find skipping with an oxygen tubing a good form of exercise

19.When your home first-aid kit consists of OP airways, maternity kits and bag and masks!

20.When your quick remedies kit for a hangover includes: 1L of Hartmann’s and a Maxalon

21.When you’ve wanted to hold a seminar on ’Suicide – How to Get It Right The FIRST Time.”

22.When you have come to the conclusion that you are sicker than 3/4 of the people in the emergency department

23.When you wash your hands before using the bathroom.

24.When you are watching TV and get annoyed and point out all the inconsistencies of the TV medics.

25.All your “funniest” stories are considered vulgar and disgusting

26.You tell the best story ever, and you’re the only one who can see the humor in it

27.“LOL” doesn’t mean “laughing out loud” but rather it means “little old lady.”

28.You have at least one “things up people’s butts” story.

29.You often finish a story with “and then he died”

30.When you think you did a great job… even though the patient still ended up dead

31.You’re covered in some bodily fluid or another more often than not and it doesn’t bother you.

32.You’re tempted to use “oxygen therapy” on all annoying people, not just patients: an O2 tank over the head fixes everything (especially in combative patients).

33.You want to throw something at the TV when they shock assystole on some TV show.

34.When a patient arrive in your ED and a relative says that you will need a chair because the patient can’t walk – umm… I will make that decision!

35.When you come home in a clean uniform after a shift and your spouse automatically becomes suspicious of your whereabouts.

36.You remember every patient by their injury or disease and not their name.

37.You describe a hospital gown as a “nice backless number”

38.You know every party illicit drug ever invented and what the “popular” ones are this week

39.You believe that most occupants of an MVA don’t have a spinal injury

40.Believe all patients lie

41.Although, unable to speak any other language, are adeptly fluent in all hand languages to signify that if the patient can walk into the Emergency Department, they can walk to the see the Doctor!

42.You know that its easier and more accurate to check a patient’s medications than to ask them what previous medical illnesses they have.

43.Have been caught out at some stage by suggesting that you will decide if a patient can walk or not, only to find that they have a broken leg.

44.You class CPR as one of your weekly exercise workouts

45You’ve described a patient who has suddenly died as having made “a good innings”

46You’ve made jokes, which you have honestly thought were funny, about a funny way in which a patient has died

The Differences Between Lucky and Unlucky People

2010-09-13T22:21:00.001-07:00

The Differences Between Lucky and Unlucky People

by noreply@blogger.com (Lockup Doc)

by Lockup Doc

What separates the lucky from the unlucky in the world? Do people have control over their “luck,” or is luck an entirely random phenomenon?

I’ve often wondered about these questions. I have heard many successful people mention that an element of luck was one important ingredient in their success, but what exactly does this mean?

A couple of years ago I discovered a book called The Luck Factor. It was written by a British psychologist, Dr. Richard Wiseman. He carried out various research studies in order to better understand luck.

Here are some of his findings:

1. “Lucky people create, notice, and act upon the chance opportunities in their lives.”

The way that lucky people think and behave makes them more likely to experience good fortune. They expect positive results.

a. “Lucky people build and maintain a strong ‘network of luck.’” Generally speaking, lucky people are more social and more extroverted than unlucky people. They smile more; tend to like people and strike up conversations with strangers. They naturally develop networks of people. In turn, they increase their odds of coming across chance opportunities that more introverted persons might not. This makes perfect sense to me. While I believe people should be able to happily exist as introverts or extroverts, this point presents a great argument for why introverts might want force themselves out of their comfort zones occasionally and learn to network with others.

b. “Lucky people have a relaxed attitude toward life.” Dr. Wiseman found that people who tended to be uptight and therefore too focused on a particular task at hand were less likely to see opportunities that those with more laid-back approaches to life. He cited several specific examples to illustrate this point. Interesting!

c. “Lucky people are open to new experiences in their lives.” Those who crave predictability and sameness are less likely to come across new opportunities than those who like variety and unpredictability. Again, there’s nothing inherently wrong with existing with either mindset, but those who fear change might find new opportunities if they shake the humdrum routine up a bit.

2. “Lucky people make successful decisions by using their intuition and gut feelings.”

a. "Lucky people listen to their gut feelings and hunches.” A larger percentage of lucky than unlucky people used their intuition; their gut feeling of whether something was right or wrong; in financial decisions, career choices, business, decisions, and personal relationships. Of course lucky people use more than just intuition in making most decisions, but this was one important aspect.

b. “Lucky people take steps to boost their intuition.” Lucky people were more likely than unlikely people to use strategies such as meditation, returning to a problem later, clearing their minds, or finding a quiet place.

3. “Lucky people’s expectations about the future help them fulfill their dreams and ambitions.”

a. “Lucky people expect their good luck to continue in the future.” I think this is one of the most important points to emphasize from this book. Lucky people have lucky expectations. On questionnaires about their expectations of positive things manifesting and negative events not occurring, positive people expect the positive and do not expect the negative. The converse was true for the unlucky. I truly believe that what we put our attention on is what expands in our lives. I spend half of my professional time treating inmates, and every day that I work with them I encounter many who have such low expectations for their own lives that it’s no surprise that they fail to achieve what they say they want.

b. “Lucky people attempt to achieve their goals, even if their chances of success seem slim, and persevere in the face of failure.” Along these lines, both lucky and unlucky people create self-fulfilling prophecies. In other words, because of their positive or negative beliefs, they behave in ways that significantly increase the odds of the expected positive or negative outcome to occur. Although the author did not specifically mention that the positive and negative groups define failure differently, I suspect that they do. I personally believe that lucky people are more likely to see failure as nothing more than a negative judgment about a result that has been produced. It’s what one does with that result that matters. I suspect that many unlucky people are more likely to see the failure to produce a desired result as a personal failure.

c. “Lucky people expect their interactions with others to be lucky and successful.” This expectation often becomes another self-fulfilling prophecy: Lucky people behave in a manner that results in others responding to them positively.

4. “Lucky people are able to transform their bad luck into good fortune.”

It’s not that lucky people never experience misfortune. However, when they do, they tend to approach it very differently than do those with an unlucky mindset.

a. “Lucky people see the positive side of their bad luck.” I think we all know that the concept of luck is relative. Whether or not we consider ourselves lucky in a particular situation really comes down to how we frame it. When involved in unfortunate circumstances, lucky people were far more likely than unlucky people to appreciate how much worse their circumstances could have been. Conversely, unlucky people tended to dwell on the negative any time that something happened that they didn’t like. For me personally, this point was the one I found most useful. While I generally have a ‘lucky’ mindset and expect good fortune, I realized that this was the one point on which I could most improve.

b. “Lucky people are convinced that any ill fortune in their lives will, in the long run, work out for the best.” Often when something happens that we didn’t expect and don’t like, we assume it is a negative. But in the bigger picture, we really don’t know—events that appear negative at the time often become blessings in disguise. Regardless of apparent adversity, lucky people hold on to their belief that in the end, everything will work out for the better.

c. “Lucky people do not dwell on their ill fortune.” This is an important point in our victim culture where people are often encouraged to bond to their wounds, forming an emotionally unhealthy identity tied to their misfortune.

d. “Lucky people take constructive steps to prevent more bad luck in the future.” When things don’t work out, unlucky people are more likely to give up and feel defeated whereas lucky people are more likely to persist and to try to learn from their mistakes.

This book was a fun and at times enlightening read. If you’re expecting a book filled with rigorous objective scientific tests, this isn’t it. But if you want to learn about some of the practical differences between those who are more successful and less successful in life, then I believe the book has some valid points. Personally I found it useful.

What do you think about this?

Photo by Greencolander

Rules of EMS, Part One

2010-09-02T21:33:00.000-07:00

Rules of EMS, Part One

Posted by kellyg in Genera
l

Skin signs tell all.
Sick people don’t bitch.
Air goes in and out, blood goes round and round, any variation on this is a bad thing.
About 70% of the battery patients more than likely deserved it.
The more equipment you see on a EMT’s belt, the newer they are.
When dealing with patients, supervisors, or citizens, if it felt good saying it, it was the wrong thing to say.
All bleeding stops… eventually.
If the child is quiet, be scared.
EMS is extended periods of intense boredom, interrupted by occasional moments of sheer terror.
Always follow the rules, but be wise enough to leave them sometimes.
If the patient vomits, try to hold the head to the side of the bus with the least difficult-to-clean equipment.
If someone dies by chemical hazards, electrical shocks or other on-scene dangers it should be the patient, not you. (Also known as rule 1313)
Any EMT, FF, LEO and/or scene chief who is more drunk than the patient is the realproblem.
There will be problems.
The severity of the injury(s) is directly proportional to the difficulty in accessing, as well as the weight, of the patient.
Make sure the rookie EMT knows that a med patch is a radio term, and not a medicated bandage.
Paramedics save lives; EMTs save Paramedics.
If the patient looks sick, than the patient is sick.
If the patient is sitting up and talking to you, then the patient is not in V-Fib, no matter what the monitor says.
It is that bad.
Full spinal precautions were custom made for obnoxious drunks. So were NPAs.
If you absolutely must vomit, than it is probably best to turn your head away from the patient.
It is generally bad to use the words “holy s***” on scene, in reference to the patient’s condition.
Patients that crash in separate vehicles should be transported in separate vehicles.
Just because someone is fully immobilized doesn’t mean they can’t be violent.
If I’m up, EVERYONE is up!
Better them (another unit) than me.
I saved the patient… from the fire department.
When responding to a call, always remember that your ambulance was built by the lowest bidder.
Never get into the front of the ambulance with someone that is braver than you are.
When in doubt, use industrial strength therapy.
If it’s stupid, but it works… then it ain’t stupid.
Algorithms never survive the first thirty seconds of patient contact.
Always honor a threat.
Always know WHEN to get out of Dodge. Always know HOW to get out of Dodge. Don’t go INTO Dodge without the marshal.
The important things are always simple.
The simple things are always hard.
If the patient is going to vomit (especially projectile) be sure to aim towards any bystanders that would NOT clear the scene. (This also works for OIC’s)
Sometimes it’s easier to beg forgiveness than get permission.
You can’t please any of the people any of the time.
They said, “Smile, things could be worse.” So we smiled and sure enough, things got worse!
Always answer a newbie’s questions. You once asked them, too.
Always trust bad feelings
Touch no one’s genitalia but your own.
The number of drugs a patient has on board is directly proportional to the number of knuckles tattooed. If the patient has every knuckle tattooed, the drug screen will simply say, “YES.”
PVC’s can be eliminated by sending a strip to the hospital.
The likelihood of a lethal arrhythmia increases with the distance of the paramedic from the “SHOCK” button on the monitor.
The ultimate QA program in EMS is an autopsy.
Best time to work a code: overtime.
Pain never killed anyone.
All fevers eventually fall to room temperature.
A patient’s weight is directly proportional to the chances the elevator will be non-functioning.
Here is a simple ETOH test: Hold your hands about 6 inches apart with thumbs and forefingers touching and ask the patient what color string you are holding. If he indicates a color, it is a positive test.
A tourniquet around the neck solves all problems.
If you drop the baby, pick it up.
Oxygen is good, blue is bad.
Never trust an ER doc with anything sharper than a tongue depressor.
GCS less than 8, intubate.
Asystole is a very stable rhythm.
A patient’s weight is in direct proportion to their altitude in the building.
A patient’s weight is directly related to the number of stair flights between him/her and the bus.
“When in trouble, when in doubt, run in circles, scream and shout”.
EMS RULE OF THREES (as it relates to codes) 300 pounds; <30 minutes to shift change; 3 stories up in the building.
Whoops: 1) the monitor just fell down the stairs, 2) the cold and flu patient just coded; 3) the wrong house. (Hint: the one with the Lab probably didn’t call 911)
Rules: 1) Don’t get dirty, 2) Don’t run, you may violate rule #1, 3) If it looks like you might get dirty doing something, let the new guy do it.
For every ALS skill we learn, we forget a BLS one.
The fire tetrahedron consists of the following: heat, oxygen, fuel, chief officer. Take any of them away and the fire goes out.
“Compassion kills.” Don’t dive into incidents.
If there is little to be gained, there is little to be lost. If there is a lot to gain, there is a lot to be lost.
If you lift an inch, crib an inch.
What do you call a medical student who finishes last in their class? Doctor.
If you think the cost of education is expensive, check out the cost of ignorance.
If it’s wet and sticky and not yours, leave it alone.
Death is a stabilization of the patient’s condition.
Every emergency has three phases; PANIC, FEAR, REMORSE.
You are bound to get a call either during dinner, while you are on the can, or at 02:00 in the middle of a great dream.
Training is learning the rules, experience is learning the exceptions.
Good judgment comes from experience, and experience comes from bad judgment.
Rocket scientists that get into stupid car crashes are the first ones to complain how bumpy the ambulance ride is.
“Poke & Hope” = blind sticking
Why do fire chiefs where white helmets? So you know where the Preparation H goes.
Never trust your bus, drug box, or airway bag to be fully stocked, in spite of the assurances of the off going crew.
If you don’t have it, don’t give up. Adapt, improvise, overcome. And if that doesn’t work, call for a second unit.
There is no such thing as a “textbook case.” Patients don’t read the textbook.
Newbies always look for large things in the smallest compartments, and vice versa.
There is no such thing as a bad call, only calls that didn’t go the way you planned.
Just because someone’s EMT or Paramedic original license date is before yours, does not mean they know what they are doing.
There are very few paramedics with 20 years of experience. There are thousands of paramedics with 1 year of experience, repeated 20 times.
Truckies are people who are over 6 feet tall and their hands drag the ground while walking upright.
Newbies have their own way of doing things.
When it comes to needles, ’tis better to give than to receive.
Listening to some EMTs talk on the radio makes you wonder why they don’t become professional auctioneers.
For every 25 calls you run, only 1 will be exciting.
Take comfort in the fact that most of your patients survive, no matter what you do to them.
The old EMS constant; no matter how bad the politics get, the doors go up and the trucks go out.
ALS really stands for “absolute loss of sense.”
Many of your patients will be healthier than you are.
Being in emergency services means you get to celebrate your holidays with all your friends, while on-duty.
Being an EMT means you get to expose yourself to rare, exotic and exciting new diseases.
EMS does not save lives; EMS is to care for people. It is 95% of what we do.

Rules of EMS, Part Two

2010-09-02T21:31:00.000-07:00

Rules of EMS, Part Two

Posted by kellyg in Genera
l

You fall, you call, we haul, that’s all.
There are two kinds of EMS calls: “Oh, shit!” and “Bullshit!”
When you join the kidney club, you usually cannot go.
Common sense isn’t.
The more reflective striping there is on your jumpsuit, the easier it is for the only drunk driver going by the MVA to find you.
If you have a ride-along you want to show the real world, nothing will happen that shift.
95% of the time, EMS is simply thwarting the process of natural selection.
Just because you’re paranoid doesn’t mean your supervisor is not around the corner.
You can’t cure stupid.
If at all possible, avoid any edible item that firefighters prepare, especially the tuna casserole.
Heaven protects fools and drunks.
We are all slaves to the god “Motorola.” And that god requires sacrifices of hot food at least once a shift.
The address is never clearly marked.
Avoid bringing your patients to teaching hospitals in July.
EMS doesn’t save lives. We only postpone the inevitable.
Even sterile water tastes great on a hot day.
The stereo must always be louder than the siren.
At the beginning of your shift, your main O2 tank, fuel tank, and stomach will be empty…but the call volume will be full.
You know you are in trouble when the directions to a patient’s house include, “Turn off of the paved surface…”
Anyone with a tooth: tattoo ratio of less than 5:1 is guaranteed to be drunk, on drugs, or both.
Anyone with more than five listed drug allergies is automatically a psych diagnosis.
Avoid hospitals with Saint, Mercy, or Memorial in their names. And St. Mary of Mercy Memorial Medical Center is a definite no-no.
All arrhythmias eventually straighten themselves out.
Dead is dead, leave it at that.
Your seriously ill patient will miraculously get better after five minutes in the ER. We call this “fluorescent light therapy.”
Periodically, aliens will abduct your patient and replace him with an exact duplicate with a totally different chief complaint and set of symptoms. This usually happens right after you call report.
Don’t get excited about blood unless it’s your own.
The pain will go away when it stops hurting.
If nothing has gone wrong, you obviously don’t understand the situation.
You should always stop CPR after the second “ouch!” from the pt.
People don’t call an ambulance because they did something right.
The quickest way to gather the relatives is to leave the primaries on while at the scene.
Every nurse is right, as long as you are in their E.D.
When in doubt, always take another set of vital signs.
If your patient is violent, you can always use topical oxygen therapy. The green paint usually wears off in about a week.
The larger the house, the furthest from a door the patient will be, and the sickest patients are always in the back bedroom.
If the patient fell and was moved by the family, they will have moved them so that climbing stairs will be involved.
The furniture will always be arranged so that a stretcher or stair chair will never fit easily.
The problem won’t be that bad until a major disaster strikes: “You’ve had chest pain for three days and you waited until the middle of a blizzard to call?”
History never repeats itself. This is never more apparent than in the E.D., when the nurse asks the patient the same questions you did five minutes ago.
You’ve never been as sick as just before you stop breathing.
If someone is pointing a gun at you, two things become apparent: 1) You should have waited for law enforcement; 2) You wish you just hadn’t made that wise-assed comment.
Fellow medics always have a better story than yours.
Just when you say, “You know, I have never had a hanging….” you will get one.
The only time you go out on a limb (as a dispatcher), and not provide coverage so a crew can eat, a serious call will come in that area.
The only time you need to fart is when you have your patient loaded in the elevator.
The only time your pants split is when there are gorgeous police officers there to assist you.
You will get caught sleeping, eventually.
Never say the kind of call you are in the mood for in the beginning of the shift, because you will get it in the worst way, i.e. an MVC in the pouring rain.
God made Paramedics and EMTs to give him a chance to change his mind.
Beware when a firefighter says, “Y’all check this out.”
Your driver will never hit a pot hole or curb unless your patient has a bad fracture.
The worse your patient’s breath, the more quietly they will talk, forcing you to lean very close to hear them.
If ever in doubt of which house you were called to, look for the stairs.
If there aren’t nurses around when you get called to a nursing home, go to the last room in the hallway. That’s always where the sickest patients are.
Never start putting your stuff away before you are told to go home, because you have just given yourself another call.
When in doubt, let your partner handle it.
When getting a TMJ (too much Jesus) call on a Sunday, never say it around your patient. It sucks when you have to tell them what it means.
If the patient pukes, it is not unprofessional to puke along with them, it is sympathetic puking. You have something in common with your patient and can relate to how they feel. This is why they made the big step well by the side door.
If the patient only moans when you listen to lung sounds, they aren’t as sick as they want to be.
If a patient calmly tells you they are going to die, you had better believe them.
When the patient is really sick, remember that the ambulance has wheels for a reason.
911: The government’s answer to Dial-A-Prayer.
The more addicted your patient is to morphine, Demerol, Fentanyl, etc…. the more allergic they are to Toradal.
You can have circulation with no breathing, but you can not have breathing with no circulation.
On trauma calls, survivability is inversely proportionate to social worth.
How you know an unconscious is a DOA: 1) If it weighs over 300 pounds… DOA; 2) if it lives more than three flights up in a walkup apartment… DOA; 3) if it’s less than 30 minutes left in the shift… DOA.
EMS providers know how to say “got shoes?” in 7 different languages.
At haz-mat scenes, remember to use the Copological Indicators: If the stripe on the officer’s trouser leg is vertical, it’s safe to go in. If the stripe is horizontal, wait for the haz-mat team. At a gas leak, send the cop in with a lit road flare. If the cop passes out and the flare goes out, it’s an asphyxiant. If the cop explodes, it’s a flammable.
Never go past the first dead cop.
There will be no dying or multiplying in the back of my unit.
The worse you have to use the restroom, the farther the distance it will be from the location of the call to the hospital.
If you haven’t yet had to use a patient’s bathroom… you haven’t been in EMS very long.
Some people can do this job, some can’t. Pray your partner is one who can.
All rhythms will eventually degenerate into one you will recognize and can treat.
If God had intended you to have a rapid response to the call, you would have been parked in front of the location.
Upon arrival at a code, check your own pulse first. If it is still there, everything else is easy.
As soon as you finish cleaning the rig up for a parade, you’ll have to drive ten miles down a muddy, unpaved road for a difficulty breathing.
If you ever go to a call and find the cops laughing on the front lawn…worry!
Remember, it’s the patient’s emergency, not yours. Try to keep your pulse rate lower than theirs.
If you drop the baby, fake a seizure.
The most effective prehospital fluid for trauma patients is a diesel bolus.
Sometimes people will die despite our best efforts.
Dead people very seldom get any better, but they never get worse.
“Can you walk? Have you tried?”
If EMS workers never eat, sleep, or go to the bathroom, nobody would ever get sick or injured.
Better to be looking at it than looking for it.
Go to work expecting to get screwed. You will occasionally be pleasantly surprised, but you will never be disappointed.
The size of the IV needle and the number of attempts is directly proportionate to the patient’s attitude.
All people eventually die.
If there is a God, you are not him. This even applies to paramedics.
The patient’s need of medical attention is inversely proportional to the amount of noise he/she is making.
If the patient says she’s in labor, it’s a UTI. If the doctor said it was a UTI, break out the OB kit.
If she says the baby is coming, believe her.
If a patient presents you with a problem you don’t know how to treat, change it into something you do.
All bystanders, and the majority of your patients, have more medical training, experience and knowledge than you. And they’re never shy about offering advice.
The best way to make a bystander go away is to ask for help.
The amount of vomit produced always exceeds the size of the container by at least a factor of 2.
The seriousness of an injury is inversely proportional to the number of escorts wanting to accompany the patient to hospital.
When your patient says, “I’ve called my doctor, and he’ll be meeting us at the hospital,” this actually means, “I am a hypochondriac and my doctor doesn’t have caller ID.”

Preparing for gastric bypass surgery by eating more

2010-09-02T18:31:00.000-07:00

by Douglas Perednia, MD

Thinking is hard work. This is why so few people bother. At least voluntarily. So whenever it seems like the threat of brainwork looms in modern American medicine, we can thank our lucky stars for the geniuses behind healthcare reform and guidelines of care.

This comes up as a result of a conversation that I had with a patient the other day. A pleasant, obese gentleman. He had been struggling with his weight and type 2 diabetes for some time, and there were now some early indications of some potentially serious long-term complications. He mentioned to me that he was working hard to prepare for gastric bypass surgery. I asked him how he was doing that.

“Why, by eating!” he replied. Huh? By eating?

“Oh yes”, he explained. “You see, I’m getting these complications from my weight and diabetes and all of my doctors think that I’m an excellent candidate for weight loss surgery. Based on my previous weights, if I can just get lose about 40 or 50 pounds, I should have much better blood sugars and need far less insulin. God, that stuff is expensive when you’re using hundreds of units per day!”

That sounded perfectly reasonable. This gentleman is a walking advertisement for the virtues of slimming down. And for gastric bypass, in fact. So why is he holding that venti whole milk mocha with 508 calories and 27 grams of fat?

“Oh, this?” He looked a bit sheepish. “Well the problem is that the surgeons won’t operate on me yet because I don’t quite fit the guidelines they have to follow for doing the operation. Insurance won’t cover the surgery until I reach a BMI (body mass index) of 40, and I’m a couple of pounds short. So I have to gain the weight and have them document that I’ve reached the magic number. Then I’ll actually lose the weight again when they put me on the special post-surgery diet to make sure that I can tolerate it. If all of that works out okay, then they’ll schedule the surgery.”

Now I realize that I’m revealing some age here, but in the old days we would have looked at the patient, considered his history, physical condition, social situation and medical compliance, and decided whether the surgery was indicated and likely to be beneficial based upon all of those things. He doesn’t quite meet the BMI criteria established by some study? Well so what? He’s a good candidate. Let’s do it. And we would. And the patient would usually get better because we wanted to pick good candidates and have them succeed. That was our job. We were the medical experts and we were being paid to think. Besides, if someone else knew way more about medicine and our patients than we did, why weren’t they the ones taking care of them instead of us?

But of course then we’d have to use our heads. Thank God those days are over. Now if the patient’s vital statistics don’t match whatever the insurer’s guideline computer tells the high school graduate who happens to be denying authorizations that day, then you’d best go away and come back when they do. No use fretting about it. You’ll never make it through the insurer’s phone trees or get a reply to your voice mails asking to speak to a medical director anyway.

I wished our patient luck, and later brought up the case with the doctor who was taking care of his diabetes. He was visibly exasperated about the whole ordeal.

“We’ve been working very hard on his diabetic control.”, she said. “He’s been pretty good about his diet, but has one of those bodies that really uses energy efficiently. It just hangs on to every ounce of weight. We had his hemoglobin A1c down to 7% (normal is 4% to 6%), but since he’s had to start gaining weight it’s back up to 7.9%. I’ll be glad when this whole ordeal is over and we can go back to treating his disease rather than the damned guidelines.”

Silly doctor. Why would you want to do that? You’ll have to think. Besides, wake up and smell the mocha. You’re being paid to follow the guidelines.

Doug Perednia is an internal medicine physician and dermatologist who blogs at Road to Hellth.

Trick of the Trade: "Pour some sugar on me

2010-09-01T18:32:00.000-07:00

Trick of the Trade: "Pour some sugar on me"

by Michelle Lin, MD

1 person liked this

Rectal prolapses are typically caused by weakened rectal muscles, continued straining, stresses during childbirth, weakened ligaments, or neurological deficits.

How do you fix them? You can attempt manual reduction of the prolapse by using direct pressure. On the other extreme, corrective surgery can be performed from either an abdominal or perineal approach.

Trick of the Trade: Pour some sugar on it.

Def Leppard is right. Rectal prolapses often are associated with quite a bit of rectal mucosal edema. Sprinkle granulated sugar onto the area. Wait 15 minutes. The sugar reduces the edema by osmotically drawing out the fluid. The rectal prolapse often reduces spontaneously or with gentle manual pressure.

References

Ramanujam PS, Venkatesh KS. Management of acute incarcerated rectal prolapse. Dis Colon Rectum. Dec 1992;35(12):1154-6.

Coburn WM III, Russell MA, Hofstetter WL. Sucrose as an aid to manual reduction of incarcerated rectal prolapse. Ann Emerg Med. Sep 1997;30(3):347-9.

Leading a hospital team of foreign trained doctors

2010-09-01T18:27:00.000-07:00

Leading a hospital team of foreign trained doctors

by John Schumann, MD

Recently, I had the opportunity to decamp from the the friendly confines of GlassHospital and trek a few miles to the north.
GlassHospital has brokered a teaching and patient-sharing agreement with a nearby religiously-affiliated community hospital I’ll call Our Lady of Blessed Proximity.
Our Lady has a residency training program, just like ours, with the major difference being that nearly all of the doctors come from foreign lands.
Something you should know about medicine in America is that there are many more residency training slots (greater than twenty thousand) than there are U.S. medical school graduates each year (fewer than seventeen thousand). International graduates compete to fill those few thousand “extra” spots. These spots typically occur in less prestigious hospitals that are often in locations less desired by U.S. graduates.

I was supervising a team consisting of two residents and two interns (residents in their first year of training after medical school). We even had a couple of “observers” show up late in the month, as they were going to soon be starting their internships and wanted to get the feel of things around the hospital.

One of the key differences between the residents at Our Lady and the residents at GlassHospital is that nearly all of the former were already full-fledged doctors in their home countries. The residents at my home place, GlassHospital, have all just graduated from U.S. medical schools and are doctoring for the first time.
Take Dipak (names and details changed to protect the innocent). He was a fully-trained surgeon back home in India; in order to land a spot here, he had to give up his dreams of surgery and become an internist. He wants to go on and subspecialize — probably in heme/onc — he likes the increased knowledge and income potential of a subfield like cancer.
Jorge mostly grew up in California. But he was born in the Philippines, and returned there to go to medical school. This limited his chances to get a more ‘prestigious’ residency slot; yet he’s the first one in his immigrant family to become a doctor, so just getting here is an accomplishment. Unlike the others, he had never practiced medicine before, so he was a touch wet behind the ears.
Samar is Jordanian; her husband is also a doctor, and has already finished his U.S. training and is working in a health manpower shortage area in a neighboring state as a hospitalist. They see each other on weekends if their schedules permit. Together they’re raising a six year-old daughter. Samar is ambivalent about whether she wants to return to Jordan to work and live; she likes it here, but feels that she’s not truly part of the culture.
Sharif is from Syria. When I found this out, I was surprised, since officially the U.S. has long considered that country a terrorist state. Sharif couldn’t love America more. He married an American woman. He has no intention of ever going back. He loves the opportunity to ply his trade here, free to make it on his own merits. Sometimes, he told me, the opportunities here feel overwhelming.
Later in the rotation, one of the observers who rounded with us for a day was named Yusuf. He was born, raised, and trained in Egypt, where he’d been an orthopaedic surgeon. The day I met him, I had a sudden urge to sit the whole group down and negotiate peace in the Middle East once and for all.
We were a team, and in spite of our differences, we were working for the common good of our patients. We all wanted to serve, to learn, and to grow as individuals and as doctors. And, I might add, to be able to think and say what we want without fear of persecution. Something that some members of my team do not take for granted.
I admired my group and the obstacles they’d overcome to land spots here. Their paths will not be easy, but with the resourcefulness they’ve all shown, they’ll likely end up successful doctors in America.
John Schumann is an internal medicine physician at the University of Chicago who blogs at GlassHospital.

electricity and empty heads

2010-08-31T23:02:00.001-07:00

Electricity and dim bulbs

by Grumpy, M.D.

I have 3 kids. None of them even in middle school yet.

And they ALL know that electricity is REALLY dangerous.

When they were younger, we used to have those outlet protector things all over the house. But it was drilled into them that YOU DON'T MESS WITH THE VOLTAGE. And so, by the time my kids were 6, we'd passed those gadgets on to Mary (her kids are younger than mine).

And we've NEVER, to date, had an issue with them trying to do anything stupid with a socket.

So you'd think a kid who's at least 14 years old, who grew up in an an industrialized nation, would grasp the simple concept of DANGER! HIGH VOLTAGE! and NOT do something idiotic. Like, say, attach jumper cables to his chest and then plug them into a wall. Right?

Fat chance.
N.H. teen who zapped nipples during shop class sues
Aug. 31, 2010 07:34 AM
Associated Press
DOVER, N.H. - A New Hampshire high school student shocked so severely in shop class that his heart stopped beating is suing his teacher, the school district and the city of Dover.
Kyle Dubois and his parents claim teacher Thomas Kelley did not warn Dubois and other students of the dangers of the electrical demonstration cords in their electrical trades class.
On March 11, Dubois attached an electrical clamp to one nipple while another student attached another clamp to the other. A third student plugged in the cord.
Dubois was critically injured.
The New Hampshire Union Leader says Dubois' suit contends he suffered permanent brain damage.
Kelley resigned from his teaching position about a month after the incident. He declined to comment on the lawsuit.

I think that what really pisses me off about this is that the family is suing the freaking teacher. Your teenage kid doesn't understand that electricity is dangerous? Who's fucking fault is that?

Of course, in these people's minds, it HAS to be the teacher's fuck-up. I mean, he's known the kid for a whole, what, 7 months out of the kid's life? The parents have only known him for at least 14 years (it doesn't say how old he is, but to be in high school has to be at least 14) and apparently didn't bother to teach him basic electrical safety (like don't put a fork in an outlet).

So he could have done something this remarkably stupid at home, too. But he did it at school, so now they can sue someone besides themselves.

Some are going to write in that I'm a callous bastard, because the kid may be badly damaged (it doesn't say the extent of his injuries). Yes, I feel bad for ANY parent who has a tragedy befall their kids. It's horrible, regardless of what the cause is.

But the bottom line is that to sue someone else for your own failings as a parent is utter bullshit.
I'd like to thank my reader Sarah for submitting the above news story.

What is an expert witness?

2010-08-31T17:02:00.001-07:00

Getting a subpoena: What is an expert witness?

by Michelle Lin, MD

Well, it's an inevitable part of working in an Emergency Department. I got a subpoena recently and now have to go in to testify on a trauma patient. I've gotten a few subpoenas before on trauma patients, but fortunately most cases were settled out of court.

First of all, I think it's an ethical responsibility of emergency physicians to describe what we saw and did in the care of the injured patient in the legal system. However, I have found that the few lawyers I have interacted with slowly expand their scope of questions to cover things NOT in the medical chart. Has this happened to anyone else? They essentially start to ask me things which an "expert witness" should answer. Expert witnesses receive expert witness fees.

"What is a typical expected course for..."
"Do patients with this type of injury usually have pain for so long?"
"What do you think about..."
"Can you describe the nature/ cause/ definition of..."
"What's the prognosis for..."

Actually ACEP has created Expert Witness Guidelines.

So I read more about our rights as emergency physicians when we get subpoenaed to testify for a patient. We are supposed to just testify about the facts on the medical chart. No opinions. If we start giving opinions, we are essentially giving expert witness testimony.

Interestingly, the California Medical Association has a recommendation on this: If asked to give expert opinion, the physician should ask if s/he is being asked for their expert opinion. If so, that they would like to receive expert witness fees. In 1995, the California legislature passed bill AB1204 that ensures a treating physician expert fee payment if asked for a medical opinion. Read more here in EP Monthly. This is becoming increasingly true in many other states.

Even better, there is a great template letter (thanks to Dr. Clement Yeh for telling me about it) that you can preemptively mail the lawyers who sent you a subpoena. It basically says that you would be happy to testify what's on the medical chart and ONLY on the chart. If they want expert opinion, you should be treated as an expert witness with "x" number of dollars/hour recompensation. It's pretty hard-core, but I think it averts many misunderstandings and potentially can you save a lot of time. All the time in court and preparing for the case takes you away from work.

Wish I had this earlier. Here is the template (download here):

Dear {name},

I was recently subpoenaed by your office. In the past, there have been several incidences where there has been a misunderstanding whether attorneys are requesting factual or expert witness testimony. In the event, you ask me to provide any response or responses that calls for an opinion or medical conclusion, that will be considered to be expert witness testimony. Receipt of this letter will confer your acknowledgement that in the event you request expert witness testimony, you and/or your agency will be responsible for bills for my time. As a courtesy, I am sending my fee schedule for your review.

My fee is $___ an hour for consultation and/or expert testimony. Expert services include review of records, telephone and or office conferences with attorney(s) or other relevant individuals, and preparation for deposition and trial if indicated. The minimum fee bill will be $____.

As is standard, all reasonable expenses incurred will be billed to your agency or firm. If travel is necessary, travel time will be billed at $___ per hour. If testimony is required the following charges apply. If I am called to testify in the morning, I assume that testimony will involve a minimum of eight hours, and you will be billed for eight hours at $___ per hour. If I am called in the afternoon, I assume that testimony will involve a minimum of four hours and you will be billed for four hours at $___ per hour. If meetings or trials are subsequently canceled on short notice your agency or firm may be billed for the time scheduled

Serious Injuries

2010-08-31T16:13:00.001-07:00

Serious Injuries

by WhiteCoat

We receive this transfer from an outlying hospital for a neurology evaluation. The patient is in his 30s and was out at the bars when he was hit in head with beer bottle during an altercation.
Since that event, he has complained of dizziness, headache, loss of vision in one eye, pain all over his body, and repeatedly running out of pain medications. He had multiple CT scans and an MRI looking for causes of his symptoms at the referring hospital. All were normal. He also had multiple x-rays and physical exams without positive findings.
He went back to the emergency department and was reportedly “pissing himself” and “s**tting himself” – as in he was sitting on the couch watching a movie and didn’t know he urinated on the couch until his girlfriend told him that she felt something wet on the floor. Also reportedly only knew that he soiled himself when he went to take a shower and noticed his underwear contained a present.
The ED physician at the transferring facility took good notes. The medical records showed that at the first visit, he was on his cell phone yelling at police why the person who threw the beer bottle at him wouldn’t be charged with a crime. After he got off the phone, he reportedly told a nurse that he had to have a “serious injury” in order for it to be further prosecuted. A cut to the head from a beer bottle wasn’t classified as a “serious injury.”
The patient never seemed to have soiled clothing in the ED and he was able to walk back and forth to the bathroom without problems – even though he couldn’t tell when he needed to go to the bathroom. He also failed several tests for malingering in the hospital that sent him to us.
I had to smirk just a little when I watched the well-tattooed muscular patient transfer from the ambulance stretcher to the bed holding a cell phone to his ear … and wearing an adult diaper that the previous emergency department had placed on him for the ride.
The neurologist discharged him from the ED after finding no abnormalities … and after he failed the same tests for malingering in our ED.
Still no criminal charges, I’m going to guess

Statins for heart disease and stroke, and debunking statin myths

2010-08-30T18:24:00.000-07:00

Statins for heart disease and stroke, and debunking statin myths

by Eric Van De Graaff, MD

There is no class of medications in the history of the world that has been better studied that statins.

This class of drugs is more properly termed HMG CoA reductase (3-hydroxy-3-methyl-glutaryl co-enzyme A reductase) inhibitors, but with a name like that a terser nickname is almost mandatory (the name statin comes from the suffix of the members of this class: lovastatin,pravastatin, etc.).

Simply speaking, this chemical blocks the metabolic pathway that produces cholesterol, which, of course, is known* to be a chief culprit in the formation of arterial blockages and is a direct risk factor for heart attacks and stroke. Following are statins currently available in the U.S.:

Lovastatin (Mevacor)
Pravastatin (Pravachol)
Simvastatin (Zocor)
Atorvastatin (Lipitor)
Rosuvastatin (Crestor)

Since the development of the first widely used statin in 1976 (lovastatin, originally isolated from penicillin fungus) thousands of patients have participated in major research studies assessing the safety and effectiveness of this class of medications and more than 3 billion prescriptions have been filled in the U.S. alone.

The theoretical benefit of widespread statin use has translated into a real effect among the current population of patients at risk for heart disease and stroke. At present, the prevalence of coronary heart disease is at its lowest in decades, despite an ongoing epidemic of tobacco abuse and obesity. Many experts in the field of epidemiology feel this is a direct result of the generalized application of the knowledge that has come from these many research studies. I personally agree that the extensive use of lipid-lowering drugs has actually cut into my cardiology business, and I’m quite pleased with that.

You would think that all this information and scientific certainty would settle any potential controversy surrounding the safety of the statins. You might imagine that doctors and patients alike would feel comfortable using a class of medications for which there is study after study demonstrating the benefit of this type of cholesterol blockade.

Not so.

Virtually every patient who has ever gone on a statin medication has heard stories from family, friends, neighbors, and acquaintances about the dangers this class of drugs harbors: muscle and joint pain, weakness, paralysis, memory loss, depression, cancer, chronic pain, liver and kidney failure. If you go on the internet and type “truth about statins” into virtually any search engine you will come up with thousands of sites that provide you with nearly everything except the truth. I tried this last week and was astounded at the misinformation that is heaped upon anyone trying to come to an unbiased opinion on the matter (I also found that for most of these sites the damaging assertions about statins serve as nothing more than a gateway to advertise some other product).

Before I proffer my opinion on the matter, let’s detour for a moment to review the hierarchy of patient-based research. Medical studies come in a myriad of different designs and span the gamut of quality and reliability. At one end of the spectrum are anecdotal reports (“As a doctor I observed that Mr. X had adverse reaction to the drug Y”) that are unquestionably the least reliable of all scientific methods in that they involve only few patients, often only one doctor, and are fraught with heavy personal bias.

At the opposite end sits the gold standard research protocol: the prospective, randomized, controlled, double-blinded study. Definitions:

Prospective: All data are collected after the study is designed. The opposite of this is the retrospective study which collects data about events that have already happened.
Randomized: Each patient to enter the study is randomly assigned to one of two (sometimes more) therapies. This differs from some studies where the clinician picks the therapy the patient will receive.
Controlled: More than one therapy is represented in the study. Generally you compare the treatment in question (such as a new drug) to another treatment that is either placebo (sugar pills that reportedly have no true effect) or the established standard of care (therapy that patients are already receiving).
Double-blinded: A radiologist once told me this means to two orthopedists trying to read a chest x-ray. It actually refers to a deliberate concealment from both the patient and the doctor/nurse/study coordinator so that neither entity can know whether the patient is receiving the therapy being tested or the control. With many medications this is relatively easy to do. With other therapies, such as surgeries, it’s very difficult.

The point of each of these provisions is to remove the effect of bias—on the part of the patient, the doctor, and the study designers—to the greatest degree possible. Unfortunately this type of study is also the most difficult to run and extremely expensive, but it yields the most reliable information we can obtain. A researcher who could successfully run such a study with a few hundred participants would be guaranteed a publication in a highly reputable medical journal.

How many patients have been enrolled in statin studies? At this point over 120,000 patients have participated in prospective, randomized, controlled, double-blinded trials specifically looking at the statin class of medications. And in every one of these studies the side effects of both the statin and the placebo have been documented with the precision of a Swiss watchmaker with obsessive-compulsive disorder. Every ache and pain, each rise and fall of dozens of lab markers, and all doctor and hospital visits are painstakingly recorded, tracked, and dissected using a mind numbing array of statistical analyses.

Modern medical science has never (and may never again) so thoroughly dissected the effect—and possible adverse effects—of a class of medication as has been the case with statins. Here’s what the research teaches us:

If you’ve had a heart attack already, or have coronary artery disease, you are at relatively high risk for heart attack, stroke and death. Those with diabetes or atherosclerosis elsewhere in their circulation (carotid or peripheral) are at similarly high risk. This group of patients has at least a 20% risk of death or severe cardiac problem over the course of 10 years. A general rule holds true about risk and therapy: the higher your risk, the greater the magnitude of benefit you get from a therapy.
If you average all the studies you will find that you can reduce the risk of cardiac-related death by about 20% among individuals at higher risk.
Statins reduce the risk of stroke by about 20-30%.
Statins are known to raise liver enzymes in a dose-dependent fashion in around 5 percent of people
Statins very rarely lead to dangerous muscle damage (myopathy).
Side effects were reported only slightly more commonly in patients randomized to receive the statin drugs (when compared to those on placebo), but the rate of drug discontinuance was similar between both groups.

This last finding is critical. It means that regardless what you may hear from neighbors and family about the dangerous side effects of statins, the truth of the matter is that among the 120,000 patients studied the side effects of the statins were no different than those of the placebo pill. Sure, muscle aches occurred, but they were no more prominent among patients randomized to receive the statin.

At least one caveat exists to all this research, however. There is one form of prominent bias that cannot be excluded from prospective studies such as these, and is in fact inherent in the design of the trial. This bias occurs when the investigator decides what type of patient should be enrolled in the research and who should be excluded. A good example is the mammoth Heart Protection Study(HPS), a research endeavor that randomized over 20,000 patients to statin versus placebo. The enrollment criteria required patients to have some form of vascular disease present (coronary, cerebral or peripheral vascular disease) and therefore excluded patients with no established history of atherosclerosis. Since healthy individuals weren’t enrolled it stands to reason that the findings of the HPS cannot be applied to the general population.

Also excluded were patients with certain medical problems. Since muscle aches and liver enzyme abnormalities are a known possible side effect of statins, HPS kept patients with preexisting muscle and liver ailments from enrollment in order to limit the confusion.

Research coordinators are free to exclude these individuals from receiving statin therapy but we clinicians aren’t. Patients with liver and muscle problems come in with heart attacks as often as anyone else does and we are left trying to decide how safe and advisable it is to start these people on statins. It’s not known whether people with other complicated medical problems (or complex drug regimens) are at higher risk for statin side effects.

Now, having bored you with my lengthy sermon on the scientific literature supporting statin safety and tolerability, let’s look at real world experience. Most every physician you talk to will tell you that the rate of statin intolerability among their patients is higher than 5%, I, too, have seen a higher than expected proportion of patients come back to my office complaining of muscle aches and fatigue after initiating this cholesterol therapy.

What to make of this? I don’t really know. I have to believe that statins in the general population result in side effects at a rate not seen in the study groups. For me to deny this would be ignoring my personal experience with patients whose symptoms improve once they stop the medication and recur if it is restarted.

That said, I also believe that the specter of statin toxicity has so suffused the general population that it has affected the way patients and doctors react such possible side effects arise. When a person who is not on a statin has joint or muscle aches or fatigue, those complaints are attributed to nothing more than old age, obesity, arthritis, or what have you. But, these days, when a patient on a statin reports the same symptoms, the statin becomes the culprit and is quickly discontinued. An example: I saw a patient this week who complained to his pharmacist of muscle aches associated with a cold and was told to stop his Crestor because “it might be killing him.” Thankfully, the patient—an elderly gentleman at great risk of repeat heart attack—was open to hearing a second opinion.

In summary, if you are unfortunate enough to have had a heart attack, stroke, vascular disease, or diabetes, you are at immense risk of suffering some vascular complication down the road. Pharmaceutical research has provided us an enormously potent tool to cut the risk of heart attack, stroke and death in such individuals, and more than a hundred-thousand patients donated their bodies to help prove the safety of this therapy. Each of you has to make your own choice about every medication you introduce into your body, but I would encourage you to put a little faith in the best science that modern medicine has to offer and submit to letting your doctor help you control your cholesterol.

* Remarkably, there are numerous so-called experts who call into question the linkage between cholesterol and heart disease and theirwebsites can be easily found. The research that implicates cholesterol in vascular disease—starting with the seminalFramingham Heart Study in the 1950s—is about as ironclad as any concept we have in modern medicine. Those who can’t get on board with the lipid hypothesis would likely have been the same ones to reject the earth-is-round theory.

Eric Van De Graaff is a cardiologist at Alegent Health who blogs at the Alegent Health Cardiology Blog.

Too many young children are medicated with powerful drugs

2010-08-30T18:17:00.000-07:00

Recently while cleaning out my office in anticipation of my new job, I discovered that I had unknowingly been witness to to an historic moment in child psychiatry. I found a binder from a course I had taken in June of 2001 sponsored by Harvard Medical School on Major Psychiatric Illnesses in Children and Adolescents.

Though I did not remember until I looked at my scrawled notes in the margins, on Saturday June 9th I attended a lecture given by Janet Wosniak entitled “Juvenile Bipolar Disorder: An Overlooked Condition in Treatment Resistant Depressed Children.”

Little did any of us at the lecture know at the time that, largely as a result of Dr Wosniak her close colleague Joseph Biederman’s ideas, we would over the next nine years see a 4,000 percent increase in diagnosis of this “overlooked condition.” These children were described as irritable with prolonged, aggressive temper outbursts that she called “affect storms.” Some children were as young as 3 and over 60% were under age 12.

As this was in a sense a new disease, there were no controlled treatment trials. Wozniak described how she and Biederman reviewed charts of children seen with this constellation of symptoms in a psychopharmacology unit from 1991-1995. Patients received tricylics, stimulants, SSRI’s, and mood stabilizers. Neuroleptics were used in 10% of visits. Mood stabilizers seemed to be the most effective, SSRI’s seemed to be associated with risk of inducing mania. Wozniak did not mention atypical antipsychotics.

So here we have a perfect storm. A new disease with no clearly identified treatment. A new drug. Between 2000 and 2010 six atypical antipsychotics, Clozaril, Seroquel, Zyprexa, Risperdol, Abilify and Geodon were approved for treatment of pediatric bipolar disorder. The number of prescriptions for atypical antipsychotics for children and adolescents doubled to 4.4 million between 2003 and 2006. Prescribing of antipsychotics for two to five year olds has doubled in the past several years. Atypical antipsychotics are among the most profitable class of drugs in the United States.

It is not surprising that these powerful drugs are effective at controlling the explosive behavior associated with what Drs Wozniak and Biederman labeled as bipolar disorder(and is currently being redefined as Temper Dysregulation Disorder in an attempt to undo some of the damage of the storm). But this perfect storm may have prevented us from understanding these children in a way that leads to meaningful interventions.

While this storm was brewing, across the ocean in London, Peter Fonagy, Miriam Steele and colleagues were discovering, in the London Parent Child Project, that a parents capacity to reflect upon and understand her child’s experience helps that child learn to regulate strong emotions. Subsequent research has shown that child may be born with a genetic vulnerability for emotional dysregulation, but interventions that address family conflict and support relationships protect against this vulnerability and facilitate emotional regulation at the level of gene expression and biochemistry of the brain.

My hope is that this storm is clearing. Our culture, realizing the potential harm of medicating so many young children with powerful drugs that have serious side effects, may now be open to new ways of thinking about these “irritable” children Dr. Wosniak described that June day 9 years ago.
Claudia M. Gold is a pediatrician who blogs at Child in Mind.

JCAHO fun

2010-08-30T17:13:00.000-07:00

21 MARCH 2007

More JCAHO fun

All physicians hate JCAHO. Truly, it is an awful organization and they do awful things to the practice of medicine*. It seems like every year there is some new fad, some new measure that they are pushing down the throats of the people trying to practice medicine in a challenging environment.

I am sure there is some good that comes of JCAHO regulations. Their intentions may be good. But when you are the practicing doc (or nurse, God help them, the burden of the regs falls much harder on the nurses), trying to deal with a sick population, half of whom are uninsured, in an overcrowded ED with too few nurses and no inpatient beds and no specialists will to take call, the miniscule, petty, trivial, small-minded rules promulgated by this unelected bunch of bureaucrats can make you crazy.

For example, a couple of years ago, it was decreed that nothing could be stored under the sink in the ED. I have no idea why -- under the sink is a perfectly good storage place for non-medical supplies. They had to turn the ER upside down finding new legal storage places for the displaced stuff. And last year it was abbreviations. I agree that some abbreviations probably are confusing and should be clarified -- that's good common sense. But they came out with a list of dozens of abbreviations which are banned, many of which are perfectly clear (such as the use of L for Left and R for right). There is no appeal for their decisions, they are passed down from on high as infallible law, and woe betide the nursing manager if the department is singled out as deficient on a JCAHO survey.

The new rule, designed, it seems, to increase patient treatment times and decrease patient satisfaction and quality of care, is this:All non-emergent medications must be reviewed by a pharmacist and mixed (if necessary) by a pharmacist.
Which sounds reasonable on the face of it until it collides with the hard reality:
We don't have a pharmacist in the ED. There aren't enough pharmacists to go around as it is, and now, instead of keeping the drugs in the ER and mixing them at the point of service (which isn't that hard), we need to send up to the inpatient pharmacy, wait for the PharmD to get around to it in their workflow, and send it back down. And we are not even talking about the dangerous stuff, but routine meds like certain antibiotics. Another interruption to our workflow, another delay in patient care, just one more in the death of a thousand cuts that is making health care that much more of an unpleasant profession.

And the scary thing is that this is an improvement from the original draft regulation, which said that all meds had to be reviewed in advance by a pharmacist.

Maybe that MBA might be a good idea after all...

* yes, this is hyperbole. get over it.

DO NOT USE MOBILES WHILE DRIVING ;NO,NOT EVEN FOR TEXTING OR TWITTING

2010-08-29T19:58:00.000-07:00

No LOL Matter

by WhiteCoat

It’s sad when you hear about deaths due to texting while driving. Dr. Frank Ryan recently drove off a California cliff while reportedly making a Twitter post about his dog.
We recently had a 22 year old patient come in from a bad motorcycle accident. Road rash all over the place. Wasn’t wearing a helmet. As we began to examine him, it became evident that he had a spinal cord injury. He had priapism and reduced rectal tone. His legs weren’t moving. MRI showed a T6-T7 injury.
It was even more sad learning how the injury occurred. He told the paramedics that he was riding his motorcycle at a high rate of speed using one hand to steer and using the other hand to talk on his cell phone. On a speeding motorcycle. He was making plans to meet a friend that evening to go out to the bars and “get some.” The only thing he “got” was a lot of IV medications, a neurosurgical consultation, and a hospital bed.
Now he’s forever more likely to “get a lot less” due to a lapse in judgment.
Is answering that message from your BFF this instant really worth the thought of dying … or of sitting in a wheelchair the rest of your life?
Don’t text and drive.
UPDATE AUGUST 28, 2010
The day after my original post and one of my first patients of the shift last night was a 21 year old young lady who gashed her head open when she was driving down the street at 40 mph and she hit a parked car … while she was texting.
The 22 year old didn’t think the wheelchair would happen to him. This patient didn’t think the crash would happen to her. No one gets behind the wheel and expects to get into a major car accident.
Someone just told me about Oprah’s campaign about texting and driving. Read about it.
It’s not a question of IF something bad will happen to you, only WHEN it will happen to you.
Don’t text and drive

Why we walk to emergencies.

2010-08-26T21:50:00.000-07:00

Why we walk to emergencies.

by impactEDnurse

Our departments medical emergency team (MET) consists of a senior doctor and nurse who respond to medical emergencies occurring throughout the hospital. We actually call them the MET team, which is kinda like saying: ATM machine.
When their pager goes off they respond by pushing this rather large trolley bristling with advance life support equipment to the scene of the emergency.
But its not like on TV.
We don’t take off running down the corridor with the doctors coat flapping behind him like a Batman cape.
We walk to our emergencies, Its safer that way.
When I was young and stupid. I did run to emergencies. We didn’t have such a large crash cart back then. In one hand you picked up a fishing tackle box full of emergency drugs and cannulation equipment, with the other you grabbed the defibrillator (which was pretty heavy back then) and off you sprinted.
One night I was running to a code, full tilt down a long underground corridor that leads from one hospital building to another.
As my arm carrying the heavy defibrillator swung past my hip it knocked the pager from my waist. The pager bounced off my knee and fell to the ground breaking open… the very instant before I trod on it.
For some reason known only to Motorola, its old pagers were packed with a hundred little small ball bearing springy thingies, and I skidded along on one leg for several meters on the now disintegrating pager, arms flapping out to the sides.
One of the paddles of the defibrillator came loose wrapping around my flailing legs.
I landed heavily on my back.
The defibrillator came crashing down; seriously injuring three of the Tweety-Birds that were now flying around my head. Once I collected myself and sat up on my elbows, I could see that I had broken the pager, the defibrillator and the world record for the slowest response to a medical emergency.
Another time one of my colleagues was on the MET that responded to a man who had jumped through a large window on the ninth floor of the hospitals main building. He landed on the roof directly above the hospital main entrance.
Initially the code was called to the ninth floor, and our intrepid team, thinking it would be far quicker than waiting for our glacial lifts, humped up the stairs (right past the crumpled roof), arriving totally exhausted to find their patient was back down where they had started.
To get to him Chris and the doc had to break a thick window on the first floor and clamber out onto the roof. They were knackered. And they fully expected the man to be dead. The roof had partially collapsed under his impact leaving him laying at the bottom of this human shaped crater.
The crumpling of the roof must of cushioned his fall somewhat, for as they climbed out to him he lifted his arm and said, “I know I just died…but I feel OK.”
Crap. Now what do we do?
Chris was checking the poor guy over and figuring out how the heck they were going to extricate him off the roof whilst maintaining spinal precautions, when an enormous section of glass from the window way up on the ninth floor sliced down like a guillotine just centimeters from where they were crouched.
Chris and the doc looked at each other, MET was trumped by WTF, and without a further word of discussion, they dragged the man unceremoniously by one arm and one leg, out of his crater, across the roof and back through the window.
And then of course there was the time I ran to a code way, way over at the other end of the hospital. I was a young nurse back then and I thought I looked pretty cool yelling at little old ladies on their hopper frames to stand clear as I sprinted past. Yes, this is what being an ED nurse is all about.
By the time I got there, I was so knackered I vomited into the physiotherapy pool.
Nope, you don’t see that on TV.

ACEP Preview – Hemostasis: Stopping the bleeding in a crashing trauma patient

2010-08-23T21:57:00.000-07:00

ACEP Preview – Hemostasis: Stopping the bleeding in a crashing trauma patient

by emcrit

Hey folks,
I’m lecturing at ACEP in Las Vegas this year. This is one of two lectures I’m giving there. If you are going to the conference and plan on coming to my lecture, don’t listen to this lecture; I’d rather you hear the real one in person.
But if you can’t make it this year, and you have 50 minutes, take a listen and let me know what you think.
Here is the Handout
Here are the Slides

Popout

Original audio source (EMCrit-Lecture-20100822-Preview-of-ACEP-Hemostasis.mp3)

Cancer in a transplant kidney, is it the doctor’s fault?

2010-08-23T20:19:00.000-07:00

Cancer in a transplant kidney, is it the doctor’s fault?

May you never be an interesting case.

That’s a cautionary proverb familiar to medical professionals. While it’s bad to get sick, it’s much worse to get sick with something uncommon or unusual. The more fascinating a case is for doctors, the more difficult it is for patients. Difficult to diagnose, difficult to treat, and often difficult to survive.

Kenneth Liew was doubly unfortunate. He was an interesting medical case and an interesting legal case. Now he’s dead and a jury is currently deliberating who, if anyone, is at fault.

Kenneth Liew was really, really unlucky. He was unlucky because he had serious kidney disease that necessitated debilitating dialysis treatments three times each week. He was unlucky because it took 10 years for a matching kidney to be found to give him in transplant. He was unlucky because after he received his kidney and after it was working well, an autopsy revealed that the kidney came from a woman who, though she died of a stroke, had unknowingly had uterine cancer as well. He was unlucky because there is not a single case like his in the whole world, so no one knew the odds that the cancer would be transmitted. He was unlucky because he died of cancer only seven months after receiving the transplant.

Despite being exhorted by her dying husband to forgive the doctor, Mr. Liew’s widow ignored his wishes and sued just about everyone she could think of including the doctor and New York University Medical Center where the transplant occurred. Eight years after Mr. Liew died, the jury has finally received the case.

First and foremost, this case has been a nightmare for Mr. Liew and his family. But secondarily, this case also represents a doctor’s worst nightmare. The doctor, transplant surgeon Thomas Diflo, lost a patient through a freak accident that no one could have known about or predicted and now he’s being blamed. I would feel sympathy for the doctor no matter what, but I am especially saddened because the doctor was one of my classmates in medical school.

Mrs. Liew is sure that somebody is to blame for something and that she deserves $3 million dollars in compensation, but it is not clear who is to blame or what they are to blame for:

· Did anyone know of the donor’s uterine cancer? Both sides agree that no one knew or could have known that the donor had uterine cancer.

· Was the patient informed that the donor had cancer? Both sides agree that the transplant surgeon informed the donor approximately 2 months after the he received the kidney.

· Should the kidney have been removed immediately thereafter? Both sides acknowledge that there was no way to predict the chances of Mr. Liew developing metastatic uterine cancer. There had literally never been a similar case in the history of medicine. Therefore, the doctor left the decision up to the patient, advising him that based upon what is known about transplants and cancer and based upon the fact that uterine cancer does not metastasize to the kidney, the chance that Mr. Liew would develop metastatic uterine cancer was low. Mr. Liew’s widow argues that the doctor should have advised that the kidney be removed immediately.

· Would removal of the kidney have made any difference? It’s unlikely. Whatever was transmitted to Mr. Liew from the donor kidney had already been transmitted.

· What caused Mr. Liew’s death? That’s not clear. Mr. Liew died of cancer, but the metastatic cancer was so poorly differentiated that no one can tell what type of organ it came from originally. It could have been uterine cancer transmitted by the kidney, but it also could have been cancer that developed spontaneously in Mr. Liew.

So if no one could have known about the uterine cancer in advance, if removing the kidney would not have made a difference and if it is not completely clear what kind of cancer killed Mr. Liew, why are Dr. Diflo and NYU being sued?

They are being sued because something bad happened and someone must be blamed. It wasn’t anyone’s fault; no one did anything wrong, but you can’t get any compensation for bad luck. Therefore someone, anyone, must be blamed and must be made to pay.

Amy Tuteur is an obstetrician-gynecologist who blogs at The Skeptical OB.