Archives for April 2005

symtym and the Specialty of Emergency Medicine

symtym  explains, much better than I could, why it bugs residency trained Emergency Physicians when docs trained to be specialists in something else choose EM, then denigrate the process of EM residency training and Board Certification to get themselves included.  A small taste:

…Emergency Medicine is the only one of the twenty-four recognized medical specialties in the United States that is routinely challenged by those not certified in Emergency Medicine as being monopolistic and "not the only path." No one ever complains about the monopolistic behavior of ABS, ABP or ABFM.

He’s on a roll, and he speaks for me here, too.

CDC: New Mosquito Repellents

CDC: New Mosquito Repellents Fight West Nile.

April 28, 2005 – The CDC says it is adding two new forms of mosquito repellent to its list of recommended products in the hopes of encouraging more Americans to guard against West Nile virus this spring and summer.

The agency says repellents containing picaridin and oil of lemon eucalyptus can both be considered along with DEET, the active ingredient in most bug sprays on U.S. shelves. Officials say DEET remains highly safe and effective but that more consumer choices could help encourage use of repellents.

..Picaridin, also known as KBR 3023, has been on sale for years in Asia, Australia, and Europe. It was only recently approved for use in mosquito sprays by the Environmental Protection Agency. The chemical has already hit stores in at least one product, Cutter Advanced repellent. Oil of lemon eucalyptus, also called p-menthane 3,8-diol, or PMD, is available in a number of sprays and lotions.

Studies show that picaridin works as well as similar concentrations of DEET, while oil of lemon eucalyptus repels insects about as well as low concentrations of DEET. Because picaridin is only available in a 7% formulation, neither product will prevent mosquito bites for as long as high-concentration DEET will, CDC officials say.

(Emphasis mine).  Anything that gets people to wear a barrier to mosquito-borne diseases is good in my book, though I’d probably avoid the oil of lemon eucalyptus unless I just couldn’t tolerate the DEET.  DEET for me, as I tolerate it quite well. – Living wills go out socially

Coming soon to a home near you: – Living wills go out socially.

Lingerie, Tupperware and murder mystery parties. They’ve been the rage for years. Now add a new one to the list: living wills parties.


I think this is a good idea, really.  I’ve droned on about advanced directives before, and the act of making your wishes known to your loved ones helps everyone when decision time comes.

Get me a spatula! STAT!

From the Cleveland Plain-Dealer: Get me a spatula! STAT!.

To promote team-building among its emergency-room doctors, administrators at the hospital have hired chef Sue Weiler, of Sue Times Two, to do a one-time hands-on luncheon class today at Sur La Table in Woodmere.

"We were looking for a creative venue that makes a good metaphor for emergency medicine. Cooking requires a fast pace, coordinated teamwork and strong leadership," said Dr. Cameron Symonds, chief resident of emergency medicine at MetroHealth Medical Center.

About 35 emergency-room physicians will be involved in this venture. The plan is to have five culinary teams at five work stations, in Sur La Table’s professional kitchen, prepare a challenging menu and serve it for lunch.

The menu will include: spinach yogurt soup with herbed pita toasts, mixed greens with manchego cheese, chunky salmon cakes with chives and crescent roll ground beef Wellington with spicy mustard sauce.

Symonds feels that bringing his medical team into a fun and relaxed atmosphere will help strengthen camaraderie.

"Our goal is to create a strong bond with our residents. A lot of emergency care requires fundamental skills and management of medical professionals," says Symonds.

Cooking is an OK metaphor for Emergency Medicine, and I’m not sure how this ‘promotes team-builiding’.  It’s a good way to find out who’s more assertive, and who has cooked before.

Sounds like a fun afternoon for the residents, though.

MedBlogs Grand Rounds XXXI

This week at DrTony: Grand Rounds XXXI.

Welcome to this week’s Grand Rounds. As you know, each week a different department here at the institution hosts this conference. Registration is free and attendance is not taken. This should come as a great relief to the medical students, who have learned that there is no advantage to being anywhere you don’t have to be.

Best Chief Complaint of the Year

A patient checked in, waited to be seen for the following:

"I get real hungry before I eat".


Site design oddities in IE

I just noticed that, at certain screen size settings, Internet Explorer (IE) causes the center section width to run all the way to the left margin, but the text stays in place.  This is with a fairly broad (1280 wide) setting, decreasing it fixes the problem.

I don’t have this in Opera or Firefox, so it’s just another example of IE not palaying nicely with CSS.  I read that the next IE browser, in beta form, comes out ‘sometime this summer’ and is supposed to play better with CSS.

So, sorry if it looks funny in your browser,  Try out Firefox (free) or Opera (free with ads, or about $40 and no ads).

Madhouse Madman Switches to Emergency Medicine

Well, not really.  But, he gives EM some love (sort-of) today.

symtym has some comments on the love, as well.

How was my night?

An unsolicited review from one of our techs:

"Doc, you got beat like a narc at a biker meet".

Good description.

Cold Fury ? The Man Who Won?t Be Pope

Best pun this month, starts out like this: Cold Fury ? The Man Who Won?t Be Pope.

Hans Grapje was raised in a Catholic orphanage in The Hague and, as a young man, aspired to become a priest, but was drafted into the Army during WWII and spent two years co-piloting B17s until his aircraft was shot down in 1943 and he lost his left arm. Captain Grapje spent the rest of the war as a chaplain, giving spiritual aid to soldiers, both Allied and enemy.

Go and read the whole thing, don’t skip to the end.

Grand Rounds Reminder

DrTony: Grand Rounds.  Get your submissions in before 6PM Monday (earlier than usual) to

Pneumonia, antibiotics, and CMS

This is the text of an email I got from one of my professional societies, AAEM.  I’m copying it here, and highlighting some of the text, to support a minor rant to follow:

AAEM Update from Dr. William Rogers of CMS (speaker at the 2005 Scientific Assembly):

Thanks to AAEM for inviting me to speak at the annual meeting. The dialog was valuable to me and I am committed to helping enforce the CMS requirement that physicians have access to information concerning billing for services they render. I must apologize for a HUGE mistake I made in responding to a question concerning "four hours to administer antibiotics for pneumonia." I said that CMS was not going to define a time period within which antibiotics must be administered to patients with pneumonia in our hospital quality measures and I was wrong. We have defined the acceptable time period as four hours. These measures will change over time and I am well aware of the challenge that many EDs will have in meeting this target. To the extent that the target encourages hospitals to make investments which will reduce waiting times and allow for more timely treatment; the goal will be serving a useful purpose. I am concerned that some overwhelmed emergency departments will resort to creative strategies to improve their scores which won’t really improve the quality of care; an approach which should not be encouraged. If the Physicians Regulatory Issues Team at CMS can be of help to the AAEM in any way, please call or email us.

William D Rogers, MD FACEP
Medical Officer, Office of the Administrator Director, Physicians Regulatory Issues Team Center for Medicare and Medicaid Services

The bold text has to do with getting antibiotics into patients with pneumonia within four hours of diagnosis of said pneumonia.  Sounds easy, right?  Well, the patient is seen, and the clock starts (I think, please correct me if the clock starts elsewhere).  It takes time for the xray order to get entered, for the patient to get an xray, for the doctor to be aware the xray has been taken, the xray to be seen by a doctor, find the chart, write an order for antibiotic, nurse gets chart, gets antibiotic, and starts it.  In a perfect world that’d take 30 minutes, tops.  I don’t know any ER doc who works in a perfect world.

The underlined text is what burns me up right now.  Deadlines can make hospitals make investments, but since CMS has decided to use the WalMart version of financial management, ie, pay a little less every year, where will this money come from?  Yes, we’re going to be forced to be ‘creative’ in the face of losing medicare funding.

Medicare (CMS) has the authority to withhold money if their goals aren’t met, so there’s a lot of emphasis on meeting the target.  However, eventually medicare payments will get low enough it won’t be wort the effort.

And that’s when the fun starts in healthcare financing.

Nesiritide: Bad news from JAMA

Again, never be the first, and never be the last to use a new drug.  Looks like the jury’s still out on this one.  Here’s some of a review from Medscape about today’s JAMA article (emphasis added):

April 20, 2005 ? The bad news is getting worse regarding the
natriuretic nesiritide (Natrecor)
, a medication with both diuretic and
vasodilatory properties that is often given in the treatment of acute
exacerbation of decompensated heart failure.

Earlier research had shown that nesiritide, despite claims, is not
associated with preservation of renal function. Now, in a meta-analysis
published in the April 20 issue of JAMA, investigators report
that patients treated with nesiritide are more likely to die in the 30
days after treatment than are patients treated with noninotrope
therapies used in acute congestive heart failure.

The investigators found that
nesiritide-treated patients were 1.74 times more likely to die
the 30-day window. Among the nesiritide-treated patients, 35 (7.2%)
died in this time period compared with 15 (4.0%) of those treated with
other medications (P = .059). After adjusting for different variables, the risk of death in the nesiritide group increased slightly to 1.80 (P = .057).

And, it turns out it isn’t completely unexpected:

"These results were disappointing but not surprising," Stephen A.
Siegel, MD, said in a phone interview. Dr. Siegel, who was not involved
in the study, is a clinical assistant professor of medicine in the
division of cardiology at the New York University School of Medicine in
New York City.

"The inotropic support concept has never worked," Dr.Siegel pointed
out. "It’s paradoxical, because if the heart is lacking contractility,
it would make sense to give a medication that increases contractility.
However, this treatment approach doesn’t seem to reduce the risk of

Dr. Siegel concluded, "It may be that we need to explores other ways
to treat congestive heart failure, such as the neuronal-hormonal
effect. The definitive answer of how to treat it hasn’t been identified
yet, but considering that inotropes don’t work, this drug class just
may be the wrong way to go."

JAMA. 2005;293:190-195    By

  Paula Moyer, MA Freelance Medical Writer

This drug has never caught on in our ED, and when used it’s been at the behest of the cardiologist who admits the patient.  Given this, I don’t see that changing.

Emergency Room Manners

Astounding rant from an ER triage nurse: Emergency Room Manners.

To review:

1) Don?t be an asshole
2) Lose the weight, stop smoking, take your damn psych meds, and take care of yourself!
3) Its not our fault or responsibility that you?re sick/injured. In fact, it?s probably yours.
4) Folks that arrive dead usually stay dead
5) It?s not like on TV
6) Years of patient abuse have (clearly) left us all a bit burnt out and jaded, so. . .
7) Don?t forget your manners when you come to my ER : )

Wow.  Couldn’t have said it better myself.  (Warning, actual ED language).

via Code:the WebSocket

Obesity Death Risk Overstated: Insurance Companies Notice? – Study: Obesity death risk overstated – Apr 20, 2005.

According to the new calculation, obesity ranks No. 7 instead of No. 2 among the nation’s leading preventable causes of death.

The new analysis found that obesity — being extremely overweight — is indisputably lethal. But like several recent smaller studies, it found that people who are modestly overweight have a lower risk of death than those of normal weight.

Biostatistician Mary Grace Kovar, a consultant for the University of Chicago’s National Opinion Research Center in Washington, said "normal" may be set too low for today’s population. Also, Americans classified as overweight are eating better, exercising more and managing their blood pressure better than they used to, she said.

The study — an analysis of mortality rates and body-mass index, or BMI — was published in Wednesday’s Journal of the American Medical Association.

(Emphasis mine)

So, now let’s all hold our collective breaths waiting for insurance companies to rewrite their body mass standards, and thereby lose the gobs of money they charge ‘overweight’ people.