A very Classical Grand Rounds: Dr. Sanity.
Welcome to Grand Rounds XXXVI ! This week we will hold our Rounds while touring an exhibit of drawings by the incomparable Leonardo Da Vinci born in 1452. Leonardo’s Self Portrait is to the left. Da Vinci was not only an artist, but an anatomist, a philosopher, an inventor, and engineer.
What an interesting way to present! And, I learned about Da Vinci’s art, so it’s truly education.
There are several excellent blog entries about Memorial Day, but this is the one I read all the way through: The Indepundit.
Get it started: grand rounds submissions: Dr. Sanity.
Please send in your submissions before Monday the 30th, 6:00pm, Eastern Time, to "patsanty"at"aol.com" with the subject "Grand Rounds." You may contribute one of your own posts or recommend one you’ve seen.
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Tonight I got one of the built-in hazards of medicine: a needlestick injury with a ‘dirty’ needle.
I was going to, well, touch-up the anesthesia on a digital block that wasn’t quite right, and as I picked up the syringe I got distracted. The next thing I knew a 27 gauge needle went right into a finger. My finger. My ungloved finger.
The first thought that flew into my mind: "Crap! I’m better than that." Really, I was terrifically disappointed in myself, and angry I’d made the rookie mistake of not watching the needle in my hand. I handle needles for a living, and they never get me, they get the patient, as intended. That’s how it’s Supposed To Be.
My next thought was "This is the last needlestick of the rest of your life". I mentally reviewed the very very brief medical history I had taken of this patient, and decided more social history was in order. After a polite explanation I addressed some of the deficiencies: "Any drugs?", I inquired. "What kind of drugs?", replied my suddenly less-than-satisfying patient. "IV drugs" said I. "Oh, no, no IV drugs." The sexual history was mercifully brief and reassuring, and no transfusions, etc. Never had hepatitis, no other problems. Good.
As the patient had seen me stab myself (then mildly curse, appear peeved, and ask a lot of pointed questions), he knew what was up and was quite gracious about consenting for testing. Blood was drawn, and then I fixed his problem. I had to get back on the horse, and despite the melodrama preceeding I realized my risk was small.
His rapid HIV was negative, which I expected but wanted to see anyway. Of the other two major concerns, my hep B is covered (I’ve had the series, a booster, and am a responder) and I can’t do anything about hep C anyway, so I choose not to sweat that. I’ll check up on those, though, out of curiosity in a day or two.
Mortality sucks. Mortality through stupidity would be unforgivable, for me, and I resolve to not make any more stupid mistakes.
It must be official, the CDC confirms it: U.S. Newswire : Releases : "Visits to U.S. Emergency Departments at AllTime High…".
WASHINGTON, May 26 /U.S. Newswire/ — Visits to the nation’s emergency departments (EDs) reached a record high of nearly 114 million in 2003, but the number of EDs decreased by 14 percent from 1993 to 2003, according to a new report released today by the Centers for Disease Control and Prevention (CDC).
The report attributes the rise in ED visits to increased use by adults,65 years old and over. Among people aged 65-74, the ED visit rate was more than five times higher for those residing in a nursing home or other institution compared with those not living in an institutionalized setting. especially those
The report also finds that Medicaid patients were four times (81 visits per 100 people) more likely to seek treatment in from an ED than those with private insurance (22 visits per 100 people.)…
Other findings in the report include:
— From 1993 through 2003, the number of ED visits increased 26 percent from 90.3 million visits in 1993 to 114 million in 2003. The U.S. population rose 12.3 percent during this period, and the 65-and-over population rose 9.6 percent.
— The average waiting time to see a physician was 46.5 minutes, the same as it was in 2000. The wait time was unchanged despite increased visits. EDs have implemented a number of efficiencies, including "fast track" units, which may have kept the wait time constant. On average, patients spent 3.2 hours in the ED, which includes time with the physician as well as other clinical services. …
— In 2003, patients arrived at the ED by ambulance in 14 percent of the visits, representing over 16 million ambulance transports. More than a third of patients who arrived at the ED by ambulance were 65 years of age and over. …
— About 58 percent of all EDs were located in metropolitan areas, and they represented 82 percent of the annual usage. Board-certified emergency medicine physicians were available at 64 percent of EDs and almost half of all EDs had a nursing triage system. …
For a copy of the full report visit http://www.cdc.gov/nchs
Well, this is what we’ve all heard, and anecdotally this fits what I see. As the nation ages, and the aged get warehoused, the ED visit rate goes way up. I’m sure there are some truly excellent nursing homes where patients are well cared for, but I don’t see their patients. I see the ones like the gentleman a few shifts ago: awakened at midnight, told ‘you have pneumonia and CHF and need to go to the hospital’, and tha patient had no complaints. He also didn’t have pneumonia, and his CHF was at its baseline. Back to the same nursing home.
The other interesting thing was the finding that "Board-certified emergency medicine physicians were available at 64 percent of EDs…", a stastic that bodes well for patients and the Specialty both. The actual quote from the study is:
"Board-certified emergency medicine (EM) specialists were available 24 hours a day and 7 days a week in the majority ofEDs (63.5 percent), and pediatric EM specialists were only found in 18.1 percent of EDs."
I’m assuming they mean EM Boarded here, and I hope that’s the case. Good for us, but the Peds EM market looks wide open.
USMC gets coin(ed): Marines are landing — on silver dollars – May. 26, 2005.
NEW YORK (CNN/Money) – On the eve of Memorial Day, the U.S. Mint is remembering America’s fighting men and women.
Wednesday in Philadelphia, Mint director Henrietta Holsman Fore led the ceremonial first strike of a new series of commemorative coin: a silver dollar honoring the U.S. Marine Corps. The piece will be minted at the Philadelphia facility, and is scheduled for release this summer.
The front of the coin features an engraving modeled on Associated Press photographer Joe Rosenthal’s picture of victorious Marines raising the U.S. flag after the battle of Iwo Jima. …
The back side of the coin bears the Marine Corps insignia and the words "Semper Fidelis" (Always Faithful), the Corps motto.
"The coin design is simple and heroic," said Fore in a statement. "The Iwo Jima image is the storied symbol of the Marine Corps’ heroism, courage, strength and versatility. It exemplifies Semper Fidelis to an appreciative nation every day around the world."…
The price of the new Marines coin was not announced, but profits from the sale of each dollar will help pay for the creation of a National Museum of the Marine Corps at Quantico, Virginia.
More info on military unit coining, though not with silver dollars that’ll no doubt retail for more than the $35 the article suggests.
This evening I took care of a young man with a shoulder dislocation. It has happened to him so many times he doesn’t know the actual number. That’s not the unusual part.
As I was preparing him for the relocation procedure (I use etomidate, a drug from the gods of medicine), I was explaining what I was going to do,
RBA, etc., and there was a brief slack period. That’s when I looked up at the TV (a few of our rooms have TVs in them, mounted well up the walls).
It was The Quiet Man, and I said (without prompting, and with pretty much a captive audience): "That movie must be pretty cheap. I’ve seen it about 5 times in the last two months. One of John Wayne’s least known films, and perhaps some of his best acting". Given the silence, I was aware that my comment was odd, so I told him the Movie Review was on the house.
The patient was enjoying the movie as he drifted off to sleep. His relocation was more smooth than the dialog, though he’ll never know it.
More evidence that just computerizing the process doesn’t make it better: Arch Intern Med — Abstract: High Rates of Adverse Drug Events in a Highly Computerized Hospital, May 23, 2005, Nebeker et al. 165 (10): 1111.
Background Numerous studies have shown that specific computerized interventions may reduce medication errors, but few have examined adverse drug events (ADEs) across all stages of the computerized medication process. We describe the frequency and type of inpatient ADEs that occurred following the adoption of multiple computerized medication ordering and administration systems, including computerized physician order entry (CPOE).
Methods Using explicit standardized criteria, pharmacists classified inpatient ADEs from prospective daily reviews of electronic medical records from a random sample of all admissions during a 20-week period at a Veterans Administration hospital. We analyzed ADEs that necessitated a changed treatment plan.
Results Among 937 hospital admissions, 483 clinically significant inpatient ADEs were identified, accounting for 52 ADEs per 100 admissions and an incidence density of 70 ADEs per 1000 patient-days. One quarter of the hospitalizations had at least 1 ADE. Of all ADEs, 9% resulted in serious harm, 22% in additional monitoring and interventions, 32% in interventions alone, and 11% in monitoring alone; 27% should have resulted in additional interventions or monitoring. Medication errors contributed to 27% of these ADEs. Errors associated with ADEs occurred in the following stages: 61% ordering, 25% monitoring, 13% administration, 1% dispensing, and 0% transcription. The medical record reflected recognition of 76% of the ADEs.
Conclusions High rates of ADEs may continue to occur after implementation of CPOE and related computerized medication systems that lack decision support for drug selection, dosing, and monitoring.
Our headlong rush to computerize medical care will do away with transcription errors, but more is needed in terms of process and decision-making.
The best single sentence describing blogging I’ve ever read: Huffington?s Toast – Not Affiliated With Arianna Huffington or The Huffington Post ? Blog Archive ? Jim Dandy.
How wonderful, to see blogging serving its purpose, i.e. giving wide exposure to a writer who would otherwise be using a rented Bobcat to fill low places on his property with rejection slips, empty Zoloft bottles, and restraining orders.
I could rent a bobcat? I’m there!
Another in a series: Iatremia: The Chaplin.News: Grand Rounds XXXV.
"A witty saying proves nothing." –Francois Marie Arouet
Welcome to Grand Rounds XXXV! As the summer begins to heat up, the memory of the box office smash hits, catchy lyrics, t-shirt slogans and favorite summer reads came unbidden to mind as I compiled this week’s offerings. May I present to you The Quotable Grand Rounds?
Go forth, read, and quote!
Funniest governtment personnell ad is for ?Lawyers? : Office of General Counsel – Who Would You Rather Work For?.
An excellent look at the family dynamics of, well, being the doctor in the family: The Examining Room of Dr. Charles.
… While the first year of schooling typically qualifies the student to fulfill such tasks as pronouncing the names of illnesses, reliably identifying the branches of the brachial plexus, or spotting portal fibrosis of the liver under a microscope, there are still several quantum leaps left before a full-fledged diagnostician is made. In our mid-twenties, still playing video games and drinking beer, we lack the grey-haired, bespectacled air of seasoned wisdom. Still our families ask for advice, much to their own peril.
An excellent read.
Nearly three years ago we bought our beautiful contemporary home, built in 1981. It had original everything, including the mechanical systems, which were nearly up to the job three years ago. Last year we really noticed that the AC struggled (valiantly) against the Texas heat and humidity, but it was an all day battle, with the units running nearly 24/7. Oh, and the electric company noticed too, and billed us for it. Owee.
Earlier this year we had the big unit replaced, and it has made a world of difference in our comfort (I’m waiting for the electric company to let us in on their take). Today we start replacing the ‘little’ unit that cools the small side of the house, and we’re looking forward to it. The company that did the first is doing the second, and they’re absolutely the most professional company I’ve ever hired. I’d give them a plug, but as I pay full price for their work, I think they should buy an ad! (Insert wry grin here).
So, I’ll be a tad busy supervising pros who don’t need my help but will get it anyway, and my posting may suffer for it. The good news is that this should take care of the AC for about 20 years, and that makes me happy!
See? There are things that make me happy.
A little concerned: Iatremia: The Chaplin.News: Are You Submissive?.
Are You Submissive?
SUBMIT TO ME!
Please submit your articles for the upcoming Grand Rounds by Monday, 5/23, 6pm EST to "news-AT-chaplin-DOT-nu" with the subject "Grand Rounds."
If not, it could be the shortest one yet.
So, get yours in, now, so Iatremia can get some sleep.