Archives for May 2005

Funniest parody website, maybe ever.

It’s filled with amusing inside-the-blog-world insider jokes, and I love it.

You might too.

U.S. to pay medical bills for illegal immigrants

It may now be more financially viable to provide care for illegal aliens than US citizens without insurance: – pay medical bills for illegal immigrants.

WASHINGTON (AP) — Health care providers can charge the government for emergency care provided to illegal aliens beginning Tuesday.

The Centers for Medicare and Medicaid Services issued final guidance Monday that sets up a system for reimbursement. Lawmakers set aside $1 billion over four years for the program, created by Medicare legislation passed in 2003.

For hospitals in border states, the additional money can mean the difference between running a profitable business or an unprofitable one, said Don May, vice president of policy for the American Hospital Association….

Two-thirds of the money will be distributed to health care providers based on a state’s percentage of undocumented aliens.  The remaining third will go to providers in the six states with the largest number of arrests of undocumented aliens.

Hmm.  Where did this ‘most arrests’ clause come from?  However, the government is (slowly) starting to fund at least one of its mandates.

This’ll still be only pennies on the dollar (in the government healthcare funding style), but it’s better than nothing.


Splitting church members: Not News

Why isn’t this getting more national press?  Splitting church members say they will keep peace. 

St. Nicholas’ Episcopal Church parishioners peacefully worshipped together Sunday, even as the congregation is splitting over denomination politics and biblical teachings, resulting in the charter of a new Midland church.

… Almost 90 percent of members and their pastors were ordered by the Northwest Texas Diocese to leave St. Nicholas’ for dissenting with the Episcopal Church’s stance on homosexuality by naming a gay bishop in New Hampshire, among other things.

"But the homosexual issue is just a small part of a greater crisis," said the Rev. Jonathan Hartzer, associate rector. "The greater crisis is cultural accommodation at the expense of biblical Christianity."

Support for the ousted Midland congregation has come from all over the world, Hartzer said, and vast numbers of believers from afar are expected travel here to attend the last service of the full congregation May 29.


Conservative pastors trying to oust a couple of Kerry voters (which is stupid and wrong, BTW) were headline news on CNN, but the vast majority of a congregation being kicked out of a church because of ‘cultural accomodation(s) at the expense of biblical Christianity’ hasn’t been Big News yet.

Why?  It’s not even my church, and I wonder.

MedBlogs Grand Rounds XXXIII

A no-nonsense, to the point Grand Rounds XXXIII (

Welcome to Grand Rounds XXXIII. For a listing of upcoming Grand Rounds click the link.

Well, click it!

WSJ on Stroke: TPA is a wonder drug for stroke!

Summary: Neurologists are excellent with acute stroke, EM docs are stupid, and anyone against TPA is backward.

I have read this twice, and am of the opinion the reporter was assigned the topic “stroke” to write about, then talked to a neurologist who was a big fan of TPA for stroke. It is filled with “they’re stupid if they don’t embrace…”, TPA for stroke (which I’ve written about before), and then it just keeps getting worse:

Stroke victims are often taken to wrong hospital

Monday, May 09, 2005
By Thomas M. Burton, The Wall Street Journal

Christina Mei suffered a stroke just before noon on Sept. 2, 2001.
Within eight minutes, an ambulance arrived. Her medical fate may have
been sealed by where the ambulance took her.

Ms. Mei’s stroke, caused by a clot blocking blood flow to her brain,
occurred while she was driving with her family south of San Francisco.
Her car swerved, but she was able to pull over before slumping at the
wheel. Paramedics saw the classic signs of a stroke: The 45-year-old
driver couldn’t speak or move the right side of her body.

Had Ms. Mei’s stroke occurred a few miles to the south, she probably
would have been taken to Stanford University Medical Center, one of the
world’s top stroke hospitals. There, a neurologist almost certainly
would have seen her quickly and administered an intravenous drug to
dissolve the clot. Stanford was 17 miles away, across a county line.

But paramedics, following county ambulance rules that stress proximity,
took her 13 miles north, to Kaiser Permanente’s South San Francisco
Medical Center. There, despite her sudden inability to talk or walk and
her facial droop, an emergency-room doctor concluded she was suffering
from depression and stress. It was six hours before a neurologist saw
her, and she never got the intravenous clot-dissolving drug.

Woah, pardner. There has to be more to the story than this; if not, there’s an idiot for an ER doc. As the vast majority aren’t idiots, the above makes no sense.

However, the ‘..almost certainly would have..administered an IV drug to dissolve the clot…’ is only about 1/10th of the story. However, just reading this article, I’d be ticked off if I didn’t get TPA for a stroke.

Stroke is the nation’s No. 1 cause of disability and No. 3 cause of
death, killing 164,000 people a year. But far too many stroke victims,
like Ms. Mei, get inadequate care thanks to deficient medical training
and outdated ambulance rules that don’t send patients to the best
stroke hospitals.

Uh, deficient medical training? Based on what fact is this assertion made? There exists a lot of controversy about the use of TPA in stroke, and that isn’t because of ‘deficient training’, it’s because very smart people have looked at the literature, evaluated the risks, combined those with their clinical experience and then came to differing conclusions.

Over the past decade, American medicine has learned how to save stroke
patients’ lives and keep them out of nursing homes. New techniques
offer a better chance of complete recovery by dissolving blood clots
and treating even more lethal strokes caused by burst blood vessels in
the brain. But few patients receive this kind of treatment because most
hospitals lack specialized staff and knowledge, stroke experts say.
State and county rules generally require paramedics to take stroke
patients to the nearest emergency room, regardless of that hospital’s
level of expertise with stroke.

There’s a paragraph about stroke care needing to be like Trauma care, deleted.

Eighty percent or more of the 700,000 strokes that Americans suffer
annually are “ischemic,” meaning they are caused by blockage of an
artery feeding the brain, usually a blood clot. Most of the rest are
“hemorrhagic” strokes, resulting from burst blood vessels in or near
the brain. Although they have different causes, both result in brain
tissue dying by the minute.

Several factors have combined to prevent improvement in stroke care. In
some areas, hospitals have resisted movement toward a system of
specialized stroke centers because nondesignated institutions could
lose business, according to neurologists who favor the changes. In
addition, stroke treatment has lacked an organized lobby to galvanize
popular and political interest in the ailment.

Nobody I know wants to ‘prevent improvement in stroke care’. And the idea that an organized lobby is needed to push this agenda is ludicrous.

A big reason for the backwardness of much stroke treatment is that many
doctors know little about it. Even emergency physicians and internists
likely to see stroke victims tend to receive scant neurology training
in their internships and residencies, according to stroke specialists.

“Surprisingly, you could go through your entire internal-medicine
rotation without training in neurology, and in emergency medicine it
hasn’t been emphasized,” says James C. Grotta, director of the stroke
program at the University of Texas Health Science Center at Houston.

This is just twaddle. EM residency programs cover neurology of emergencies very well, thank you. It’s part of the EM curricula, and it’s part of the tests and training. IMHO, EM docs see way more acute strokes than do neurologists.

Many hospitals don’t have a neurologist ready to deal with emergencies.
As a result, strokes aren’t treated urgently there, even though short
delays increase chances of severe disability or death. Even if doctors
do react quickly, recent research has shown that many aren’t sure what
treatment to provide.

True, most hospitals don’t have neurologists available to treat emergencies (and those that do have trouble getting them to come in). That ‘lack of neurologists’ has nothing to do with a delay in stroke care. Delays are delays, and every hospital has a way to prioritize tests and treatments. Lack of neurologists doesn’t equal lack of priority.

For example, a survey published in 2000 in the journal Stroke showed
that 66 percent of hospitals in North Carolina lacked any protocol for
treating stroke. About 82 percent couldn’t rapidly identify patients
with acute stroke.

What? Couldn’t rapidly identify patients with an acute stroke? That’s just nonsensical. Any EM trained doc, or an ER nurse with 6 months’ experience can identify people with ‘possible stroke symptoms’ and start the eval right then. As for the lack of protocol, well, there’s a whole argument about checklist medicine, and whether protocols are helpful or harmful.

As with other life-threatening conditions, stroke patients are better
off going where doctors have had a lot of practice addressing their
ailment. A seven-year analysis of surgery in New York state in the
1990s showed that patients with ruptured blood vessels in the brain
were more than twice as likely to die — 16 percent versus 7 percent —
in hospitals doing few such operations, compared with those doing them
regularly. A national study published last year in the Journal of
Neurosurgery showed a similar disparity.

Okay, here we start mixing our apples and oranges; that was (probably) about aneurysm surgeries, very different for the vast majority of ischemic CVA’s.

Another major shortcoming of most stroke treatment
, according to many
neurologists, is the failure to use the genetically engineered
clot-dissolving drug known as tPA.
Short for tissue plasminogen
activator, tPA, which is made by Genentech Inc., has been shown to be a
powerful treatment that can lessen disability for many patients. A
study published in 2004 in The Lancet, a prominent medical journal,
showed that the chances of returning to normal are about three times
greater among patients getting tPA in the first 90 minutes after
suffering a stroke, even after accounting for tPA’s potential side
effect of cerebral bleeding that can cause death
. But several recent
medical-journal articles have found that nationally, only 2 percent to
3 percent of strokes caused by clots are treated with tPA, which has no
competitor on the market.

Some authors of studies supporting the use of tPA have had consultant
or other financial relationships with Genentech. Skeptics of the drug
point to these ties and stress tPA’s side-effect danger. But among
stroke neurologists, there is a strong consensus that the drug is

If they were pushing, say, Bush administration talking points and got caught taking money for it, they’d be pariahs to the press. Double standard for those pushing medical interventions, I suppose.

But, let’s not gloss over the side effect: taking an injured brain and making it substantially worse, in 6-9% of cases. That’s not an intervention to rally around, it’s one to be feared, and to be engaged only when the benefits very clearly outweigh the risks.

The article is very much longer, and reads like the neurologist dream agenda. The slant of the article is so pro-neurologist and so anti-EM doc, though, and gives short shrift to the other side of th TPA controversy, it’s impossible to take seriously.

Police jail driver they say hit nurses

Update on the Arlington Nurses : Star-Telegram | 05/07/2005 | Police jail driver they say hit nurses.

Posted on Sat, May. 07, 2005

Police jail driver they say hit nurses

By Susan Schrock

Star-Telegram Staff Writer

ARLINGTON – A woman who police say intentionally struck two nurses with her car in an Arlington hospital parking lot was booked into jail Friday morning after psychiatric evaluation.

Gladys Wangui, 34, of Arlington is charged with two counts of aggravated assault with a deadly weapon. She is in the Arlington Jail with bail set at $50,000.

Witnesses told police that Wangui appeared to speed up as she drove toward the two women.

One nurse was taken by helicopter ambulance to John Peter Smith Hospital in Fort Worth, where she remained in serious condition Friday, police said.

The other nurse was treated at the scene.

Wangui was taken to JPS for emergency psychiatric evaluation and was transferred to police custody about 10:30 a.m. Friday, police said.

She has not told investigators why she hit the women, Alanis said.

"We don’t know what her intent was or her mental state," said Alanis.

He added that Wangui does not have a criminal record.

The assailant is in jail, one nurse is home, but another is in the Trauma center.  Keep your eyes open and expect threats around the hospital.

CPR instructions should focus on chest compressions

For those who don’t know what to do:  CPR instructions should focus on continuous chest compressions, UT Southwestern physicians recommend.

Cardiopulmonary resuscitation (CPR) instructions given over the phone by emergency dispatchers to lay rescuers should focus primarily on continuous chest compressions instead of the traditional ABC’s – "airway, breathing, circulation," according to Dr. Paul Pepe, chairman of emergency medicine at UT Southwestern Medical Center.

Please note this is only for telephone recommendations from emergency dispatchers to bystanders doing CPR.  The article is well-written, and recommends that people who know what they’re doing (regular CPR, with breaths given, etc) ‘should be encouraged to continue’, but this is aimed at the person who doesn’t know CPR, or is too stressed out to do anything but chest compressions.

‘Virtual doctor’ makes day care calls

Color me skeptical: – ‘Virtual doctor’ makes day care calls – May 5, 2005.

Little Jaeda was examined soon afterward by a University of Rochester pediatrician and given antibiotics. Using telemedicine tools wielded by a day care staffer, the diagnosis was done through the Internet.

This would make for interesting questions, and I think telemedicine is great for some things, but diagnosing ear infections and dispensing antibiotics isn’t it, at least not in any kind of suburbanized, or better, area.  This is no better, and probably as bad, as just picking up some Amoxicillin at the grocery store on the way to daycare.

Medicine is a one-on-one thing, up close and very personal.  Accept no substitutes.

Nurses hit by car in hospital parking lot: by (Alleged) Drug Seeker!

In Arlington: | 05/05/2005 | Nurses hit by car in hospital parking lot.

By Susan Schrock

Star-Telegram Staff Writer

ARLINGTON _ Two nurses were injured when they were struck Wednesday by a car driven by a 34-year-old woman in a Medical Center of Arlington parking lot, police said.

Witnesses told police the woman appeared to accelerate her car "up to 20 to 25 miles per hour" as she drove toward two nurses who were walking toward the hospital about 6:30 p.m., said Lt. Blake Miller, a police spokesman.

One nurse suffered minor injuries and was treated at the scene. Another nurse was taken by helicopter to John Peter Smith Hospital in Fort Worth, where she was listed Thursday in serious condition.

Witnesses detained the driver until police arrived. The woman was taken to JPS for emergency psychiatric evaluation and may face criminal charges in connection with the incident, which is still under investigation, Miller said.

Wow.  I always wonder what’s going to happen on the walk to my car (and I don’t work at the hospital where this happened).  My head is on a swivel to and from the car, looking for something.  Maybe I’m a paranoid, but I tell lots of drug seekers ‘no’, etc.

Here’s hoping these two nurses recover very quickly, and the driver gets what she deserves.

Update: Driver was (allegedly an) Angry Drug Seeker!

The driver was angered because a doctor at the hospital refused to
prescribe her a certain type of drug, according to sources at the

Galen’s Log: Use of Vancomycin in Loxosceles mersenius envenomation

Galen has quite the talent for tongue-in-cheek humor:  Galen’s Log: Use of Vancomycin in Loxosceles mersenius envenomation.

Despite intensifying research, Loxosceles mersenius remains an elusive  species.  Out of the 94% of patient reporting the spider bite, only 6 percent actually recall seeing a spider within a 48-36 hour window of noticing symptoms, and only a few samples have been submitted for research.  Detailed testing revealed the specimens to be mashed remains of garden variety house spiders, while another umbillical specimen turned out to be a benign (though albiet frightening appearing) collection of dark cotton/polyester blend fibers.

Though I don’t want to spoil the ending, not every human with an abscess has theirs caused by a spider bite.

I committed one of the ER Doc Sins Today

It’s never good when you get an after-hours call from the ED you work in.  There I was, enjoying my day off, when my wife hailed me: "It’s Doctor Lantz on the phone".

Lantz: "Hey, uh, we’ve got you penciled in today for the 5 PM shift, in place of Dr. X".

Me, looking at watch and noticing it’s 5:25: "Oh, phoo."  Remembers discussing trade with X, but no details emerge.

Lantz: "So, you won’t be here 25 minutes ago?"

Me: "I’ll be there as soon as I can."

Fortunately for me, he’s a reliable guy and did an excellent job covering my absence.  This is one of the Cardinal Sins of the ER Doc.  You can have one about once a year and not show up on the radar, and that’s about my score to date.

Some of you are asking yourselves, "How can you forget to go to work?"  The answer is seven shift start times and no set pattern of shift days off or on, plus the inevitable trades.  That’s how.

So, yes, I screwed up and it bothers me.  Confession is supposed to be good for the soul, or the conscience, or something.

First Nursing-Only Blog Carnival: Thinking Nurse

Link: Thinking Nurse.

This is it! The very first carnival dedicated to the ways of thinking, feeling and acting we call ‘nursing’, an activity of ‘Head and Heart and Hand’, the place where science and art meet, clash and fuse in the strange and wonderful synthesis of daily life.

Seems veddy British. It’ll be interesting to see if specialty-specific blogging becomes more in vogue. (I’m against it, for the record).

Junk mail and junk calls that I paid to get

…or, why I will not be giving money to any political party in the future.

This last Presidential election cycle I gave a very small donation to one of the parties (doesn’t matter which).  This meager donation has resulted in 1-3 phone calls per day from affiliated ‘give us money’ groups, along with innumerable mailings from similar political groups, again wanting access to my wallet.

I stopped being an NRA member a while back mostly because of the continuous pleas for more money, now!  Seems my membership or donation money is me paying to be on a mailing list.

Phooey on that.  I will never again give money to any political party that won’t put, in writing, that I will not be contacted again.

Stroke drug side effects limit use

Emergency Medicine isn’t sold on TPA for stroke: Stroke drug side effects limit use.

Stroke drug side effects limit use

Ann Arbor, MI, May. 2 (UPI) — The only drug approved to treat stroke victims is not used by all U.S. emergency physicians because of concerns about side-effects, a Michigan study found.

The drug, called rt-PA, carries a 6.4 percent risk of a brain hemorrhage  in stroke victims, a concern that causes about a quarter of emergency room physicians to avoid using it, according to University of Michigan Health System researchers.

The study, published Monday in the Annals of Emergency Medicine, found emergency physicians were more likely to use the drug on heart attack patients, who have a 1 percent risk of brain hemorrhage.

It’s also called the "Walk or Die" therapy, as some of those treated can get a lot better or very very much worse.  I don’t know any ER doc who is happy about the whole ‘TPA for CVA’ idea.  There was a big push to TPA strokes after the first study (by NINDS, done by the NIH).  To the best of my knowledge, there have been studies that tried to replicate the NINDS results, and none have been able to get the same good outcome ratio of the original study.

This application for TPA crosses my ‘First Do No Harm’ line.  It’s a drug that may have an (unpredictable) upside, but has a huge downside in stroke.  To me, the definitive study of who, and when (and where) for TPA in stroke has yet to be done.

MedBlogs Grand Rounds XXXII

12 hours early (MD/PhDers are like that) comes: Tales of a MD/PhD student: Grand Rounds XXXII: A Day In The Life of a Medical Student.

Finish studying and do a final check of Medlogs. Stumble upon a post by The Anonymous Clerk asking Does NPO Include Holy Food? Decide to head to bed. Because tomorrow will be filled with interesting clinical correlation lectures instead of biochemistry, I’m actually planning on going to class in the morning….