ACEP becomes more relevant: Case Report on Back Pain

ACEP announced a year or two ago that they would, as a professional society, review expert witness testimony to determine if it met the Societies’ standards for accuracy.  Now their first review is out, and it’s interesting to read. 

The medical case looks like one of those ?what? cases we’re all familiar with, when a patient presents with one thing and has a bad outcome of something unrelated.

I’m going to abstract those things I found pertinent(I wound up putting the whole thing here), and make a couple of comments:

A postmenopausal African-American female patient presented to the
emergency department with a chief complaint of fairly persistent pain
"inside her back" for two days prior to her evaluation. While the
patient did not verbally describe the location of her pain, nurses
noted that the patient pointed to her low back as she described the
pain. The patient attributed her pain to "overexerting" herself doing
yard work two days prior to evaluation. She also reported a history of
nausea of unknown duration.

Upon her presentation, the patient’s pulse was 104 and her blood
pressure was 157/110. Her height was 5′ 0" and her weight was 270
pounds. She had no SOB or diaphoresis.

Okay, big, round, back pain.  Very common ED complaint.

The patient’s medical history included hypertension and obesity. She
had a positive family history for atherosclerotic heart disease.

The physician’s examination of the back showed no abnormalities. The
pain was unable to be reproduced with bedside maneuvers. The remainder
of the physical examination was not discussed in the depositions. A
urinalysis showed 1+ bacteria.

Okay, so we’re not really second-guessing the medical care here, we’re looking at whether the expert witness testimony meets ACEP standards.

The patient’s pain resolved without intervention. She was apparently discharged home with Lortab and Motrin.

On discharge, the patient’s BP was 140/90 and her pulse was 80.

That’s not bad, at all.

The following day, the patient’s husband found her poorly
responsive. She was brought back to ER and later died from unknown
causes.

An autopsy was performed and showed that the patient’s heart was
hypertrophied and there was narrowing of coronary vessels. There was no
evidence of clot or plaque ruptures found in any of the coronary
arteries.

This is a terrible, and from the presented information so far, completely unforeseeable event.  Now, bring on the plaintiff’s experts:

[Read more...]

Happy Birthday, Mom

Momonahorse


From all of us.

Grand Rounds Reminder, Redux

Get ‘em in before Monday, August 22nd, 8pm EST to

Lance rides ‘Tour de Crawford’ with Bush

I’ll bet it was hot there, too: SI.com – More Sports – Lance rides ‘Tour de Crawford’ with Bush – Saturday August 20, 2005 6:52PM.

WACO, Texas (AP) — It’s no yellow jersey, but President Bush on Saturday presented Lance Armstrong with another shirt to show off his biking experiences — a red, white and blue T-shirt emblazoned "Tour de Crawford."

The leader of the free world and the world’s biking master rode for 17 miles on Bush’s ranch for about two hours at midmorning. Bush showed Armstrong the sites of the ranch that he calls "a little slice of heaven," including a stop at a waterfall midway through the ride.

They were accompanied by a small group of staff and Secret Service agents and a film crew from the Discovery Channel, Armstrong’s Tour de France sponsor, which had exclusive media access for the ride. Footage was shot for a program on Armstrong to air this week.

I couldn’t find a link to that show, but I’ll check again next week.  The really disturbing thing is learning there are "Presidential Bike Socks".  Oy.

Cycling: the sport of Angry Loners?

I have recently taken up cycling as a hobby / exercise program, and I’m enjoying it greatly.  I told friends that "I needed a hobby that doesn’t involve sitting on my backside" until it was pointed out that’s the position for cycling.  Now I just say I need a hobby out of my Comfy Chair.  I digress.

So, for the past 5 weeks I’ve been riding 3-6 times a week, in nice short local rides (longest so far is 23 miles, so Lance I’m not), and have noticed something odd: less than half the riders I meet even provide a courtesy acknowledgment while passing (and this is Texas, where waving while driving still lives (but be careful which finger)). 

Other riders seem friendly, and perhaps I’m reading something into it I shouldn’t, but these folks either aren’t having any fun or are just loners.  Time will tell, but I wonder what other rider’s experiences have been?

Update: if so, perhaps I picked the right sport for me!

Merck loses first Vioxx lawsuit – Aug. 19, 2005

Merck loses first Vioxx lawsuit – Aug. 19, 2005.

NEW YORK (CNN/Money) – Merck has been held liable by a Texas jury in the first lawsuit involving its former blockbuster drug Vioxx, in a case that could have a profound effect on thousands of other cases filed against the company.

Plaintiff Carol Ernst has won her lawsuit in Texas Superior Court, which blames Vioxx for the 2001 death of her husband, Robert Ernst, a 59-year-old marathon runner and Wal-Mart worker who was taking the arthritis painkiller at the time of his death. Ernst died of a heart attack.

The verdict held Merck liable for the death.

The jury awarded more than $250 million in total damages — a $24 million penalty to Carol Ernst for mental anguish and loss of companionship and $229 million in punitive damages.

Ernst’s Houston-based lawyer, Mark Lanier, was seeking $40.4 million in damages and after the verdict said he expected the punitive damages award to be reduced according to Texas law.

After the verdict, Merck said it would appeal the jury’s finding.

Update: commentary from Dr. Lowe
Aggrivated DocSurg
Point of Law discusses Texas Damage Caps.
Galen’s Log

Blogger for Word

I don’t use Blogger, but if I did I’d be trying out this puppy: Blogger for Word.  Yes, it’s an add-in toolbar for Word that lets you write in the best word-processor around and then post to your blogger site.  Genius, and should help to decrease the misspellings and grammatical errors on other sites, but not here.

via Clinical Cases and Images – Blog, Which does use Blogger.

The .MD domain

Yesterday I added another BlogAd (and many thanks to the two of you who click through and look at the advertisers), and learned something: there is a " .MD" domain available, like .com, .net, etc.

The advertiser has some clever ideas about selling more than domain registrations to medical types, and I’m not endorsing them, I just think it’s fairly clever from a business standpoint.

However, recalling that the .TV domain was purchased fair-and-square from the tiny island of Tuvalu, I wondered where the .MD originated.  I figure you wonder, too, so here it is:

Moldova, map via WorldAtlas.com

So, this would seem a natural for a Moldovan MD, and I wouldn’t look down on any doc who decided to get their own .MD domain.  I don’t plan to personally, though.  GruntDoc.MD?  Nah.

Oh, and there’s no .DO domain, if you were wondering.

Update: I stand corrected, there IS a .DO!  There’s also a .NP and .PA.  Many thanks to Tim at Symtym for doing my homework for me.

Silly Season: Barrichello quits Ferrari for BAR Honda

What?: BBC SPORT | Motorsport | Formula One | Barrichello quits Ferrari for BAR.

Brazilian Rubens Barrichello is to leave Ferrari at the end of this season to join BAR-Honda.

The 33-year-old, who has won nine Grands Prix for Ferrari, has signed what BAR said was a "multi-year deal".

He will end his contract with Ferrari a year early after getting fed up playing second fiddle to team leader and seven-time champion Michael Schumacher.

"I am very excited to confirm I will be at BAR. I wish to thank Ferrari for six fantastic years," said Barrichello.

Barrichello will have equal status with Jenson
Button at BAR if the Briton – who is trying to negotiate his way out of
a move to Williams – is allowed to stay at the team.

If Button leaves, the Brazilian will lead BAR.

Barrichello’s place as Schumacher’s number two at Ferrari will be taken by Felipe Massa, currently with Sauber.

Good news for Massa, but this is an odd choice, to jump from the most dominant team in F1 (this years’ performance notwithstanding) to be second-banana at BAR (which is admittedly doing much better this year, and improving).  One wonders what will become of Takuma Sato, the driver not named in the replacement swaps.

My guess: Barichello’s betting the courts send Button to Williams, making him the number one driver.  I hope he has it in him, either way.

via F1 and A1 Grand Prix

In the mailbag: Is EM for me?

In the mailbag:

Hello, Doc. I have cherished the idea of becoming an emergency room physician for quite some time now. The gratification of saving people’s lives aside (the effects are immediate and obvious), just to be able to earn the privilege of being a doctor is an enormous challenge (and reward no doubt) in itself. However as I researched the subject of ER physician further, I discovered that alas, what a rosy colored picture my naivet? had painted for me. The "scumbag medicine" (as it’s sometimes called), has lost much of it’s glory to me as I contemplate the reality of an emergency room
career: the obnoxious patients (or…hopeless junkies) being treated, the ever present bureaucratic interventions and threats of malpractic suits inflicted even on the good doctors.
Just to provide me with little additional information to aid my choice and hopefully clear up the confusion in my head, would you mind give a few thouhts as to whether is it worth it to be an ER physician and what has motivated you to apply for an ER residency slot in the first place?

First, I sincerely wish you luck in your path to medical school, and through the travails of medical education.  You will not be bored.

As for Emergency Medicine, my motivation was steered by past experiences and reinforced by my early medical training.  I took an EMT course during the summer following High School graduation, and I think that early exposure to emergent / prehospital medicine has had a profound steering effect on my career.  After a year of college, I took off a year and worked full-time in an ED as an EMT, while attending night school to become a Paramedic, so by then I was completely hooked on the EM path.  A surgical internship sealed my desire to have a specialty that didn’t involve living in the hospital, so EM was the course for me.  I have never regretted that decision.

Emergency Medicine does have the benefit of (occasionally) being able to make a difference, right then, which is appreciated both by the patient (if awake) and doctor, and those times are terrific.  No, more than terrific, they’re exhilarating, but we’re all pros so we downplay their effect (no high-fives in the resus bay, alas).  The immediacy of those interactions is striking, keeps me interested and helps me go back to work. 

There are very real downsides to EM as a profession, and the patient population can be one of them (if you let it).  The more I practice the less the drunk/high/malingering/drug seeking get to me, and that’s a good thing.  I cannot imagine getting through the end of my career if I let obnoxious behavior or less than satisfactory patients get to me on a personal level (and it used to, believe me, but part of the ‘professional veneer’ is realizing the patient is the one with the problem).  The reality is there are plenty of patients who are trying to be nice (or at least not deliberately awful), but it’s human nature to dwell on the ones that make your life painful.

Other downsides: 24/7/365.  It’s the reality of our specialty, someone has to be there, all the time, and sometimes (really, a lot of the time) it’s you.  The third straight weekend spent in the ED can wear on the psyche, if you let it.  Add in more job-insecurity than most other physician professions, a diminishing call list of specialists willing to help the sick and injured, higher than average medmal actions, and EM has its drawbacks.  However, if you can see the problems you can deal with them, and knowing what you’re in for is the best preparation.

For me, there’s no better profession.  I hope that helps.

Garmin Support: Round 2

For the first round, see here.  Their service (handled in the US!) was very good, and my earlier apprehension was unfounded (as many of the commenters predicted).

I got the unit back roughly 8 days after first sending it in, and they had had to replace it, at no charge to me.  It got here Monday morning, and I rode with it Monday and Tuesday (it’s now Wednesday AM).  Just now I decided to charge it more using the USB cable that transmits the data to the computer (and makes very pretty and informative graphs).  The USB is not coming out of a hub, just computer to device.

‘Bzzzt’ said the USB connector while plugging in, and viola!  Another bricked Forerunner 301.  It’s a really neat gadget, and the heart rate monitor is first rate, but this is going to get expensive if it continues.  I suspect the little cable connector is powering across something it shouldn’t in the plug-in sequence, though I’m not forcing anything, and it fits well once plugged in.

So, another request for an RMA is off.  I like it, but wonder if anyone else is having these issues.

Team Health Files Form S-1 With SEC

In the "?Is this good news?", department: Team Health Files Form S-1 With SEC.

KNOXVILLE, Tenn., Aug. 16 /PRNewswire/ — Team Health, Inc. announced today that it has filed a registration statement with the Securities and Exchange Commission relating to the proposed Initial Public Offering ("IPO") of its common stock.

The shares in the IPO are being offered by Team Health and certain selling stockholders. Team Health, Inc. intends to apply to have its shares listed on the New York Stock Exchange under the ticker symbol "THH." The IPO is expected to take place later this year.

Lehman Brothers and Merrill Lynch & Co. as joint book-running managers and JPMorgan are acting as representatives of the underwriters in the IPO.

The offering will be made only by means of a prospectus.

About Team Health Founded in 1979, Team Health is headquartered in Knoxville, Tennessee. Team Health is affiliated with over 7,000 healthcare professionals who provide staffing and administrative services in the areas of emergency medicine, radiology, anesthesia, hospitalist, pediatrics and other healthcare services to over 470 hospital clients and their affiliated clinics and surgical centers in 44 states. For more information about Team Health, visit http://www.teamhealth.com.

Full disclosure: I interviewed with a Team Health regional affiliate several years, right out of residency, and as they stiffed me with the travel expenses they promised to reimburse, I’ve never held them in high regard.

That’s neither here nor there, and TH is a company whose officers are probably going to get rich while the docs who, you know, actually provide the professional services won’t get the Big Payday.  My ignorance about stock, etc, is legendary, so if there’s a big upside for the working doc, I’d love to hear it.

Many Discharged Patients Do Not Know Diagnoses, Medications, Side Effects

From the Mayo Clinic: Many Discharged Patients Do Not Know Diagnoses, Medications, Side Effects.


The authors report that 72 percent of the patients were not able to list the names of all of their medications, however, more could state the purpose of their medications. And about 58 percent of the patients were unable to recount their diagnosis or diagnoses.

"All methods that enhance the patient’s understanding of his or her discharge treatment plan focus on one central aspect — proper communication," says Dr. Friedman. "Although not all patients are noncompliant because of poor communication, this is probably the leading cause of noncompliance."

Dr. Friedman notes that communication involves many aspects, including language (speaking to the patient in terms the patient understands), practicality (giving the patient a regimen that can be followed without much disruption to daily life) and time (spending reasonable time counseling the patient and ensuring that the patient actually comprehends the instructions).

"Without willingness of the health care team to devote time to communication, the careful and effective treatment that was delivered in the hospital may not continue after discharge because of patient noncompliance," says Dr. Friedman.

I have no doubt this is a universal problem.  Patients recently discharged from my hospital who return frequently have their copy of their handwritten discharge instructions.  They are variably legible, don’t have a diagnosis written anywhere un them, frequently use the medical abbreviations for medicines (T.I.D., etc), and the patients don’t remember even who their doctor is.  There is certainly room for improvement.

The authors go on to recommend some ideas they hope would help, but I doubt the practicality of many of them.

MedBlogs Grand Rounds 1:47

It’s that time: Circadiana.

Of all the carnivals out there, Grand Rounds tends to have some of the most creative hosts (to be fair, Skeptic’s Circle and The Tar Heel Tavern had some very creative hosts, too) and I have done some creative thematic carnivals in the past, but for today I decided to "play it safe" and just present a simple introduction to medical bloggers and their best recent posts, organized by Rooms – the places where stuff is happening. So, let’s do it!

Grand Rounds Reminder, Redux

This week it’s over at Circadiana.  Submissions should be sent to .