Welcome to Grand Rounds 2:19 – the Down Under Edition. I hope you enjoy this selection of posts from the medical blogging community this week!
With that short-and-sweet introduction begins this week’s collection, from Australia!
Ramblings of an Emergency Physician in Texas
Welcome to Grand Rounds 2:19 – the Down Under Edition. I hope you enjoy this selection of posts from the medical blogging community this week!
With that short-and-sweet introduction begins this week’s collection, from Australia!
A few months ago, I went to see a patient with the common “N/V/D” complaint.
After introducing myself, I did the med-school trained thing and asked the patient to tell me, in their own words, what the problem was.
“I have a culinary tract infection” was the answer.
Well, exactly right. I do have a fun job.
I’ve been preparing for the first of three lectures I’m scheduled to give this year. I like lecturing, as I always learn something, and I’m a bit of a ham.
So, I’ve spent the last several days preparing for a talk.
Here are the steps:
Decide what you’re going to speak about. (Done).
Get literature, review, and make an initial outline. (Done).
Find out how long you have to speak. (Hmmm).
Make a lecture. Lots of PowerPoint slides. (Done).
Step Three is where I went off the rails. I thought I was speaking for an hour, and I discovered, tonight, that I have only 30 minutes. I’ve got 89 slides, and they’re not all one-liners.
So, now I need to pare it down a bit. By half.
Lesson learned. Anybody need some ‘surplus’ Powerpoint slides?
Update: The talk went well, though I went about 5 minutes over. Still too many slides.
If you come in with your girlfriend who “might be” pregnant who’s also having some abdominal pain, good.
If your main concern is the age of the baby, “…cause I want to know if I’m the daddy”, you have a LOT more problems than a pregnant girlfriend, so not good.
When the sono shows a fetal age which is outside your range of, well, courtship, do not then start yelling at your girlfriend. Bad. Really bad.
I’m glad I was able to share that with you.
Welcome to Grand Rounds, the weekly best the medical blogosphere has to offer, and a hello to all the new readers from WebMD. I’m honored to be hosting for the third time – it has come a long way since Kevin, M.D. last hosted way back in 2004.
That should keep you busy for an hour or two.
It’s been 4 years, and I can finally talk about it. Some.
Todd Treadway was my best friend. I’m odd, in the I have very few close friends and a lot of acquaintances. Todd was a friend, but not just to me, to everyone. He was that kind of guy. Everybody liked him. My brother counted him best friend as well, and there was no rivalry over it. He was just a terrific fellow.
We went to HS together, graduated together, and started JC together. Neither of us moved on or out of out little West Texas town. Friday and Saturday nights, when not accompanied by the Distractions of Women, were spent together. Usually playing cards. Dull, wholesome bunch, we were. Engines were rebuilt, time was spent. A whole lot of time was spent, in the way that friends do. The kind of ‘there’s always tomorrow, and we’re all in this together’ way friends have.
Todd was the photographer at my wedding (I was broke, and he volunteered). He was a big part of my life.
He worked hard, in a copy shop for as long as I could remember until he got a Masters degree, then went into social work in the State’s psychiatry wing, and eventually became a licensed psychologist. He married a wonderful psychologist, and they had a good life together. They were as happy as married people with jobs and careers can be, maybe a little happier.
He loved the Mercury Cyclone, so much so that he had two of them: one to drive and another to restore, when he finally got around to it.
A motorcycle killed him. Well, technically it was the pickup running a stop sign that killed him, but since he entered that space and time on a bike, the motorcycle did him in. The helmet didn’t help. It was quick, which is some solace, but not much.
Maybe by accident and maybe on purpose, he made my brother and I smile at his funeral. He once told his wife in passing “I want Wagner at my funeral”, and she asked if we knew what he meant. We did; nobody watched Apocalypse Now with Todd as many times as we did and doesn’t recognize his affinity for the Ride of the Valkyries. We played it. It sounded good in a big Lutheran Church.
They say time heals wounds.
I really hope so.
MedBlogs Grand rounds features the best writing about medical topics in the blogosphere, brought to you weekly with rotating hosts. Though the topics are medical, the posters do not need to be for consideration.
Without further ado, a quick announcement:
Hearty Congratulations to the 2005 Winners of the Medical Weblog Awards!
(Whoever they are). The announcement will be today, over at MedGadget.
And Now, our Feature Presentation
Dust in the Wind meets up with an angry former patient:
Many months ago I was involved in caring for a patient who was very badly hurt in a serious motor vehicle collision. The community I live and work in is relatively small. I have heard through many sources that this person was very angry and having many issues related to the accident. One of his most pressing concerns was that his favourite clothes were cut off.
I was the cutter.
GeekNurse wishes us to know about the Science of Correct Bear Placement. I trust there’s a medical publication in the offing.
Impacted Nurse tells the tale of tragedy, of a life cut short, and those affected by it:
And then she stepped out before him, and he braked hard, but already she had hit the car with a dull thud that was felt rather than heard, above the Mozart string quartet that he so loved, but would never be able to listen to again.
Doctor Disgruntled on Clausewitz, defensive medicine, and teaching residents:
One of my favorite of Clausewitz’s observations is on the subject of “friction” in the chain of command. He notes that “countless minor incidents – the kind you can never really foresee – combine to lower the general level of performance, so that one always falls short of the intended goal. Iron will-power can overcome this friction; it pulverizes every obstacle, but of course it wears down the machine as well.”
I recently consulted on an older gentleman brought in from an outside hospital who had a defibrillator that had fired >8 times in the prior two weeks. I find this totally outrageous as in my opinion these events should be equivalent to being shocked by lightning.
Doctor (formerly known as the Madhouse Madman) tells the tale of a tragic death narrowly averted, and ends with:
I’m constantly amazed at the serenenity of our “admitting diagnosis” when compared with what actually happened. Or what could have.
Dr. Charles, one of the truly gifted writers in the MedBlogosphere, Tells of the Four Packs on One Match a day lady:
“Yes, young doctor, that’s right,” she rasped. “One match at seven A.M., and I’m lit for the rest of the day. But don’t worry; I won’t smoke in your office.”
Kevin, M.D. says:
It’s ridiculous to think that doctors lower their standard of care based on whether their patients have the right to sue.
and gets an argument in the comments.
sleepdoctor points out something I hadn’t thought of: Bedwetting child? How do they sleep?
However, pediatricians frequently neglect to ask their enuretic patients about symptoms of obstructive sleep apnea, a common cause of nocturnal enuresis.
The Cheerful Oncologist, one of our other bright-star literary medbloggers, has an allegorical tale that very well describes the relationship between physician and patient. If I had a regular practice I’d frame one for every exam room.
Dr. Emer (Phillippine Blog Award Winner) comments on the recent Lancet study that showed iron supplementation for iron-deficient children actually made their malaria outcomes worse, and points out that his country of the Phillippines has both.
Robotic Surgery Blog has some interesting questions following a big surgery on a very elderly patient:
Heroic measures as patients get older. What patients are too old for what type of care. In any other country I do not believe (the patient) would have received this operation.
The use of an expensive technology- what kind of benefits really exist?
One of the criticisms of robotic surgery is that it costs more and is unnecessary. In properly trained hands, this story shows what kind of benefits can be achieved. My previous four nonagenarians all spent 9-14 days in the hospital and all needed rehab stays of about 2 weeks prior to going home.
Anxiety, Addiction and Depression Treatments attempts to answer an important question:
…what is the relationship between traumatic events and drug and alcohol addiction? Can a traumatic event, such as 9/11 be used to explain a drug problem, and therefore, the actions that might result from that addiction?
After poring over the voluminous literature that has been published on the comorbidity of drug addiction and post traumatic stress disorder, the answer appears to be… maybe.
Agggrivated DocSurg gets the award for the best post title: The Straight Poop on Anal Fissure Therapy. And then proceed to tell us how to fix them
Ever had an anal fissure? Speaking as someone who has treated many folks with them, and who developed one in medical school, I can assure you that they are a wee bit painful.
Red State Moron talks about prenatal diagnosis and termination, and ends with:
…the way in which information is conveyed regarding birth defects (chromosme anomalies included), can have a substantial influence on a patient’s decision to continue or terminate a pregnancy complicated by a fetal anomaly. Which I think is unfortunate. All the more reason to try to provide patients with as much data as possible, whenever possible, prenatally.
Intueri has a pateint who notices something in nature missing in his life:
“Does that bother you?” I asked, uncertain why it would.
“Yeah,” he sadly answered. “They can organize their lives better than I can.”
The Healthcare IT Guy is trying to organize a healthcare blogger author/reader meetup:
Your friendly neighborhood bloggers are considering a meet-up at the HIMSS ’06 conference next month in San Diego. Will over at Candid CIO came up with the idea and it met with unanimous approval of it being a great idea through several e-mail exchanges with other bloggers this weekend.
The Medical Blog Network wonder if the Wikipedia effect will carry over into medicine and publications:
Wikipedia is giving closed-source encyclopedists a run for their money. We will keep watching Medscape / WebMD progress.
on the same note,
Clinical Cases and Images Blog has a nice point/counterpoint to the ‘medblogs/wiki and peer-reviewed content’ idea:
Point: User-created content has the power to expand and correct peer-reviewed content. Then, you need Google Medicine to find what you are looking for in this enormous mash-up of blogs/wikis/journals/books/sites that we call Web 2.0.
Counterpoint: Peer-reviwed literature is not going to be replaced by individual blogs. The Web 2.0 phenomenon is very new and we still have not figured out what is the best way to use it in medicine.
The idea of “open content” is great but what if the content itself is not that great?
Actual point and counterpoint added by me.
Medical Connectivity interviewed some tech folks you’ve never heard of who are trying to bring order to the “wireless wild west” in hospitals. Until reading this, I hadn’t really thought about it, but there are so many different wireless systems in my joint it’s a wonder they work at all. Read to see what GE is teaming up to do about it.
NHS Blog Doctor (a new blog that’s really taking off) has a solution for the NHS’s funding woes:
The only way to solve this is to put a charge on the front end. I have said it before. I am saying it again, and I will keep on saying it. The last time I said it I got over two hundred e-mails from people, most of whom remain wedded to this nonsense of “free at the point of entry.”
The NHS is only “free at the point of entry” when it is not closed.
Health Business Blog has something to say about the economics of Pharma, while taking an editorialist to task. Here’s the teaser:
The writer assumes that companies will stop selling their drugs in low-price markets and that the US price for drugs is the “market price.” In fact, pharmaceutical companies have been able to practice price discrimination —
In a first for me, three blogs not only commented on the same topic (States requiring a certain percentage of their payroll on healthcare for their employees), but submitted their posts together, as complimentary! So, here they are:
Insureblog starts it out with:
Statements like “employers should pay for it” and “requiring companies to provide health insurance” reveal a stunning ignorance of how our system works:
Heath Policy says:
The problem with states compelling coverage is that, while they have the muscle to do so, they don’t necessarily have the resources to cope with the fallout.
We are not a pure capitalist society…we regulate how much profit ends up being made in many different ways. Companies are free to make fair profit, not unfettered profit.
Those are just snippets, and there is some thoughtful input in the comments.
Fixin’ Healthcare wonders if WalMart might just have some answers in health care:
Now, Wal-Mart is using its business model in an attempt to drive down the cost of health care plans. ….., who better than Wal-Mart and their business model to further test this approach?
Medviews has a solution to the closure of hospital-based Diabetes centers:
Let hospitals do the work that they were meant to provide- acute care. Let the outpatient folks do what they are geared up to do- provide care in an integrated fashion in a community setting
DB’s Medical Rants on the pharmaceutical industry: the good, the bad, and the ugly. He’s got some reform ideas:
1. Require the FDA to have the pharmaceutical industry fund independent studies on new drugs. …
2. Outlaw DTC advertising. …
3. Require transparent drug pricing. …
medpundit thinks companies firing people for smoking off the job is wrong:
Some companies have taking to firing people for smoking – at home. There’s an awful lot of hue and cry about our loss of freedoms at the hands of the Bush Administration, but it seems that there’s much more loss of freedom at the hands of medicine. It’s an example of medical advice taken to an extreme.
Hospital Impact wants us to think about the Hospitals of the Future:
…there is some evidence that better design actually leads to better care. Check out the Center for Health Design’s Pebble Project. While these great results can’t all be attributed to design, “evidence-based design” is an inevitable force of the future.
Interested-Participant reports some New Zealand research on the psychological effects of abortion, and has a prediction:
The abortion rights advocates will be screaming about this research. I’m sure they’ll dispute the methodology of the study and significance of the findings. It’s also probably a safe assumption that the mainstream American media will downplay the research, if it’s reported. And, that’s a big ‘if.’ Leftist news outlets likely will not want the public to know that abortions lead to long-term adverse consequences.
The Biotech Weblog points out the “hedgehog protein” could hold a cure:
… if we can activate the pathway, we might be able to prevent or reverse osteoporosis and simultaneously prevent or reduce fat accumulation,” he said.
Aetiology, in a post titled “Are female night owls screwed?
As I write this at 2AM sitting under annoying fluorescent lights, am I increasing my risk of developing breast cancer? Maybe, according to a recent study showing that melatonin-depleted blood can spur the growth of mammary tumors:
Oh, and several of the Science Bloggers have moved over to a sorta-group blog, ScienceBlogs
Terra Sigillata is by a pharmacologist, and his introduction is very interesting, but here’s the crux:
Terra Sigillata is a metaphor for the fact that the Earth itself has provided medicines to various cultures for centuries.
A new blog by an experienced pharmacologist, this’ll be one to watch.
Orac had a Rodney Dangerfield moment or two, and his defense of the academic research physician is passionate and pointed.
A Difficult Patient found an automatic trivia generator, and it’s allowed several heretofore unknown tidbits to travel out. For instance:
- It takes 8 minutes for light to travel from the Sun’s surface to GruntDoc.
- Physicians have often been found swimming miles from shore in the Indian Ocean.
- Jacob Reider once lost a Dolly Parton lookalike contest.
- It is impossible to fold Dr. Charles more than seven times!
- Until the 1960s, medpundit was not allowed to enter Disneyland.
- Only one person in two billion will live to be Shrinkette!
- It takes more than 500 peanuts to make “Dr. Green”.
- There are roughly 10,000 man-made objects the size of DP (the Difficult Patient) orbiting the Earth.
Someone has a little too much time on their hands…
Pharmagossip has the answer to the question “Could homeopathy prevent a pandemic?” You’ll have to click over for the answer.
Doc Around the Clock isn’t enjoying the password change procedure in his hospital:
After picking a new password at our hospital one would think trying to obtain security clearance at the Pentagon would be a walk in the park. Here is a recent adventure I had in trying to choose a new password and the continual pop-ups I would get when I would find my password invalid.
I feel a rant coming on this, myself.
Emergiblog has an extraordinary tale, a first-day nobody would ever forget. I won’t ruin it by abstraction. Just read it.
Next week’s host: Kevin, M.D.
I’ve enjoyed my reign as “Best Medical Weblog”, and hope the crown rests well on the next brow. The only thing I’m really going to miss is the jet.
I like having a MovableType blog because the search is very well done, allowing you and me to find things written here before pretty easily.
That having been said, some of the search phrases used here are interesting, in different ways.
Search: query for ‘tenn’
Search: query for ‘single payor’
Search: query for ‘insurance’
means someone wants to know what I’ve had to say about TennCare (not much).
Search: query for ‘piss poor protoplasm’
Means there’s a surgeon or EM doc poking around.
But this one gave me a chuckle:
Search: query for ‘name of pill two active my wife ‘
Search: query for ‘name of pill two active my wife wild’
Not found here, but send me an email when you do.
Don’t forget to get your submissions in, and after that remember to Go Vote For the MedBlogs Awards
Today in the email, from the Editor of one of the two big EM trade newspapers:
“Imitation is the highest form of flattery.”
Dear Editorial Board, Advisory Board, Contributors, and Readers:
Since its earliest beginnings Emergency Physicians Monthly has taken pride in the fact that we are the only “independent” publication in EM. EPM was started by a working EP who just wanted an open, educational, relevant forum for the entire specialty, whether the reader was academic or community, corporate or independent, boarded or cross-trained. It would have been nice to have been an “official” publication of the College or the Academy, but it would have required us to take one “party line” or another. So we didn’t. We could have sold to a large publishing house, but then we would have seen the world only through “corporate eyes.” Instead, we stayed “independent.” And since the fall of 2005 we have been proud to make it a part of our banner. Recently we noticed that our other major competitor, Emergency Medicine News, decided to abandon the motto they had used for over 20 years in favor of a new one that proclaimed it to be “Emergency Medicine’s Only Independent News Magazine” . While the claim of independence may be a little bit of a stretch for EMN (they’re owned by Lippincott, Williams, and Wilkins, publisher of nearly 300 journals, which is itself owned by Wolters Klewer, an international conglomerate) we are nevertheless flattered by the imitation. I can’t blame EMN for wanting to be perceived as “Independent”. What with all of the corporate scandals and bad press for big business, everyone is rooting for the little guy. As a business, they are entitled to claim whatever they want. But it brings up a good topic of discussion. Independence in journalism is a real thing, not simply a word that you choose in a marketing meeting. One of the defining characteristics of an “independent” publication is that they are invested in the community. An independent bookstore owner that I know is a genuine promoter of local parks, for instance, because he is a local resident and his customers are local residents. He is in the community and he has to live with what he does. Similarly, EPM is 100% concerned with the well-being of emergency medicine. It is all we know, and all we care about.
I think that we need to preserve this concept of “journal independence,” but we may be too close for objectivity. So we are polling readers to find out what they think. How important is it to be truly independent? Who is independent? What does this specialty need from a publication? We’re all ears.
Mark Plaster, MD
Emergency Physicians Monthly
(emphasis in original)
By happy coincidence my copies of both arrived a day or two ago, and here are their banners:
Both are good for EM and EM Docs, and both have treated me remarkably well personally. My interactions with Dr. Plaster and his family-run publication have been very nice, and they seem to be ‘more independent in style and spirit’.
This post brought to you by GruntDoc, the only Independent Emergency Physician Blogger in Fort Worth.
We have scribes at our hospital ED, and they’re not just amazingly bright young people who help us with charting, they’re amazingly bright young people who bring various other talents with them.
A talent that’s often useful is the Spanish language here in Texas. Often, we’re pressed for time, and a scribe with any Spanish-language talent is a sought-after commodity.
One of my colleagues relates that once he asked a new scribe if they spoke any Spanish.
The answer? “I speak conversational Spanish”. (Doc is pleased).
So, off to the patient’s room. Scribe gets through basic introductions okay.
“Is she having any vaginal discharge?” is the question, aimed at the scribe for relay to the patient.
“That’s not really conversational Spanish”, says a scribe now completely beyond their ability.
All’s well that ends well, but now we all have an appreciation for how medical and conversational language differ.
The MUSC Tiger has the visual joke of the day.
If you don’t get it, ask a woman to explain it.
From a classmate:
The American College of Emergency Physicians (ACEP) today released the results of their state-by-state surveys of the State of Emergency Medicine. Most states aren’t going to be happy (and we all knew this when we got an email from the Texas College of Emergency Physicians President telling us not to panic when the grades came out).
Well, they’re out, here. The grading was done on the following categories: Access to Emergency Care, Quality and Patient Safety, Public Health and Injury Prevention, and Medical Liability Environment. Reading any one states’ results will tell you what they were looking for.
Apparently they didn’t find the answers here in my home state of Texas:
Here’s a State by State Comparison of grades. No final grades of A, nor F. Six B’s, which is as high as any state got, and 3 D’s, the lowest score available. There is plenty of room to argue the relative merits of the grading scale (how, exactly, do the numbers of residents and residency programs contribute to Quality and Safety? for instance), but this is an excellent starting point. On the other hand, I doubt any hospital is going to be putting a big poster of this up in their ED waiting rooms.
The point of this exercise is, as I understand it, to bring public (read: lawmaker) attention to the state of your emergency departments. I don’t pretend to know what The Answer is (I suspect it’s a lot of little answers), but what we’re doing now for EM access, and funding, is remarkably poor for such a rich country.
And ACEP is to be commended for doing the work to highlight this issue.