Archives for April 2006

A glimpse into my night

me: "When did you last get a tetanus shot?"

patient: "Uh, last time I was in the Pen; it was either ’97 or ’98."

me: "Thanks. You’ll need another, then."

Just working shifts

That’s why there’s nothing going on here.

 I had yesterday off, and actually took it off.  I don’t think I did anything.

 It was nice.

Rumors of my demise, yada yada …

Yippee, the blog is back.  HostingMatters, by blog host, was the victim of (yet another) DOS attack, and it knocked me off for most of today.

 True to their form, HostingMatters did a good job, and now I’m back.

More to follow…

DreamCatchers Creations

In the mailbag:

I am an Army Sergeant First Class and soon to retire (after 22 long years).

My wife and I own a business that builds PCS, retirement and other related military gifts that will withstand constant household moves – they won’t just fall apart like most AAFES crap; and we charge a Soldier’s price: so they are all great quality AND affordable. We also build for Police, Fire, Civil Service, etc. We offer up to 10% discounts on all products to Soldiers. We are willing to donate portions of discounts to "reputable" Blog Sites (like as well, that utilize proceeds toward Soldier and family support.

The bottom line is I’m trying to get the word out about us in a short time, since being Active Duty and building for/running the shop takes up almost every hour I’m awake.

So, if you’re in the market, here’s an option, DreamCatcher’s Creations ( )

(Disclaimer: I have no financial relationships with them, don’t specifically endorse them, but hope the best for any veteran and their businesses).

Good News on the Coffee Front


Medscape Medical News
Coffee May Not Increase Risk for Heart Disease
News Author: Laurie Barclay, MD
Release Date: April 25, 2006

April 25, 2006 — Coffee does not increase the risk for coronary heart disease (CHD) in men or women, according to the results of a large, prospective cohort study reported in the April 24 Rapid Access issue of Circulation.

"We found that coffee consumption was not associated with an increased risk of CHD," lead author Esther Lopez-Garcia, DrPH, from the Universidad Autonoma de Madrid in Spain, said in a news release. "This lack of effect is good news, because coffee is one of the most widely consumed beverages in the world…. The length of follow up is important because it allowed us to examine the long-term effects of coffee consumption."

Drink up! (Starbucks not listed as a study sponsor).

Three D’s of Effective Leadership

Today, while performing a reduction and splinting, I decided it was time to enlighten my nurse and tech with some leadership education: Specifically, the Three D’s of Effective Leadership.  (I didn’t spend all those years in uniform for nothing).

I elected to share them with you when, on going back to the patient’s room, the patient’s family member asked me to recount them so he had them right (he wasn’t asleep during the reduction, like the patient).  Smart fellow, and attentive.  He has them and it’s only fair you do, too.

So, here they are, the Three D’s of Effective Leadership: Decide, Delegate, and Disappear

Decide: you cannot lead without making a decision.
Delegate: Leadership is different from management.  Delegate so you can Lead.
Disappear: Nobody goes to the delegate when the leader is around.  Let the delegate work.

So, there you are.  Use your new powers for good, and not evil.

Word to the Wise IV

…via the in-house code team…

When your patient is extubated (no longer on the ventillator), make sure to cancel the PRN paralytic order.


Just sayin. 

MedBlogs Grand Rounds 2:31

Health business blog: Grand Rounds 2:31

Welcome to the 83rd edition of Grand Rounds, hosted here at the Health business blog!

I noticed at least a couple of changes since I hosted #40 almost a year ago. First, the pre-Rounds writeup on Medscape (thanks Nick) and second, the sheer number of submissions. Now, let’s get started…

Editor’s picks (aka Dave’s Faves)…

Another batch of the medical blogging world’s finest.

In the Foothills of Medicine, by Dr. Robert McKersie

In the Foothills of Medicine

I was offered a complimentary copy of Dr. Robert McKersie’s Book "In the Foothills of Medicine", as long as I’d write a review of it. I thought this to be a fair trade, and probably poor judgement on Dr. McKersie’s behalf, as I’m not a professional book reviewer, I’m just a grunt doctor.

It’s an interesting study of becoming a doctor (FP), who came to medicine later in life after a time of being a teacher. His written communication skills are terrific, and he’s also a good storyteller. There are many excellent vignettes of his patient care experiences, and patients who touched him. There’s also a painful chapter about love, a lover and loss that makes me appreciate how brave he was to write about it, and include us in his life.

Dr. McKersie is also involved in Himalayan HealthCare, wherein he travels into the mountains of Nepal and practices medicine there. It’s quite a different life and practice from that we’re used to in the US, and his descriptions (almost) make me want to participate. Clearly he enjoys these working vacations, and it shows in his writing.

The cost of medicine, and a desire for some sort of universal health insurance (and frequent readers know about my feelings there) is a very frequent theme in the book, and frankly it’s a bit of a distraction. On more than one occasion, having involved us in the compassionate care of a patient, there’s ‘money’ sticking its head into the story; in a couple of the stories it’s valid, but in several it’s just jarring. I think one, or maybe two of these mentions would have made the point, and frankly I began to scan ahead to see where the ‘money’ paragraphs were so I could just skip them.

In all, a good book, and I hope he keeps writing. He has a skill for it, and a natural openness into his life and practice that’s good for physicians and patients alike.

Dr. McKersie has a web site, where you might also purchase his book, or read about his other interests. 

My last words on Las Vegas

When the food in the airport is cheaper and tastes better than the food in your tourist attractions, your city is screwed up.

Update: And, no Guinness in tourist-trap bars?  What? 

ACEP, other lessons learned

It’s over, and having fun in Vegas trumped blogging. So, now that we’re home safe and sound, here’s some other things I learned / reinforced while there:

  • we’re state-of-the-art with our procedural sedation where I work. Good news.
  • for crashing patients, get the sono to the bedside, and think about dissection as a cause early
  • trendelenberg position doesn’t improve BP, and should be abandoned unless trying to start a central line
  • shock for fib, then do CPR without checking for ROSC for 2 minutes (big change)
  • GERD flare-ups and cardiac ischemia are often linked! (Weird but true)
  • soon, the 64 detector CT will do away with diagnostic caths (but not yet)
  • morphine is not helpful for decompensated CHF (dCHF); no appreciable venodilation
  • morphine is, however, a significant risk factor for needing to intubate in dCHF (5x)
  • BiPap and Cpap are equivalent for dCHF, and getting them started early is the key
  • Brugada syndrome is more prevalent than previously thought: look for it in your syncopal patients
  • add colchicine to aspirin for your pericarditis patients
  • things to avoid in pericarditis: indocin and steroids

A fun time was had by all, and it was a good, if sparsely-attended conference with very good speakers.

Now to start incorporating this into my practice…

Unclear on the concept…

…of gambling and money flow.

While I was in conference this morning, my wife decided to play here in Las Vegas.  I asked her how it went.

"Oh, I’m up $20.  Unfortunately, you lost $20."

Aah, now I get it. 

ACEP Day 1, Lessons Learned

Lots of good lectures on day one, and here’s a partial list of ‘things I learned’ today:

  • a better way to make a splint for 2nd and 3rd metacarpal fractures
  • a better way to make a splint for a distal radius fracture
  • nebulized Lidocaine can help for coughing in COPD (and there’s one study saying it helped get people off long-term inhaled steroids)
  • there’s a deep brachial vein just medial to the brachial artery just above the elbow: it can be accessed by a blind stick, but sono is better, and it’ll need a 2" catheter
  • Putting a finger in the supraclavicular fossae while threading the guidewire in subclavian line placement cut the number of mis-placed lines to zero in one (small) study
  • As for Chest Pain, "Atypical is Typical"
  • a proposed reason for the drop in meth lab seizures in the southwestern US: Tijuana pharmacies bought more pseudoephedrine than all the US pharmacies put together last year (see also: globalization, outsourcing)
  • suspect ethylene glycol poisoning and looking for flourescin with a woods’ lamp?  Look on the face (splashes while drinking) along with the urine
  • CT angio is now better than formal pulmonary angiography 
  • Methadone can cause adrenal insufficiency
  • And, for the quote of the day: "You’re not that smart in the ED, and it’s OK: Intelligence in the hospital is Altitudinally based"

Good meeting so far, and nice to see an old friend here. 

We went out on the town, had some fun, and made sure to leave enough money behind so they can leave the lights on. 

Day 2 looks good, too! 

MedBlogs Grand Rounds 2:30

I’m a little late to the party, but:

Welcome to Fat Doctor’s Grand Rounds, Vol. 2, No. 30

Six pack of Diet Coke to focus my tangential thoughts: $2.99.
Bottle of acetaminophen to soothe my throbbing brain: $4.38.
Aborting all attempts to be clever: Priceless.


What Happens in Las Vegas Stays in Las Vegas

…unless you blog it.

 Tonight I got to Las Vegas for the ACEP Spring convention starting early this morning.  I walked the place a bit with my spouse, who has accompanied me on this trip.  We didn’t go very far (or far enough), and had some expensive food for dinner.

On the way back to the hotel we had an interesting interaction: a fellow who was clearly under the influence of a lot of stimulant drugs and was acting bizarrely and aggressively.  We were followed for a ways, and it was unsettling.  (I was thinking what I’d tranquilize him with in my ED, which was odd).

Anyway, we’re back in our hotel, and I’m looking forward to a good convention.  My wife has a ‘gambling allowance’ and is looking forward to using it.

More as it happens…