A unique method for obtaining cultures

At my ED, the techs are often relegated the task of obtaining the GC/chlamydia culture specimens from male patients with appropriate symptoms.  Male techs, male patients, no problem.

Recently, I asked one of the more-experienced techs if he had difficulty with the procedure:

"No, I don’t do it".

What?

"I hand the stick to them, and have them do it themselves".

Really?

"I tell them, you stuck it in; you stick it in".

Aah.  Interesting.

Humble student infected with rabies

via the Houston Chronicle:

Chron.com | Humble student infected with rabies

May 10, 2006, 1:04PM
Humble student infected with rabies after apparent bat bite

By JENNIFER LEAHY and LEIGH HOPPER
Copyright 2006 Houston Chronicle

An Humble High School sophomore infected with rabies is fighting for his life as federal and county disease investigators try to determine how many of the student’s classmates may need preventive treatment, a school official said today.

The student may have been exposed to a bat approximately four weeks ago one afternoon while asleep in his bedroom, said Humble ISD executive director for public information Karen Collier. Reportedly, a neighbor saw the bat hovering above the victims face, caught it with a towel and threw the bat back out of the open window.

The student began showing symptoms Thursday and was admitted to Texas Children’s Hospital, Collier said….

The article has links to the CDC’s Rabies info page, as well as a link to an article about the Milwaukee survivor last year. Really, the Chronicle did a nice job with the reporting and the other links: it’s an excellent example of how to integrate the dead-tree publication with the online presence. Excellent.

Humble, Texas map.

A four-week incubation period seems really short, indicating that the victim was probably infected near the head. (Rabies travels up nerves to the brain, which is when the symptoms start; get bitten on the ankle it takes longer for the virus to make the trip than if bitten on the face).

My prayers to this young man and his family.

Update: CDC’s Health Alert Network email in the extended entry –

Final update: He died. More prayers for all affected.
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This week’s reason to dislike the AMA

The Blog That Ate Manhattan: AMA – The American Marketing Association?

Astounding the degree to which the AMA will go to sell out doctors.

(I found this via Grand Rounds: a good post in a blog I don’t read often. Go read Grand Rounds!)

MedBlogs Grand Rounds 2:33

Aetiology: Grand Rounds n.2 v.33

Welcome to Grand Rounds at Aetiology! Grab a cup of joe, take a seat, and enjoy the best of this week’s medical blogging. Just make sure to wash your hands when you’re done…you never know what’s lying around here, between the kids, the dog, and the lab…

This is another excellent Grand Rounds, and the number of posts is astounding. This should keep you busy all week.

I get mail!

Okay, I (occasionally) get unhappy emails from people other than unemployed plaintiffs’ attorneys, but this one was my first full bore, barely coherent hate mail, ever (verbatim):

There are real people out here and you son of a bitch play with your jokes and supposed wit and generally filled with shit garbage out of that pea brain of yours. Go find your own personal hell and stay there- forever! 

I am at a loss to explain this, frankly.  Were I heavily engaged in political debate I’d expect this sort of invective from some mouth-breathing moron, but I don’t get it.  I’ve looked over my last several posts, and none are of the "you should die, screaming" offensive variety.  Weird.

Anyway, my supposed wit is undamaged by this assault and my pea brain is already thinking up new jokes.  I just hope the correspondent gets back on their meds, and I get lost from their address book.

Required Reading from Respectful Insolence

Respectful Insolence: A sign of the times

When you hear there is no medmal problem in America, consider this little bit of anecdotal evidence:

… 

One question that is inevitable is whether or not I had ever been sued. The question usually asked (1) whether I had been sued in the last three to five years (the exact time depending upon the company) or (2) whether I had ever settled a case out of court. If the answer was "yes," then inevitably would follow the request for full details of the case. Last week, I was filling out one of these forms, when I came across the usual question, but its form was vastly different than what I remembered from previous applications in the late 1990′s and early 2000′s.

Has there been, within the past five years, more than one malpractice judgment found against you or malpractice settlement made, with or without prejudice, in excess of $50,000?

Notice the difference. The insurance company no longer asks if you’ve been sued. It only asks if you’ve lost or settled more than one malpractice suit for more than $50,000 in the last five years. The assumption is clearly that many good physicians will not only have been sued in the last five years, but will have lost or settled one case for more than $50,000!

Read the whole thing.

 

Hat tip to Overlawyered 

How Hard is Medical School?

How Hard is Medical School? was the question, and Tulane MS1 Niels Olson answers:

I found this question in my site statistics. Someone had typed that question into a search engine, and one of my pages came up. It’s a tough question to answer, because it’s relative. I mean, really, hard compare to what? Compared to qualifying as a tactical action officer in the Navy? Well, not really, but then, that didn’t take four years. Harder than labor? My wife assures me med school isn’t that bad, but that labor only lasts so long, though I’m sure it must seem like forever.

‘Medical school isn’t hard, there’s just so much of it’ is what all the docs told me before I started. I tend to agree there….

It’s really a pretty good answer (better than my “it’s like trying to get a drink out of a fire hydrant” routine answer), and perhaps you’ll agree.

MedBlogs in the News

An article about medical bloggers in this Sunday’s Dallas Morning News (requires free but annoying registration). Yrs. Trly is featured, and there’s even a photo (which shows why I’m a blogger and not on TV).

Medical pros connect online
Blogs and online forums by, for health care workers, students provide insights, support
12:00 AM CDT on Sunday, May 7, 2006
By SUSAN KREIMER / Special Contributor to The Dallas Morning News

In the world of blogs, he’s known as GruntDoc. It’s a throwback to his stint as a surgeon in the U.S. Marine Corps, where infantrymen were somewhat affectionately called "grunts."

"Now I’m an emergency medicine doc who just works shifts. I’m a grunt in the doctor world," said Dr. (read the article), 42, of Emergency Medical Consultants Ltd. He works primarily at Harris Methodist Fort Worth Hospital. In his spare time, he runs a Web site to educate as well as entertain (www.gruntdoc.com).

"My blog traffic is a ripple on the big pond, getting 500 to 800 unique visitors a day, with just a few commenters," he said. "The comments are generally very good, and I frequently learn a lot from them."

Blogs and forums hosted by health professionals and students are proliferating. They may be miles, even continents, apart. But in cyberspace they connect. Through words and experiences, they provide an insider’s glimpse into their fields.

"A person may think that their desire to help people is out of step and perhaps a bit odd," said Peter Lucash, a former hospital administrator who is a Charleston, S.C.-based business consultant to medical practices. "Reading some of these blogs is a confirmation that these feelings are real, that others share them – and that there is purpose, value and honor in going down this path.

"Blogs such as the ones written by nurses and physicians, who tend to be highly opinionated and self-assured people, offer different perspectives on the highs and lows of the job. TV shows give a very false impression of the day-to-day working life in health care."

Doctor’s views

The most sought-after and hilarious page of his blog features a rap video from nurses at the University of Alabama in Birmingham. A co-worker told him about it after receiving word via e-mail.

"I liked it so much I decided to host it," … "I got an e-mail from one of the performers in the video a few months back letting me know they’re making a rap album, with more of the same type of songs."

"The ED [emergency department] is a remarkable place, much more interesting than on TV," he mused.

Although most would classify him as a medical blogger, health care isn’t the sole subject of his ramblings.

He also blogs about family, auto racing and anything else that interests him.

"The occasional spleen-venting I find very therapeutic," … "I don’t have any real goals with my blog or blogging, other than to stay sane."

 A nice article, and I’m deep into my fifteen minutes here.

Other blogs mentioned:
allnurses.com
www.advanceweb.com/pa

And, Dmitriy Kruglyak, publisher of the Medical Blog Network is the person who got me involved in this interview.  His site URL isn’t given in the article (neither are several other bloggers), which seems quite a dead-tree thing to do, especially in an article about blogs.

Prodigal State: Tort reform brings doctors back to Texas

OpinionJournal – Cross Country


So what has happened since September of 2003, when the new law went into effect? After years of losing doctors, Texas has added nearly 4,000 since passage of Proposition 12, including 127 orthopedic surgeons, almost 300 anesthesiologists, over 200 emergency room physicians, 146 new obstetricians, 58 neurologists and 24 neurosurgeons. The Texas Medical Board is anticipating some 4,000 applicants for new physician licenses this year alone–double last year’s numbers, and 30% more than the greatest growth year ever.

The threat of lawsuits has been a particular barrier to attracting and retaining pediatric specialists. Since 2003, Texas has gained 20 pediatric cardiologists, 14 pediatric oncologists, almost 50 new perinatologists (obstetricians specializing in high-risk pregnancies), 10 pediatric surgeons and 8 new pediatric endocrinologists.

Medically underserved counties in Texas are benefiting as well. Jefferson, Webb and Victoria Counties, as well as the counties of Cameron and Hidalgo in the Rio Grande Valley, have all experienced an influx of physicians. Additionally, the market for insurance to protect health-care providers against the cost of lawsuits has become more robust and competitive. In 2002 there were only four companies writing policies. Today that number has more than tripled. And all of these trends are expected to continue.

Okay, anecdotes are just that, but these appear to be real numbers. Given that it’s a trend reversal, and the only real change in the Texas healthcare climate has been tort reform, I think that gets the majority of the blame / credit. 

I’m not in love with caps, as it seems quite a blunt axe to solve a complex problem.  However, as no other solution was viable, this is the one we wound up with.

via Jim in Plano, and yes, we still need to take a lunch. 

Sam’s MS 150: Best of Luck, riders!

 I was planning to ride today and tomorrow in the Multiple Sclerosis 150 mile ride here in DFW, sponsored this year by Sam’s Club.  I have a very nice bike, though I’ve been working so much I haven’t gotten a lot of riding in for preparation.  I’m mostly sure I could finish day 1, though day 2 would be a challenge, to say the least.

No matter.  This weekend we’re so shorthanded I have been scheduled on.  I’m not terribly happy about it, but if there’s nobody else, well, then it’s on me.  So, I’ll be there in spirit, if not in person.  I have a nice riding outfit for the team, and I suppose I’ll just wear it while riding for fun (I see a lot of old team jerseys when I ride, so now I’ll join that club, though on a pass).

It may rain, and that’ll be better than the blazing sun I would have predicted.

Good luck, riders, and if you not riding have an extra buck, the MS Society is taking donations.

FatDoctor has a stroke

Fat Doctor: Update

Greetings from UCSF Medical Center, room L872, where I was admitted Friday night with several new strokes, bilateral frontal lobes this time. Turns out my bad mood was nothing but poor perfusion; a few intracranial stents this afternoon should do the trick. Please forgive the brevity of this message. Typing is a challenge with limited use of my left hand.

There are other updates, and she’s had a stenting procedure. Read the site for the rest of the updates.

I’ll add my best wishes to the chorus in her comments for a full and speedy recovery. Though new to me, she blogs with a personal and accessible voice, and we need more like her.

Thanks to DOW for the heads-up.

DB’s MedRants in the ACP Observer

via Kevin, MD: ACP Observer, May 2006 – Internist stirs passions, debates with a medical blog

Internist stirs passions, debates with a medical blog One internist’s blog helps him connect with a farflung virtual community—and giveD free rein to his inner ‘rant’

From the May ACP Observer, copyright  2006 by the American College of Physicians.
By Janet Colwell

To colleagues at the University of Alabama facilities in Huntsville and Birmingham, Robert M. Centor, FACP, is a respected academician and administrator, serving as associate dean of the Huntsville regional medical campus, director of general internal medicine in Birmingham and attending at the Birmingham VA Hospital.

But to hundreds of Web surfers, Dr. Centor is the "DB" of "DB’s Medical Rants," a Web log—or blog—he created in 2002 to broadcast his views on health care and medicine far beyond traditional academia.

And, I’d add my congrats to Kevin’s! 

Kevin, MD turns two today

Kevin, M.D. – Medical Weblog: Two years young

He’ll skip the terrible twos, I’m sure.

 Many congrats to the InstaPundit of the Medblogs!

The ‘wrong’ fluid

Tonight I performed a paracentesis on a patient, and it wasn’t usual.

I was presented with a female patient whom every female nurse who saw her said ‘…she looks like she’s going to have quadruplets…’.

History: several months of abdominal distension, slowly, to the point that she now has trouble breathing, and is at the end of her psychological rope. Signficantly, the patient is in her early forties, no other medical history, and was told to stop drinking recently "because you’re killing yourself".

Exam: Pretty unremarkable except for a way-past-term size distended and tense abdomen. Patient is uncomfortable but not toxic. So, for diagnostic and therapeutic purposes, let’s get some fluid out of this abdomen. I do this routinely, so, no biggie. RBA discussed, etc. I did a bedside sono and confirmed the area chosen to start had no adherent bowel, etc.

Procedure started. Hmm, this fluid looks really really dark, and not like any cirrhosis fluid I’ve gotten before. For a brief second I wonder if I’m in her colon despite the sono, but given the rate and copious nature (six liters, and plenty left where that came from) it’s not colon. But it’s not ‘right’, either.

A CT is ordered. And resulted. "Massive ascites, a 40x20x13cm pelvic mass, with some others, ‘of ovarian origin, probably cystadenocarcnoma’…".

Good news, not cirrhosis. Bad news: cancer. It was a malignant ascites. The patient took the news with more equanimity than I was expecting. A GYN oncologist was consulted, and the patient admitted for a long and arduous course of probable surgery and chemotherapy.

The crux of this case was having done a lot of paracenteses for cirrhosis and knowing that the fluid from this one was ‘wrong’, spurring a more through ED workup. Sometimes experience helps. That was my most interesting patient this week. And it’s only Tuesday.

CPOE Return on Investment

In the email today comes an abstract from "J Am Med Inform Assoc. 2006;13:261-266", entitled "Return on Investment for a Computerized Physician Order Entry System".  I’m going to put the whole thing in the extended entry, but here’s the Results section, and I wonder if you see the same thing I did:

 Results: Between 1993 and 2002, the BWH spent $11.8 million to develop, implement, and operate CPOE. Over ten years, the system saved BWH $28.5 million for cumulative net savings of $16.7 million and net operating budget savings of $9.5 million given the institutional 80% prospective reimbursement rate. The CPOE system elements that resulted in the greatest cumulative savings were renal dosing guidance, nursing time utilization, specific drug guidance, and adverse drug event prevention. The CPOE system at BWH has resulted in substantial savings, including operating budget savings, to the institution over ten years.

Answers are invited in the comments. 

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