MedBlogs Grand Rounds 2:39

Dr. Deborah Serani: Grand Rounds: 2:39

When I was in graduate school, my most enjoyable times were on Thursdays, when “Grand Rounds” was scheduled in the hospital where I had an internship. Some 20 years later, here I am still learning and sharing in the Grand Rounds tradition.

What do you mean there’s nothing to read on the internet? Go, now, and have fun!

Hubris

Senior Citizen from Mexico is brought in by a relative, accompanied by CT scans, ultrasound reports and the announcement “(loved one) needs a surgery”.

Well, this was worked up in Mexico, didn’t they want to do the surgery there?

“Yes, but they said there were only two doctors in Mexico who do this surgery, and, they wanted money. (Loved one) has Medicare, so here it is free.”

At this point, I’m thinking “we’re suckers”. And then, as I had to do a history through an interpreter, came this from the family member:

“You should learn to speak Spanish”.

So, they came for the free medical care, and I got some free advice.

I want to scream. The bile is back. Vacation is history.

Radiology Grand Rounds Announced

From Sumer’s Radiology Site: Schedule For Radiology Grand Rounds

Finally the Date for the first Radiology Grand Rounds is decided, it will be hosted on Sumer’s Radiology Site on every Last Sunday of the month. This June The First Ever Radiology Grand Rounds will be Hosted on 25-6-2006. Archive For Future Radiology Grand Rounds will be available here- Radiology Grand Rounds

I will accept anything that is relevant to Radiology or Medical Imaging but you don’t have to be a Radiologist to contribute. I’d love to hear from physicians, Patients, Nurses, Medical Students,Radiographers, Imaging Technicians etc, etc. Send submissions to sumerdoc@yahoo.com and anybody interested in Hosting Radiology Grand Rounds in future.

Hmm, the specialization of medicine is becoming more evident in Grand Rounds!

IOM Report on Emergency Medicine

The Institute of Medicine has released their report on the state of Emergency Medicine in the US: Nat’ Academies Press, Hospital-Based Emergency Care: At the Breaking Point (2006) (this is the link to the free, read-it-online version).

It’s utterly no surprise to anyone who works in an ED, and probably not to anyone who has visited one either, but the whole system is in serious trouble.

All the coverage I’ve seen has been worded remarkably similarly, meaning it’s too long to read, so the press reports are probably being gleaned from the Executive Summary. I intend to read the pertinent parts tonight after my shift.

A shift during which I expect to see a large number of patients, some terribly ill in a bed in a hallway, and some others who have a doctor but cannot wait to take their cold there tomorrow. Yes, the holiday is over, and the bile is returning.

Coffee May Protect Against Alcoholic Cirrhosis

From Medscape today came several comment-worthy news items, but this is the headliner, and (potentially) effects the most people:

June 13, 2006 — Coffee may be protective of cirrhosis, particularly alcoholic cirrhosis, according to the results of a cohort study reported in the June 12 issue of the Archives of Internal Medicine.

“A minority of persons at risk develop liver cirrhosis, but knowledge of risk modulators is sparse,” write Arthur L. Klatsky, MD, from the Kaiser Permanente Medical Care Program in Oakland, Calif, and colleagues. “Several reports suggest that coffee drinking is associated with lower cirrhosis risk.”

In this study, 125,580 multiethnic members of a comprehensive prepaid healthcare plan who had no known liver disease supplied baseline data at voluntary health examinations from 1978 to 1985. Through 2001, 330 of these members were diagnosed as having liver cirrhosis, including 199 members with alcoholic cirrhosis and 131 subjects with nonalcoholic cirrhosis, confirmed by medical record review. ….

[technical details omitted]

These relative risks for coffee drinking were consistent in different subgroups. Tea drinking was not related to alcoholic or nonalcoholic cirrhosis. Cross-sectional analyses revealed that coffee drinking was related to lower prevalence of high aspartate aminotransferase and alanine aminotransferase levels. The odds ratio of 4 or more cups per day (vs none) for a high aspartate aminotransferase level was 0.5 (95% CI, 0.4 – 0.6; P < .001), and it was 0.6 for a high alanine aminotransferase level, (95% CI, 0.6 - 0.7; P < .001). Inverse relations were stronger in those who drank large quantities of alcohol.

“These data support the hypothesis that there is an ingredient in coffee that protects against cirrhosis, especially alcoholic cirrhosis,” the authors write. “The absent relation of tea drinking to cirrhosis might mean that the relation is less likely due to caffeine than to some other coffee ingredient.”

(emphases mine)

I’ll drink to that!

MedBlogs Grand Rounds 2:38

It’s that time: The Haversian Canal: Grand Rounds Vol 2 No 38

Of 42 entries from 39 authors, 25 met the criteria I put forward in my call for submissions. Of my original categories, two gathered no enteries that meaningfully fit the categories: Case studies and ethics. My explicit goal was the 30 best articles from 30 authors. My aim was to motivate the authors, as a whole, to stretch a little further. Was it successful?

Another good group of links. Should keep you occupied for the whole morning.

AMA recruiting gimmick

Today in the mail came a big envelope, and a full-page flyer trumpeting "AMA membership for 1/2 price".  It’s a nice ad, with a cute kid and a caring doc.

The devil is in the details: Yes, it’s half-price membership, because it’s for a half-year of membership.

AMA is half-off their rocker

AMA: Not a member since 1998. Not likely to be, at this rate.

Cheerful Oncologist has moved

Well, now.  A couple of days ago it was Dr. Charles, and now The Cheerful Oncologist has moved over to ScienceBlogs.

http://www.scienceblogs.com/thecheerfuloncologist/

They must be giving away free pens over there at ScienceBlogs …

via Kevin, MD 

Too relaxed to rant

This is an odd turn of events: I’m still too relaxed to rant, to get the bile flowing, etc. 

Blame it on the vacation, but I cannot get worked up about anything (and there’ve been some things happen that would normally make me nuts: at the part-time gig I had a shift wherein the hospital didn’t have five (5) medications I requested on one shift.  ! )

This too shall pass, but it’s nice while it lasts. 

I’ve been busy preparing for another lecture, about neck trauma this time, that I’m giving Tuesday (I think, I need to call somebody…).  It’s a topic that nearly any one facet could make an hour lecture, and I’m giving an overview in 45 minutes.  Only about 65 slides, though, and for once I’m finished more than 24 hours ahead of the deadline.

 

The old me will be back, too soon. 

 

Dr. Charles has moved

His new address:

 http://scienceblogs.com/drcharles/

 Please make a note of it.

Brazos County SO has a sense of humor

brazosSOsuv.jpg

Hat tip to Bert for the photo. 

How docs can be our own worst enemies

I have a relative who had an urgent gallbladder removal recently, and he’s doing well, thanks.

However, we’ve been having some email exchanges about his workup, and specifically a trip to the ED that didn’t diagnose GB dz.  (Patient presented with lower abd pain, N/V; presumably had labs done, though he doesn’t know the results, and had a CT to r/o appy.  No appy by CT).

So, he went home, felt better for a week, then worse again, and went to his PCP.  This is where it’s so easy to look smart by subtly (or non-subtly) saying ‘well, the answer is "x", and they missed the boat by not finding it’. For instance, from an email (excerpt):

…he said I was showing classic symptoms of a bad gall bladder. When he pulled up the results of my CT scan on his computer, he said the results clearly backed that up. He even questioned why the ER doc would not have ordered an ultrasound after seeing the same results. At any rate, he sent me to a surgeon right away. The surgeon agreed with the diagnosis and ordered an ultrasound,…

(emphasis mine).

Now the seed has been planted, and it germinates in law offices with predictable results.  (He’s not going to sue, but now a lot of doubt has been planted in his mind).  It’s the kind of doubt that makes people go from ED to ED for a ‘second opinion’.

I am NOT advocating a code of silence or anything nefarious, but we ALL need to remember that second-guessing and criticism of other docs is neither constructive nor smart.  I have had complaints in the past, generated when the patient followed up with their doctor who (allegedly) tells the patient ‘you should have had ‘x test’, and that ER doc completely missed it by not ordering one’, resulting in a letter complaining about their care, etc.

So, let’s just save our snide critiques for the politicians, okay? 

I’m Back!

And, I need a vacation to rest up from my vacation…

That’s not going to happen, alas, as I start work again tomorrow morning.  (Yes, I know, if you take that many days off you’re going to work more frequently to make them up, but that doesn’t make it more fun).

Big, big thanks to Nick from Blogborygmi and Symtym for keeping the place occupied and lively during my absence.  Much better work than I do, and unfortunately now the bar has been raised a bit too high.  Lower your expectations, everyone.

Really, I had as much fun as possible with my clothes on, and it was a Disney vacation, so they stayed on.  Hopefully in a few days I’ll do the internet version of ‘1000 slides of my vacation in only 4 1/2 hours’.

Now to unpack and do some a lot of laundry. 

Big Love for Academic Emergency Medicine

I was pleased when I opened my mailbox today, and the new Academic Emergency Medicine burst out. It’s really a treat, on par with my subscription to the New Yorker. Why? Because AEM really expands my concept of what research, and emergency medicine, can be. I’m not kidding, and I’m not damning by faint praise (and EM is too small a community for me to get away with it, if I were).

The first article that caught my eye was entitled, Laser-assisted Anesthesia Reduces the Pain of Venous Cannulation in Children and Adults. Now, over the past year I’ve become pretty good at starting IV’s, I’m starting to incorporate ultrasound guidance on some tricky, urgent cases. But I’ve never really focused on minimizing pain, as my patients can attest. In the OR I’ve seen the anesthesia residents sometimes use lidocaine (and I certainly give it before a spinal tap) but I had no idea lasers were an option. Apparently, using a handheld laser over the planned IV site will ablate th topmost layer of skin, allowing transdermal anesthetics to seep though. Patients reported less pain in a randomized controlled trial (the patients and researchers were also blinded, though it’s not clear whether it was by design protocol, or from the power of the lasers).

Anyway, the next time I see an administrator strolling through the ED, I’m going to ask for a handheld laser. The evidence supports it, patients love it, and I’ve always, always wanted a laser gun.

Another eye-catching study was called, Single Question about Drunkenness to Detect College Students at Risk for Injury. The question was, "Hey, buddy, want to go grab a drink?"

Ha! No. I kid. The question was "In a typical week, how many days do you get drunk?" Any answer greater than or equal to "1" was associated with a fivefold increase in EtOH-related injury, a more than twofold increase in falls requiring medical treatment, and a more than twofold increase in being sexually assaulted. It’s a better marker than binge drinking, or anything else out there. The study was limited to ten North Carolina colleges — we’ll see if it’s generalizable beyond that. But the ED is a great place to make an intervention in a young college kid’s life, and this one question is a heck of a start.

It’s not all great in this month’s AEM — I was a little disappointed that Childhood Injuries Caused by Falling Televisions didn’t contain any blockbuster revelations (did you know there’s no ICD-9 code for falling televisions? for shame!) but on the whole this journal kind of inspires me. Anyone else out there a fan of AEM?

–Nick

MedBlogs Grand Rounds 2:37

What would GruntDoc do today? Why, link to this week’s Grand Rounds, and give an excerpt!

Not until the last moment did I realize that my Grand Rounds falls on a day of apocalyptic significance, celebrated by some. My hope is that TMBN’s new ideas will not cause the end of the world and instead bring us "Hell of a Grand Rounds"!

Amen to that. Tune into the Medical Blog Network’s edition of Grand Rounds, and see what everyone in the medical blogosphere is talking about. My interview with Dmitriy Kruglyak is available on Medscape (registration required).

– Nick