USAAEM web presence

USAAEM is the Uniformed Services Chapter of AAEM, and they have their own page / URL tied in with AAEM.

If you’re a military EM type, it’s for you.

Thanks from a family

Last night I cared for a patient from out of town. The patient had a migraine, which was fairly usual for the patient, but was an unwelcome addition to the families’ vacation.

Standard migraine therapy (not involving a narcotic) was applied, and as expected the patient was pain-free after about 30 minutes. Much incredulity over ‘How did you make her better so fast’?

The best part: effusive thanks from the 5 and 8 year olds: “You fixed or mom, so we can stay on vacation and not have to go home”.

Emergency Medicine: making the world safe for vacationers of all ages.

Testosterone to Epitestosterone Ratios: Cheater or not?

The Floyd Landis announcement today, and the sports radio coverage of it sent me to the internet. One of the radio reports says the discrepancy was in the ratio of epitestosterone (E) to testosterone (T) in the urine, about which I was ignorant.

So, off to MD Consult, where Primary Care: Clinics in Office Practice, Volume 32 • Number 1 • March 2005 says the difficulty catching athletes abusing T for performance enhancement was cracked by:

…measuring the ratio of testosterone to epitestosterone, with a result of greater than 6:1 considered suggestive of exogenous testosterone administration [34].

[34] was a reference to Issues in detecting abuse of xenobiotic anabolic steroids and testosterone by analysis of athletes’ urine. Catlin DH – Clin Chem – 01-JUL-1997; 43(7): 1280-8 which says:

…The process of determining if an athlete has used testosterone (T) begins with finding a T to epitestosterone (E) ratio > 6 and continues with a review of the T/E-time profile. For the user who discontinues taking T, the T/E reverts to baseline (typically approximately 1.0). For the extremely rare athlete with a naturally increased T/E ratio, the T/E remains chronically increased. Short-acting formulations of T transiently increase T/E, and E administration lowers it. ….

So, what’s to be done? It’s not only a retesting of the ‘backup sample’ but a comparison of ratios from previous samples. Landis has been racing long enough there’s probably 200 gallons of his pee in little bottles available for comparison.

I should note this is from a 15 minute session looking at the first literature hits; also, I don’t have anything to do with drug testing in sports. I’m waiting with you to see what happens.

Landis Tests Positive

Well, crud:
SI.com – More Sports – 2006 Tour de France – Tour de France winner Landis gives positive drugs test – Thursday July 27, 2006 11:36AM

LONDON (AP) — Tour de France champion Floyd Landis tested positive for high levels of testosterone during the race, his Phonak team said Thursday on its Web site, raising questions about his victory.

The team suspended Landis, pending results of the backup “B” sample of his drug test, just four days after Landis stood on the victory podium on the Champs-Elysees, succeeding seven-time winner Lance Armstrong as an American winner in Paris.

The Swiss-based Phonak team said it was notified by the UCI on Wednesday that Landis’ sample showed “an unusual level of testosterone/epitestosterone” when he was tested after stage 17 of the race last Thursday.

Bye-bye Tour de France win.

The good news? Now he’s got plenty of time to get that hip fixed…

How Pandemics Will Spread: An Object Lesson

Take an over-intelligent American in a foreign country.

Let said American get sick with a possibly contagious illness. What’s the first thing they want to do? Get back to the US. For example, from CNN:

BOGOTA, Colombia (AP) — This Andean highlands capital has twice felled famed hacker and security consultant Kevin Mitnick.

“I’m looking forward to getting on the first plane to the United States,” Mitnick, 42, said Wednesday from his hospital room in the Colombian capital, where he said he’d been laid up for about three days with a bad flu.

Mitnick blamed Bogota’s 8,700-foot (2,650-meter) elevation and a prescription drug he was taking for that trip to the hospital.

This time it was simply a nasty flu, accompanied by a fever reaching 40 degrees centigrade (104 degrees Fahrenheit), that prevented Mitnick from attending a big weekend hacker’s conference in New York.

“I tried to get to the airport to get to the plane to New York and just couldn’t make it,” he said.

(empahsis added).

This is a smart person, make no mistake. And, It’s my prediction that aluminum birds will bring bird flu when it comes, not feathered ones.

Change of Shift #3 is up

Change of Shift: Volume One, Number Three // Emergiblog

Rotund Radiographically Rejected

CNN.com – Study: More Americans too fat for X-rays, scans

More and more obese people are unable to get full medical care because they are either too big to fit into scanners, or their fat is too dense for X-rays or sound waves to penetrate, radiologists reported Tuesday.

With 64 percent of the U.S. population either overweight or obese, the problem is worsening, but it represents a business opportunity for equipment makers and hospitals, said Dr. Raul Uppot, a radiologist at Massachusetts General Hospital.

Our population, or a majority of it, has eaten itself into livestock proportions. Now I frequently have patients I cannot CT.

Oh, take your ‘do a history and a careful physical exam and you won’t need as many scans’ and stick it in your ear. I defy you to clear the c-spine of a 450 pound patient with tingling in the arms. Won’t fit in the CT or the MRI, even the ‘open MRI’.

Weighty problem. Not funny.

Cutting Remarks: An unsolicited review

Dr Sidney Schwab has written a book, and I bought one.

It’s aimed at a general audience, and while not a ‘natural’ writer his prose is very accessible and he takes great pains to make the medical jargon easily understandable.

His topic is that physical, emotional and intellectual challenge that is residency, specifically a surgical residency in a city by a bay in the 70′s. Intense situations make for indelible memories, and that’s what this was for him (and anyone who’s done a residency worth a damn) and he’s given us an inside look. A non-too-sparing look, as well, with instructors he felt were sub-par identified as such. There’s some tense memories, and it’s obvious he reigned some of it in while telling the story.

And, he made me laugh out loud. Really, I was laughing aloud after reading a particular passage (about a retractor), and that’s a rarity for me.

Recommended. Here’s where to get yours.

MedBlogs Grand Rounds: Volume 2, Number 44: The Garden

Blooming here.

A Proper British Grand Rounds.

Patient-Consumer Parade 4 is up.

The Patient-Consumer Parade 4.

Aggravated DocSurg Public Service Announcement #1

Aggravated DocSurg Public Service Announcement #1:

For those of you who missed out on a few lessons in physics and biology, here is today’s little tip to help you from ending up in my ICU:

Hehe. It’s a visual thing…

Floyd Landis Wins!

SI.com – More Sports – 2006 Tour de France – Landis becomes third American to win Tour – Sunday July 23, 2006 3:14PM

PARIS (AP) — The highs and lows of Floyd Landis’ nail-biter of a bike race ended without a hitch Sunday as he won the Tour de France and kept cycling’s most prestigious title in American hands for the eighth straight year.

The 30-year-old Landis, pedaling with an injured hip, cruised to victory on the cobblestones of the Champs-Elysees, a day after regaining the leader’s yellow jersey and building an insurmountable lead in the final time trial.

“I kept fighting, never stopped believing,” Landis said, shortly after he received the winner’s yellow jersey on the podium, joined by his daughter, Ryan.

How tough is he? He needs a hip replacement, but won anyway.

Notes from Dr. RW: Notes from Dr. RW is one year old

Notes from Dr. RW: Notes from Dr. RW is one year old:

Notes from Dr. RW is one year old
One year ago today, on a lazy afternoon with too much time on my hands, I logged on to Blogger, took the plunge, and haven’t looked back since.

I would like to thank the supporters of this blog….

Many Happy Returns!

Leaving AMA: A Patient’s Perspective

In the mailbag, a very well-written exposition from a patient about leaving AMA:

I was in for a [surgery] and had jumped through all the hoops (completed basic physical therapy, and my bowels and urine system were up and running).

[Surgery] was ready to release me but noticed and elevated resting pulse. It cost me two days in the hospital and testing found nothing except when my body is stressed, my resting pulse is high.

Here’s the issue. I was miserable for those two days. I wanted to be home. I like the scale that hospitals use to describe pain 1 to 10 and don’t let it get much over 3 because it will set you back. Let’s substitute mental emotional pain for physical pain. Anger, depression, fear, panic, clostrophobia… Confinement to a hospital room, hospital gowns, and drugs exacerbate the problem. It’s hard to stay ‘grounded’. On a misery scale I was a 7 or 8.

Consider this; pain passes, misery leaves indelible marks. We see this with rape victims and returning soldiers. When the misery scale gets too high it becomes a long term issue.Here’s the problem. Someone like me who’s had a miserable indelible experience in the hospital is going to be much more difficult to get back in the hospital the next time hospitalization is needed. You can say “Quit whining and be logical” and I’m going to agree that it is not logical to avoid needed medical care, but humans don’t make decisions based on logic, at the core, decisions are usually based on emotive factors.

When you are faced with a request to leave AMA, ask about the misery scale level. Can you do anything to relieve the stressors? Will hospital privileges help? Is what we are doing really that urgent? Can I contract with the patient for outpatient followup? Remember it’s not just the short term medical issues, and they may override the patient’s misery level, it’s also the long term ability to have your patient believe that a doctor is truly their advocate for health.

That’s an excellent presentation of just some of the stressors that induce patients to leave AMA.

When notified someone wants to leave AMA, we ‘offer all services of the hospital’, but often that’s not well understood (by either side in the conversation). And generally all offers fall on deaf ears, as when someone has mustered the courage to ask to leave AMA, they’re decided on leaving. The patient wants to go, but wants, usually, to be grown-up about it, announce their intentions and exit. It would be ever so much easier for them to simply walk out (I’m using my ED as an example), so I respect those who announce their intentions, though overall we tend to be very patronizing to them.

Thanks for the letter. I hope you’re not scared-off for life.

Dr. Anna Pou Is Not a Murderer

Waking Up Costs vouches for the NOLA indicted doctor: Dr. Anna Pou Is Not a Murderer:

I just learned that a former colleague and friend has been charged with second degree murder in the death of four patients at a New Orleans hospital after Katrina. I worked with Dr. Anna Pou in the operating room when we were both in Galveston, Texas for three years in the late nineties.

There’s more, and it’s worth reading.

Update: Link fixed thanks to reader Walt.