Archives for September 2006

ATLS Sillyness

I have to recertify my Merit Badge in ATLS next week, and have been reading the text in preparation.  This is because the test is over the book, not what’s actually done in ATLS, so you have to know what the book answer is, even though it may be 1-3 years behind current practice due to publication lag, etc.


Here’s the howler I found a few days ago, just by literally flipping open the book and starting to read:

Chapter 1: Assessment/Secondary Survey:


a. Inspect…

b. Auscultate for the presence or absence of bowel sounds

c. Percuss…

The average trauma room is as noisy as standing next to a city bus at idle on a busy street.  Often raising ones’ voice is necessary to be heard.  It’s not only not useful it’s entirely impractical.  The money is in the other exams, and I am amazed this got through.

More sillyness as I find it.


Oh, and I detest Merit Badge Medicine.  Both of my Professional Colleges have strong stands against the practice (ACEP and AAEM).  Nonetheless we do it ‘because we need it to keep our Level II Certification’.  So, it’s the surgeons’ fault I have to put up with this idiocy.

Update: I passed. I missed a question on the written though, so I’m a little bummed.

Cut to Cure cannot cut out the midlevel…

A nice, well-thought-out rant from Bard Parker:

Overextended…… I’m probably going to make some of my readers angry by posting this, but what the hell… First off let me say this is not an attack on physician extenders (NP’s, PA’s) whatsoever. I have a NP working with the trauma service and they are more helpful than the residents are. Some of the extenders are more capable than the physicians who supervise them. They also work in underserved areas delivering care to those who otherwise might not receive it. This is a beef I have with some physicians who utilize them, IMHO, in an unprofessional manner…

I don’t have much of this where I am, and consider myself fortunate for that. Read the post to understand what’s at stake.

fartED: ImpactED airs his experiences

fartED.: “I don’t know if the hospital cafeteria is to blame, or perhaps its the high stress levels, or a flare up of sun-spot activity, but we have some heinous issues with flatus percolating throughout the ED right now. Just the other morning a senior doctor *trod on a duck* right in the middle of a handover […]”

The first comment tells me they have a fun group working in this Australian ED.  And their euphemisms are pretty good, too.


And from a different post on his site, an excellent graphic:

Heh.  I’m assuming he means patients are in the center, but it could be the docs.  Who knows.

LA State Medical Society Supports Dr. Pou

FOX News.comNEW ORLEANS  —  A state medical organization on Wednesday came out strongly in support of the Louisiana physician accused of killing four critically ill patients at Memorial Medical Center in the aftermath of Hurricane Katrina.

Dr. Anna Pou and nurses Cheri Landry and Lori Budo, were arrested and booked on second-degree murder after an investigation by Louisiana Attorney General Charles Foti, who said the trio injected a lethal cocktail of sedatives into the four bedridden patients, after determining they were too ill to be moved.

“The Louisiana State Medical Society is confident that Dr. Pou performed courageously under the most challenging and horrific conditions and made decisions in the best interest of her patients,” said a statement from LSMS President Dr. Floyd A. Buras. The statement was released Wednesday.

Speaking Sunday night on the television show “60 Minutes,” Pou emphatically denied killing the patients.

“No, I did not murder those patients,” said Pou, …

The LSMS statement said that Pou has a long and distinguished career as a “talented surgeon and dedicated educator” which should not be tarnished by the accusations against her.


Scalpel or Sword Hits the Bullseye

My Photo Read to see what a day (well, every day) includes in the ED: Scalpel or Sword?: ER Dogma. Here’s a good list.

Too much testosterone kills brain cells: It’s Official

via CNN:

Health NewsWASHINGTON (Reuters) — Too much testosterone can kill brain cells, researchers say, in a finding that may help explain why steroid abuse can cause behavior changes such as aggressiveness and suicidal tendencies.

Tests on brain cells in lab dishes showed that while a little of the male hormone is good, too much of it causes cells to self-destruct in a process similar to that seen in brain illnesses such as Alzheimer’s.

This is one of those truisms of Trauma: Testosterone is a Neurotoxin.  Now it’s been proven. 



CDC: Almost Half of Hospitals Experience Crowded Emergency Departments

This also in: water is wet.  Really, I’m surprised it’s only reported as half.

The CDC Report from the National Center for Health Statistics was released today:

Staffing, Capacity, and Ambulance Diversion in Emergency Departments: United States, 2003-04. Advance Data 376. 24 pp. (PHS) 2006-1250. Click to open PDF file 1.1 MB

I like some of their bullets, so I’ll stick them in here:

bullet graphicAn average of 4,500 EDs were in operation in the United States during 2003 and 2004.

bullet graphicCrowding in metropolitan EDs was associated with a higher percentage of nursing vacancies, higher patient volume, and longer patient waiting and treatment durations.

bullet graphicHalf of EDs in metropolitan areas had more than 5 percent of their nursing positions vacant.

bullet graphicApproximately one-third of U.S. hospitals reported having to divert an ambulance to another emergency department due to overcrowding or staffing shortages at their ED.

The thing I wanted to know is their definition of ‘crowded’, which isn’t on the summary page, but is on page 5:

Crowding in the ED is a result of demand exceeding capacity.  Although crowding is often measured as an opinion of ED staff or recently measured as full waiting rooms (23,24), NHAMCS did not collect these data elements. To estimate the number of hospitals experiencing ED crowding, responses to the SCAD and BT supplements and estimates of throughput from the NHAMCS visit data for each hospital were used.  Therefore, in this report, the measure of whether the ED experienced crowded conditions was obtained using the following criteria: having any ambulance diversion hours reported, having a mean waiting time for urgent cases greater than 60 minutes, or having the percentage of cases left without being seen greater than or equal to 3 percent.

(emphasis added)

That’s an okay measure, I suppose, though we could have quibbles with any of those definitions (hopefully they’re fixing their survey tool to ask for actual bodies-in-beds percentages rather than these surrogate markers).


Take-home message?  If yo go to any ED, be prepared to wait.  And hope you don’t have a hand injury.

Update: I posted the above, then my New England Journal Title page arrived, and It’s Official: Crisis in the Emergency Department.

It’s a good summary editorial of the recent IOM findings, and has a nice graph (NEJM knows how to make a pretty graph): 

Figure 1


Read the editorial and it’s pretty good, but here’s the paragraph that made me think there might be a breakthrough:

Economic forces underlie these trends. When Congress enacted the Emergency Medical Treatment and Labor Act (EMTALA) in 1986, everyone in the United States acquired a legal right to emergency care. But no funding was provided to pay for it. Not only did this unfunded mandate contribute to the closure of numerous emergency departments and trauma centers, it also created a perverse incentive for hospitals to tolerate emergency department crowding and divert ambulances while continuing to accept elective admissions. Rather than improving access to emergency care, EMTALA diminished it. (my emphasis)

So, then recommendations are made, and they’re pretty good: streamline and consolidate a lot of bureaucracy, stop boarding patients in the ED, regionalize EMS and trauma decisionmaking, etc.

What’s not mentioned?  EMTALA.  He correctly identified it as a major problem then promptly ignored it in the conclusions.  It should either be paid for (it’s THE unfunded mandate that’s killing our ED’s), or scrapped. 

Radiology Grand Rounds IV is up

My Photo  at Dr. Sethi’s site.

Most Lawyer Screwings are Figurative… – Attorney: I’m Anna Nicole’s baby’s daddy – Sep 26, 2006
My input would be redundant.

MedBlogs Grand Rounds 3:1

Our Third Year Begins!!

Welcome to the second anniversary of the weekly roundup of the best blog writing among health and medical writers. We’ve come a long way since Nick Genes started this weekly review as a forum of physicians writing for each other, and now have a more active participation from an incredibly diverse number of voices. Nick was kind enough to interview me for Medscape’s weekly introduction of the hosts, and I’m amazed that he has the time and energy to keep this up while in residency.


I have no idea how many links this is, but it’s a lot, and it’s good.

Chris Sims’ Splenic Fracture

I got home from another day at the ED to this headline on CNN: NFL quarterback loses game, then spleen

First thought?  Wow, he signed a really bad contract.  The article cleared some things up:

TAMPA, Fla. (AP) — Tampa Bay quarterback Chris Simms had his spleen removed after taking several hard hits in 26-24 loss to the Carolina - News and Scores from Sports IllustratedPanthers and was resting comfortably in a hospital Sunday night.

There was no immediate word on how long the fourth-year pro might be sidelined. The recuperation time for a normal person is four to six weeks, though it’s unclear how long it might take to heal enough to play football.

“Chris is doing well and we anticipate a full recovery,” team physician Dr. Joe Diaco said in a brief statement, adding the 26-year-old son of former New York Giants quarterback Phil Simms was in stable condition…

He took a good hit according to the article, and that might have been what did it (speculation). 

For those who wonder what a ruptured spleen might look like, here’s a CT illustration (mouse over for the text explanation (requires java)):


(this is NOT Chris Sims’ splenic CT; this is one with a better story I’ll tell someday).


To get an appreciation of what is involved in a laparoscopic splenectomy (I’m guessing that’s what he had, the article didn’t say, but it makes sense) here’s a demonstration.

A quick recovery to Chris Sims, and prayers for his family.

Must-see X-ray; also, a foreign-body tale

Movin’ Meat has the X-ray of the year, to date, and a good story to go with it.


It’s a good lead-in to my tale of a patient with a similar presentation, but not explosive; similar, though.

Patient is brought in by family, unable to get patient to take her meds.  Patient has a long and colorful psychiatric history, and the street drugs don’t help (go figure).  Patient is fully-psychotic and fully-agitated, initially.  Much needed sedation is ordered, and a LifeSaving Foley is started.

The foley nurse reports: “I was getting ready to put the foley in, and noticed this thing that looked like a string down there, and so I pulled it to get it out of the way, and then it happened.”

What happened?

“I got a necklace out.”


“A necklace.  See?.”  A nice, silver-toned necklace is displayed, in a specimen bag.  “So, I wonder…”

?Wonder what?

“Is there something else in there?”

Well, yes; yes there was.  2 more necklaces and three lipsticks, to be exact.  (We debated sending them to pathology, as ‘objects removed’ from the human body, but restrained ourselves).


I’m not proud this patient was referred to (never by me) during the remainder of her stay as “The Jewelry Box”, but I understood.

via the indespensible Kevin, MD

Change of Shift, 7th Edition

…is up, here.

Best Chief Complaint of the Night

I had another in the series recently:

“I feel all jittery and out of sorts.  I think somebody contaminated my crack with another drug.”

The patient couldn’t decipher why we weren’t interested in getting to the bottom of the drug-adulteration issue.

MedBlogs Grand Rounds 2:52

Tundra Medicine Dreams

Welcome to Grand Rounds, the medical blogosphere’s weekly carnival of the best writing and thinking on topics related to health and healthcare. This week’s edition comes to you from the beautiful state of Alaska.

And, the last episode of the Second Year of Grand Rounds!