Kevin, M.D. : Flea

Kevin, M.D. – Medical Weblog: Flea
Flea
Stunning news. The Boston Globe on Flea, his trial and how his blogging ultimately led from a possible victory to settlement:

As Ivy League-educated pediatrician Robert P. Lindeman sat on the stand in Suffolk Superior Court this month, defending himself in a malpractice suit involving the death of a 12-year-old patient, the opposing counsel startled him with a question.

Was Lindeman Flea?

Flea was undone in court by his blogging. Incredible.

Change of Shift: Volume 1, No. 25 // Emergiblog

Change of Shift: Volume 1, No. 25 // Emergiblog

Welcome to Change of Shift, a compilation of the best of the blogosphere by and about nurses!The June 14th edition will mark the first anniversary of Change of Shift! This is a shout out to all nurse bloggers and all the doctor bloggers who work with them to send in your best posts by or about nursing for inclusion in this special edition.

TPA and Stroke 2

Geez, the NY Times (obscure liberal paper in the Northeast) has interviewed several neurologists (and exactly one Emergency Medicine Physician) and has written a four-page article on stroke. They got little right.

It’s a tour-de-force in obfuscation of fact, presentation of tragedy as preventable, and the presentation of TPA as an ignored wonder-drug, MRI should be the standard of care for new strokes, and frankly there’s no redeeming value within. Nevertheless, I shall persevere, and even if it makes nobody other than me happy, I shall fisk to my hearts’ content. (Many thanks to Notes from Dr. RW for bringing this to my attention, and for taking the hit for the rest of us and reading the NY Times, you poor wretch).

I was going to address this in the article as I got to it, but it’s too good / on point to bury below the fold. Here’s all you need to know about tPA for CVA (from AAEM), in a nice graphical form:

Lost Chances for Survival, Before and After Stroke

By GINA KOLATA

Dr. Diana Fite, a 53-year-old emergency medicine specialist in Houston, knew her blood pressure readings had been dangerously high for five years. But she convinced herself that those measurements, about 200 over 120, did not reflect her actual blood pressure. Anyway, she was too young to take medication. She would worry about her blood pressure when she got older.

Then, at 9:30 the morning of June 7, Dr. Fite was driving, steering with her right hand, holding her cellphone in her left, when, for a split second, the right side of her body felt weak. “I said: ‘This is silly, it’s my imagination. I’ve been working too hard.’ ”
Suddenly, her car began to swerve.

“I realized I had no strength whatsoever in my right hand that was holding the wheel,” Dr. Fite said. “And my right foot was dead. I could not get it off the gas pedal.” …

Dr. Fite is one of an estimated 700,000 Americans who had a stroke last year, but one of the very few who ended up at a hospital with the equipment and expertise to accurately diagnose and treat it.

Dr. Fite has been active in the practice and politics of Emergency Medicine for a good while, and I was unaware of her stroke. I hope she’s recovering well.

Stroke is the third-leading cause of death in this country, behind heart disease and cancer, killing 150,000 Americans a year, leaving many more permanently disabled, and costing the nation $62.7 billion in direct and indirect costs, according to the American Stroke Association.

But from diagnosis to treatment to rehabilitation to preventing it altogether, a stroke is a litany of missed opportunities.

Many patients with stroke symptoms are examined by emergency room doctors who are uncomfortable deciding whether the patient is really having a stroke — a blockage or rupture of a blood vessel in the brain that injures or kills brain cells — or is suffering from another condition. Doctors are therefore reluctant to give the only drug shown to make a real difference, tPA, or tissue plasminogen activator.

This is a truckload of hooey. Any Emergency Physician worth the title does this for a living, and while it’s challenging to sort wheat from chaff, it’s why Emergency Medicine exists as a specialty. Yes, there is a tremendous differential diagnosis, but that goes with the territory. And reluctance to administer tPA for stroke is more than reluctance, there are solid reasons to be very very careful with the decision.

[Read more...]

MedBlogs Grand Rounds 3:36

From Medskool » Blog Archive » Memorial Day Grand Rounds
Welcome to Grand Rounds Volume 3, Number 36. Before we jump into it, for those Americans visiting (or anyone with such an inclination): no matter how you honored the fallen yesterday, no matter your politics, please take another moment to remember those who have made the ultimate sacrifice.It has been a real honor to put together Grand Rounds this week. There were, as usual, a ton of great submissions.In the debate over whether to filter Grand Rounds, I stand on the populist side. I think I’ve included everything that was submitted. Even the submissions that ended up in my spam box. Hopefully, despite that, it isn’t terribly verbose.

Another non-themed nice job.

Next week’s at Inside Surgery.

Doctor Doofus

Is there a doctor on the plane? is the account of a Canadian physician who volunteered his time, twice, on a flight from Montreal to Paris.

Good for him for coming forward. I’m much less impressed with his desire for compensation from the airline for his efforts.

via Kevin, MD

Dr. Leap: I’m the doctor, that’s why!

I’m the doctor, that’s why! (This months EMN column) at edwinleap.com
This is the age of intellectual democracy. In a frightening departure from millennia of human tradition, everyone is now an expert in everything. Turn on the television or surf Internet news services. We somehow believe that polls of individuals are useful for guiding policy, in everything from international politics to morals and religion. Legislators and marketing experts trust this information, as if masses of humans had extensive experience in diplomacy and warfare, in economics and federal tax structures, rather than what so many do have expertise in; video games and the accumulated out-takes from American Idol.

It’s especially odious in the world of medicine. How many times do we argue with patients that they don’t need an antibiotic or x-ray, admission or laboratory test? A family once skeptically asked me to show them the x-ray I had taken of their child, who swallowed a coin. Once they saw it, they were satisfied that I hadn’t missed anything. They weren’t radiologists, but they were experts. Because any idiot can be a physician, right?

Sing it, brother!

Fat Doctor – Yes, she’s back

Fat Doctor – Famine-resistant physician comments on life at work and home. Occasional whining.

Good news? She’s back!

Bad news? We chose the same WordPress theme.  I’ll get over it, nice to have her back.

U.S. Memorial Day History and Information on U.S. War Memorials

U.S. Memorial Day History and Information on U.S. War Memorials

Thank a service member, or their family, today.

Prius Tank #3

44.8 MPG, correlated very well with the dashboard estimator.

This tank I just drove it like I would any car, and it surprised me by turning in the same mileage as when I was consciously trying to maximize the mileage. I don’t suppose that’s a huge surprise to anyone but me, but I thought it’d make a difference for the worse. Nope.

And, it’s a nice car, the nicest sedan I’ve owned.

The Dirty Volume

What the heck:

My first time to have a ‘Dirty Volume’. Imagine my volumes’ shame.

Cellphones for Soldiers

Alerted by Mary Lu, I’d like to give a Memorial Day weekend plug to a good cause, Cell Phones for Soldiers.

From their site:

Cell Phones for Soldiers hopes to turn old cell phones into more than 12 million minutes of prepaid calling cards for U.S. troops stationed overseas in 2007. To do so, Cell Phones for Soldiers expects to collect 15,000 cell phones each month through a network of more than 3,000 collection sites across the country.

The phones are sent to ReCellular, which pays Cell Phones for Soldiers for each donated phone – on average, each phone represents 60 minutes of talk time for our troops.

“Americans will replace an estimated 130 million cell phones this year,” says Mike Newman, vice president of ReCellular, “with the majority of phones either discarded or stuffed in a drawer.  Most people don’t realize that the small sacrifice of donating their unwanted phones can have a tremendous benefit for a worthy cause like Cell Phones for Soldiers.”

Cell Phones for Soldiers was founded by teenagers Robbie and Brittany Bergquist from Norwell, Mass., with $21 of their own money. Since then, the registered 501c3 non-profit organization has raised almost $1 million in donations and distributed more than 400,000 prepaid calling cards to soldiers serving overseas.

So, follow the link, and send in your defunct cell phones.  It’s good for recycling, and it’s good for the troops.

ER Longitudinal Care

Yes, that’s an oxymoron, but it happens, and it happened to me tonight.

One of the many reasons I’ve always liked Emergency Medicine is that there’s no seeing the same patient over and over again.  Some doctors live for that, but not me.  I hated my Internship, and partly because of seeing the same patients with the same problems day after day.  I had the same patient on day one and day 365 of my internship, and month upon month on different rotations, and watching that poor person die in stages still haunts me.  Heartbreaking, really.

However, reality is that in any ED there’s going to be some small number of patients that are seen frequently enough we get to know them, and they’re not ‘our patients’, but they’re sill patients we know, and some we take interests in, for whatever reason.  Sometimes it’s the ‘how are they still alive’ wonder, and sometimes it’s because we’ve made a life-changing diagnosis.  Like the patient I saw again today.

I saw this couple one year ago: they were very nice, and the husband had unmistakable signs of a brain tumor.  I remember them because of the history obtained on that first encounter: He’d been having symptoms for a month or two, but they’d had this trip planned for months, so they’d gone on their lifelong dream vacation to Alaska, and had a great time.  They drove straight to the hospital from the airport after getting home.

I was the physician who got to tell them about the walnut-sized mass in the brain responsible for the symptoms.  I explained tumor and edema to a silenced couple that expected bad news but not that bad.  They were polite, and hopeful that the future would bring a cure.  They weren’t alone in that regard.

I’m also the EM doc who’s seen them several times for the unending complications of the therapies: the seizure, the antiseizure medication toxicity, the post-op infection (fortunately not of the brain), etc.  Today I was leaving the ED and saw him: face swollen from steroids, listless, spouse at the bedside still looking hopeful.  Spouse recognized me instantly, but my former patient didn’t react to my presence.

“Hello, I just saw you and hope you’re being treated well.  I’m not sure why you’re here…” and the blank look in his eyes stopped me dead.  Either there was no recognition or it’s that “I want you dead’ look, and frankly it was a tossup.

‘Yes, we remember you’ said the wife, and pleasantries were exchanged.  I cannot imagine the things they’ve been through, the life changes endured, the sacrifices, the heartbreaking setbacks.  ‘I remember you’ said the husband, not meaning it.  He didn’t know me from Adam.  That’s okay, it’s not about me, at all, it’s about a loving couple, and their life together. 

Hope they remember their vacation, forever.

DB’s is Dead Wrong on ED CT Overuse

Yesterday, Dr. Centor (whom I respect as a calm voice of rationality) went off the rails and joined the ED bashers with this:

Ask almost any inpatient clinician and you will hear that the ER does too many CT scans. I understand why they do them – but I disagree with the philosophy. They do CT scans in the hopes of decreasing malpractice suits.

Prior to CT scans, we diagnosed appendicitis clinically. Some patients have clear signs and symptoms; other patients have more confusing presentations.

Umm, “too many” depends entirely upon where you’re standing in the physician continuum. Let me tell you why we order CT scans, from the perspective of the grunt level EM physician.

We see the entire panoply of the human condition (as it applies to medicine), and have the terrific joy and challenge of sorting it out into recognizable bits. Without being dramatic, it’s not much like medical school taught us the physician-patient interaction would be. It’s entertaining but challenging, and more than a few of our patients have a limited education and vocabulary, and are literally unable to express themselves in terms that most ‘regular office’ patients can routinely display. In fact, some of them can do little more than yell “It hurts” and point at their bellies in the most vague way. Laying hands on their abdomens is usually a fruitless exercise in discerning hopefully whether the pain is from the upper or lower portion, to better guide the lab and radiologic / sonographic evaluations.

As for appendicitis: we’ve all, every one of us, had a case that was a Slam Dunk appy, we were so happy we’d made the diagnosis clinically we called the surgeon, who asked the following: “What’s their white count, their UA, and their CT show”? We’ll tell them (deflated a little, don’t they trust us?) that we don’t have a CBC back yet, the patient couldn’t pee now without extraordinary coercion, and why do a CT on a perfect case (?) to be told “call me back when you have them, and don’t do this again”. So, we learn: work everyone up, then call. It’s not only the ED docs who are responsible for increased use of scans.

Want to admit a patient with pancreatitis to the Internal Medicine service? “What’s the CT show?” is the admitting teams’ question. Us: Didn’t get one; had it before, has it again, patient states it feels just like their last pancreatitis flare-up. “Get a CT and call me back” is the usual refrain, and another ED doc gets dinged for an ‘unnecessary CT’, and the admitting team can cluck about the number of scans ordered in the ED. It’s not only the ED docs who are responsible for increased use of scans.

Finally, yes, we order a decent number of marginal CT’s, and it’s not just because we’re afraid of suits (we are*), it’s because all of us have several cases of What the Heck(!) they have What(?) from a CT that might, in retrospect be seen to have been more CYA then CVA, but find significant pathology. (My speciality is finding renal cell CA in patients that it’s not expected in, 3 so far). (Nobody gripes about those CT’s, by the way; a positive CT is a ‘goodCT’, even if in retrospect it wasn’t solidly indiated).

It’s like everything else in medicine: more complicated than it might seem on the surface.

*EM docs are sued at fairly high rates, and not because we’re stupid or negligent as a group or specialty. We’re sued because a) we have an interesting population of patients with varying disease, co morbidities, presentations and expectations, b) nobody loves their ED doc, especially when they get the bill, and c) we’re easy scapegoats for the next doc who’s only too glad to shift any potential liability to the ED doc (see b).

Never Fear, changes are happening

There are, even as we speak, legions of astoundingly talented coders and WP specialists converting this blog, and the look will be changing.

Rants to resume shortly.

There will be a short hiatus

…while this blog is converted to Word Press.  See you on the other side!