Archives for September 2007

Bee Stings

Nothing deep here, just a patient who was attacked by what I have to assume were ‘killer’ bees. Patient has a mobility problem prohibiting him from running, or walking briskly for that matter.


(photo with permission, but modified anyway)

And how many stingers are there?


That many (and three basins because three people spent about an hour getting all these out).

The patient did very well, and was discharged from the ED.

Photosensitivity solution

A corneal ulcer is painful, and at least some of the pain comes from iris spasms, which are treated with eye dilating drops (paralyze the iris, it stops spasming). This is good for pain, but makes every light unbearably bright.

So, what does an enterprising self-employed person do, who needs to get some work done?


She improvises (picture posted with permission).

Oh, Good, I’m not a sociopath

I’ve got that doctor ability to see pain, treat pain, occasionally inflict pain for the duration of a treatment, but not let it affect me on any emotional level. Some would think that’s sociopathic. Good, news, it’s a learned trait:

Doctors control emotions with patients

CHICAGO, Sept. 27 (UPI) — A U.S. study suggests physicians shut off the portion of their brain that helps them appreciate the pain their patients are experiencing.

Because doctors sometimes have to inflict pain on patients as part of the healing process, they also must develop the ability not to be distracted by the suffering, said Jean Decety, a professor of psychology and psychiatry and co-author of the study.
“They have learned through their training and practice to keep a detached perspective; without such a mechanism, performing their practice could be overwhelming or distressing, and as a consequence impair their ability to be of assistance for their patients” said Decety.

The research that included the use of functional magnetic resonance imaging brain scans shows for the first time that people can learn to control such a response….

I’m not as nice as I could be, but I’m not a bad person.

Wild headline department

I was looking forward to reading about something new in Trauma (which would be a nice change) when I started this article:

Toxic Shock Drug Might Aid Trauma VictimsU.S. News & World Report

Norepinephrine added to fluids protects against blood loss, study finds

By Carolyn Colwell
Posted 9/27/07

THURSDAY, Sept. 27 (HealthDay News) — The drug norepinephrine may come to the rescue of trauma victims suffering from heavy blood loss and shock, a French study in rats suggests.

Oh.  French rats. 


FDA Warns About Cancer Pain Drug Fentora


Due to recent reports of deaths and other problems associated with the cancer pain drug Fentora (fentanyl buccal) tablets, the U.S. Food and Drug Administration on Wednesday issued a warning about the drug to doctors and patients.

Fentora is a powerful opioid pain drug used only for the treatment of breakthrough pain in cancer patients who no longer respond to standard opioid pain treatment, the FDA said….

The agency reminded doctors and other health professionals that it is critical to follow product labeling when administering Fentora, and that it’s dangerous to use Fentora for any short-term pain such as headaches or migraines. Fentora must not be used in patients who are not opioid tolerant.

Emphasis added.

Fentanyl is very nearly a wonder drug for very short-term pain relief, given IV, in the Emergency Department.  Predictably short onset, short half-life, then they’re back to baseline.  (And it seems to make everyone want to scratch their nose while ‘out’, which is a little amusing).

Fentanyl in the patch form is also a good adjunct for pain control win those with real, chronic pain (cancer patients, usually, but there are others).  Usually patients come to the ED when one gets destroyed, or they run out over a long weekend.  I’m not sold on starting these patches on patients in the ED, so I don’t.

While I see the utility of an oral fentanyl tablet, I’d be the last to give it to anyone.  I have no idea the variability of dosing from person to person.  How much does a dry mouth decrease or increase their intake?  At least with a patch there’s some baseline for dose delivered.

We’re always looking for better ways to treat real pain in the ED, but this confirms it’ll have very little use in any ED.


As one who’s played one and two, this is sooo much better. Wow.

It makes the Xbox360 a worthwhile purchase.

Update: $170 million in Halo3 sales in One Day. I’m in plenty of company, if not good company.

Update2 10-1: the ending wasn’t what I wanted, but no spoilers here.  Still quite the entertaining game.

Medgadget’s Sci-Fi Writing Contest: Return of the Prose

Medgadget’s Sci-Fi Writing Contest: Return of the Prose

Welcome to the second annual Medgadget’s Sci-Fi Writing Contest! Those of you old enough to remember our last year’s competition, will recall the excitement, the competitive gallantry, and the results: an amazing set of stories that looked at the past and saw the future of medicine. We saw the world free of chronic diseases, and we witnessed medicine being practiced on planets many light-years away. Let us see the future of medicine again!

Just like last year, here are the rules:

So, go on over and have a look at the rules, and write like crazy. They’re offering a free iPhone for First Place.

Yrs. Trly. returns as a judge. (Yes, it’s ironic that someone with my writing style gets to be a judge of prose. It makes me chuckle, in fact).

Delusional Behavior

No, I’m not talking about bloggers who think their party has the corner on brains and answers, I’m talking about those few patients who arrive to the ED with a Chief Complaint that’s not real.  Oh, it’s real to them, just not in reality.

Every EM doc has had these patients, and they can be imminently frustrating to deal with, which is why I now don’t.  Allow me to explain with a few heavily-sanitized for-their-protection encounters I’ve had:

  • Patient comes in wanting me to remove the device planted in their head by the CIA.  Normal exam, not a danger to self or others, but has fixed belief there’s an implanted device (fixed delusion).  After a thorough exam, I offered an X-ray of the skull to demonstrate that there wasn’t anything foreign in there.  “Oh, they don’t show up on X-ray” was the response, and this is the crux of the problem trying to deal with these patients: they don’t want to be told the truth, they want their belief to be validated, real or not, sensible or not.
  • Patient presents with CC ‘all my organs have been removed’.  When queried as to how they’d be alive with no organs, answers ‘they put someone else’s’ in’.  After exam showing no signs of drug or alcohol abuse, and notable for none but trivial scars of living, I pointed out that I’ve seen lots of patients with organ transplants, and they have rather remarkable scars, but you don’t. ‘They replaced my skin after’ was the response.  There’s always an answer that refutes rationality.
  • Patient presents with complaint of a foreign body in their nose, for 5 weeks, and there’s nothing there.  ‘No, it’s right there’, pushes on completely normal area of nose.  Examined 3 times for patient’s benefit, and no amount of reassurance can convince them it’s not there. 
  • Delusional parasitosis is probably the most common of them, but it’s harder to determine there’s not an actual cause initially, especially as they’ve usually scratched themselves into cellulitis by the time they’re seen.

These patients aren’t dangerous, not suicidal, and no amount of ED intervention will fix their problem.  I have finally learned not to spend a ton of time with attempts at reason, as the human brain has a remarkable ability to explain away rationality to believe whatever they want.  Though tempting, I won’t try a “got it out” ploy as a) it’s unethical and b) they’re delusional, not stupid, and lying will just make the problem worse.  They lack the insight to question their self-diagnosis, so psych referral is not just dismissed but is a really good way to get them to go from disappointed to angry in about two seconds.

After two thorough attempts to explain the absence of actual physical confirmation of their complaint, I then refer them to their PCP for further evaluation, and that’s it.  It’s disappointing for the patient, and for me, but there’s a limit to what I can fix in the ED. 

MedBlogs Grand Rounds 4:01

Year Four begins:

Kevin, M.D. – Medical Weblog: Grand rounds: Anniversary edition
Welcome to the Anniversary Edition of Grand Rounds, the weekly carnival of the medical blogosphere. This is my fourth time hosting, and I want to thank Nick Genes for the honor of kicking off the 4th year of Grand Rounds.

Congratulations to all of you for making the healthcare blogosphere what it is today. Informative. Opinionated. Dynamic. Controversial. Grand Rounds is the weekly celebration of the best that we have to offer, and gives physicians, nurses, patients, and other health professionals an emphatic voice in today’s constantly evolving world of medicine and health.

Another four-time host!

Doc Shazam has a New Look

Check out Mr. Hassle’s Long Underpants, a newly-converted-to WordPress blog, for her new look!

And, to prove she’s a ‘real’ EM doctor, she’s had this day.

Texas Lawyers

Well, Texas is reporting the heck out of docs, but what of our attorneys?

Overlawyered: Texas: “Public left in dark on accused attorneys”

How pathetic is the State Bar of Texas when it comes to protecting clients from rogue lawyers? This pathetic:

Dallas attorney Bruce Patton has a clean disciplinary record, according to the State Bar’s Web site, which provides profiles of the state’s 80,000 or more practicing attorneys. But consider this before you hire him to draft your will: Patton is in state prison after being convicted of a felony two years ago….

Texas medical licenses fees doubled last year, and the Board is spending a lot of time and money pursuing docs. I’ve read the reports, and wonder at the real stories behind them, but I’m fairly certain docs in prison would have lost their licenses.

Unlike our attorneys, apparently.

A nice day at work

I had a nice day at work. So did at least one of my patients.

We were busy, and the patient had his third anterior shoulder dislocation in about 18 months. Nice square shoulder of dislocation, normal sensation over the deltoid and distal neurovascular function, nothing terrible or unexpected. Essentially he just wanted / needed it reduced after an atraumatic dislocation.

I asked if he’d ever tried any of the reduce-it-yourself maneuvers for shoulder dislocation, and he asked ‘do you mean the one where I lie on the edge of a bed with a weight in my hand?’, telling me he really had been through some relocations before.

I briefly explained a very straightforward method (this is not medical advice: if you dislocate your shoulder, go to the ED, and that is medical advice) wherein the patient laces their fingers, flexes the hip and knee, and then places the laced fingers in front of the knee. Then, relaxation is the key, as the patient gently leans back / lets the leg go forward, and tries to relax. The idea is to have the scapula rotate forward (opening the glenoid fossa and gently pulling the humeral head into alignment) aiming for the clunk of happiness.

I got busy seeing other patients and got a call about 10 minutes later “…the patient thinks their shoulder is back in”. It was! To say the patient was happy would be an understatement. A quick x-ray showed normal alignment, and home went a patient with a new skill.

It’s the happiest I’ve been in a while, and I didn’t do anything.

Why I accept a lot of transfers

I’m lucky enough to work at a big community hospital with a lot of resources, and we get a decent number of transfers from smaller surrounding hospitals. The ED doc is stuck taking the call from the sending doc, to both make sure we have coverage for the specialty they say they need, and to ward off the occasional inappropriate transfer / transfer that would be much better served going elsewhere*.

Recently I took a call, the synopsis of which was ‘unstable angina but normal enzymes, some Q waves on the EKG, and pain free: need transfer because we don’t have cardiology’. Unstable angina is often managed by non-cardiologists, but I accepted, rationalizing it’d be an easy transfer anyway, and you never know.

You never know, indeed. When the patient arrived, the EKG with the ‘Q waves’ they did looked like this:


Got a nice quick trip to the cath lab. (For those scratching their heads, this is an acute MI, the machine’s screaming MI in the automated printout, but apparently the doc looking at it didn’t believe it)(the machine is frequently wrong, but you need to look hard at the tracing when it’s saying something you don’t expect).

This will be read as a guy in the Ivory Tower looking down on the little guys in the trenches, and it’s not intended that way. It is why I’m going to accept anything cardiac for a long, long time though…

(* This does not mean I’d commit an EMTALA violation by refusing a transfer, it means sometimes patients are better served elsewhere. For example, while we have a hand surgery call list our joint cannot do re-implantations, so while technically we can handle hand injuries a few patients need transfer to a more appropriate facility).

Sports Fines

(Entirely non-medical, as is now my unintentional theme.)

Sports radio will be all over the Patriots fine and loss of draft pick(s), their penalty imposed for (getting caught) cheating. Their fine is $500,000 for the coach and a team $250,000. And, it’s entirely appropriate it gets talked about.

What you probably won’t be hearing much about is the whoppingly monstrous fine levied the same day against the McLaren Formula 1 racing team. Think $750K and a draft pick is big for cheating? How about a $100 Million Dollar fine (and loss of constructors points) for the leading team, decided to be cheating by the World Motor Sport Council.

What’s scary is that both teams have the money to pay their fines, apparently. Orders of magnitude difference in the money; cheaters occasionally win, but they at least get fined.

For a FAQ about the F1 contretemps, see the BBC.

Pros and Cons of military service to pay for medical / professional school- HPSP (the health professional scholarship program)

Pros and Cons of military service to pay for medical / professional school- HPSP (the health professional scholarship program)

In this article I want to write about the pros and cons of the military as a way of financing medical education. I may not be fully aware of the recent changes to the HPSP program but I did a fair amount of research about the topic before I ended up not going though with it. I want whoever is thinking about doing this to think seriously and give it some critical thought before signing up.

A very thorough look at the dollars and decisions of being a military physician.