Archives for October 2007

How in the world does this happen?

I read about this and wonder:

Untreated ER patient dies at Olive View

The 33-year-old man, reporting pain in his chest and left arm, waited more than three hours, then stepped outside and collapsed.

latimes.comBy Jack Leonard and Charles Ornstein
Los Angeles Times Staff Writers
October 31, 2007
Christopher Jones arrived at Olive View-UCLA Medical Center in Sylmar on Sunday complaining of chest pains.
Jones, 33, was told to sit in the waiting room until it was his turn. He didn’t receive a simple test to determine whether his heart was functioning properly, a measure that is standard practice nationally in cases of chest pain, Los Angeles County officials said.
After more than three hours, Jones got up, walked outside, collapsed face down on the pavement and died within minutes.

That’s horrible.  I cannot fathom how this happens, though I wonder if their EKG at triage for chest pain has an age limit he didn’t meet, through no fault of his own.  If it did then, I’ll bet it doesn’t now.

I hear this from nurses, doctors, Paramedics: “30 year olds don’t have heart attacks”, and I tell them politely that yes, they do.  In our ED last year we had a 16 year old with an MI.  Consultants like to tell us we overtest in the ED (‘why get a troponin on a 25 year old with chest pain?’ they ask, with a condescending tone and a ‘you’re another dumb ER doc’ look;) they never seem to remember the positive ones.

Chest pain is usually not life threatening, and we make that determination after the workup is complete, not before. 


How far is Olive View from the recently closed King-Drew?

The incident, which is being investigated by state regulators, is the latest case of questionable patient care delivered at Olive View, a public hospital run by the county. The California Department of Public Health has cited Olive View for medical and other problems five times this year.

Sounds a little too familiar… 

Mac OS X Leopard

I just upgraded the Mac.  Totally painless.  I started it, went to work, came back and it was up and running.

Now I sound like one of those horrible Mac-o-philes.  Yick.

Your next box should be a Mac.  I cannot believe I just typed that, but it’s true.

Project Valour-IT

I supported this non-partisan worthy effort before, and will continue to. From their description:

Every cent raised for Project Valour-IT goes directly to the purchase and shipment of laptops for severely wounded service members. As of October 2007, Valour-IT has distributed over 1500 laptops to severely wounded Soldiers, Sailors, Airmen and Marines across the country.
Originally Valour-IT provided the voice-controlled software, but now works closely with the Department of Defense Computer/electronic Accommodations Program (CAP): CAP supplies the adaptive software and Valour-IT provides the laptop. In addition, DoD caseworkers serve as Valour-IT?s ?eyes and ears? at several medical centers, identifying possible laptop recipients. …

Thanks to the efforts of the Military Order of the Purple Heart, Valour-IT is also able to reach patients in VA hospitals who would benefit from a Valour-IT laptop.

I’ve donated, and will either keep bumping this to the top periodically, or will put it in the sidebar (when I can figure out how to without flanging the display):

It was hard for me to decide on the USMC over the USN, but although my uniform said Navy and my paycheck said Navy, 80% of my time was spent with the grunts.I just sent them a couple of bucks. Could you?

Medical News: Medical Community Mobilizes in Shadows of California Wildfires – in Emergency Medicine, Emergency Medicine from MedPage Today

Medical News: Medical Community Mobilizes in Shadows of California Wildfires – in Emergency Medicine, Emergency Medicine from MedPage Today

SAN DIEGO, Oct. 25 — Despite the pervasive clouds of wind-blown smoke that enveloped southern California and displaced an estimated million persons, the emergency departments here did not face an exceptional strain.At the University of California San Diego Medical Center, elective operations and procedures were postponed. UC San Diego physicians were dispatched to triage duty at Qualcomm Stadium, where thousands of persons congregated after mandatory evacuations.

“So far we are only seeing very mild respiratory issues, some coughing or shortness of breath, but nothing serious,” said a spokesperson.

That’s good news.

Yahoo News: Sex and doctors: ER medics best placed to win hearts

Sex and doctors: ER medics best placed to win hearts on Yahoo! News
Sex and doctors: ER medics best placed to win heartsThu Oct 25, 7:06 PM ET

If romantic fiction is any guide, any doctor looking for love would be advised to be an emergency room surgeon or deliver babies rather than practise colon resection or remove in-grown toenails.

So says Irish physician Brendan Kelly, who — with a bravura contempt for the effect this endeavour could have on his mind — has probed at length into the burgeoning literary field of medical romance.

In an offbeat letter published in Saturday’s Lancet, Kelly describes the typical plot structure and characterisation in 20 randomly-selected medical romance novels.

Of the male protagonists, six worked in emergency medicine, five in surgery and three in obstetrics, neonatology and paediatrics, he found.

There was a marked preponderance of brilliant, tall, muscular, male doctors with chiselled features, working in emergency medicine,” says Kelly, a University College Dublin psychiatrist.

Well, okay, the rest of the description doesn’t exactly fit yrs. trly, but the rest is dead-on, IMHO.

Bloggers Blog: Carnegie Mellon Study Ranks Most Informative Blogs

Bloggers Blog: Carnegie Mellon Study Ranks Most Informative Blogs

Read the post, but basically they ranked the Top 100 ‘Informative Blogs’. Two appear that I’ve considered Medical blogs, #89 is Dr. Sanity and #98 is the ScienceBlogs borg.

Congrats to those two!  (If I missed one, let me know).

Addicted to Medblogs: Dr. October is …MDOD

Addicted to Medblogs: Dr. October is …MDOD

Another in her entertaining series.  And, she has 15 readers?  And me with my nine…

Troops unite to save soldier knifed in head – Army Times

Troops unite to save soldier knifed in head – Army Times
Troops unite to save soldier knifed in head
By Patrick Winn – Staff writer
Posted : Wednesday Oct 24, 2007 14:01:27 EDT

It felt like a nasty sucker punch. Yet when he strained his eyes to the hard right, there was something that didn’t belong: the pewter-colored contour of a knife handle jutting from his skull.Sgt. Dan Powers, stabbed in the head by an insurgent on the streets of East Baghdad, triggered a modern miracle of military medicine, logistics, technology and air power.

His survival relied on the Army’s top vascular neurosurgeon guiding Iraq-based U.S. military physicians via laptop, the Air Force’s third nonstop medical evacuation from Central Command to America, and the best physicians Bethesda National Naval Medical Center in Maryland could offer.

It required extraordinary hustle from a string of ground medics, air medics, C-17 pilots, jet refuel technicians and more. Not an hour after the attack, Powers, a squad leader with the Army’s 118th Military Police Company, was draped in sheets on a medical gurney bound for Balad Air Force Base, about 30 minutes away by helicopter.

Watch a video of the examination of Sgt. Powers in Iraq, with the knife still in his head, here, courtesy of MilitaryTimes.

And, if you want to see one example of how hard the services work to save one life,

…the operations center was telling him to change planes, directing him toward a different C-17 Globemaster, one with a plus-sized fuel tank. Red 7, the center said, would be picking up a severely injured soldier from Balad to fly him nonstop to Andrews Air Force Base, Md., just outside Washington.

“Our initial reaction was, ‘I don’t believe you,’” Bufton said. “Nobody goes to Andrews Air Force Base from Balad.”…

Watch the video, and marvel that he wants very much to go back to active duty.

A warning to trolls on this post: your comments will be deleted and your IP address banned.

Hat tip to FFM.

Addicted to Medblogs: Request for Match Day Stories

Addicted to Medblogs: Request for Match Day Stories

Proto magazine is looking for short, exciting Match Day stories from doctors who participated last year or just remember like it was yesterday. How were you affected by the tension of the moment? Did you faint with relief (or disappointment) upon opening your envelope? Did another student’s reaction catch your eye and make you think?If you didn’t match, were you lost in “the scramble?”

Please send your stories to Carrie Jones at carrie_jones @ and include your full name and contact information with your submission. If we like your story, we may need to contact you for a brief follow-up. If you’d rather remain anonymous, we can withhold your name for publication.


I ripped of her whole post, but mainly because a) it’s a good cause and b) she mentioned me and some obscure blogger.

My Match Day story is a super-denouement, and is 14 years old, so I’ll not be adding it. For now.

Life Saving…culture stick?

I now get to indulge in one of my favorite pastimes, pointing out when I did something silly. I was reminded of this by some of my wonderful nurse colleagues, who drew a parallel with a prior post of mine, the Lifesaving Foley (which I tried to make up for with this one).

The setup: a patient with a symptomatic pericardial effusion, hypotensive but hanging in there, and the thoracic surgeon is coming to see why they’ve re accumulated an effusion, as the patient just had a pericardial window about 6 days ago.

(For those not ‘in the business’ the pericardium is a tough fibrous sack which surrounds the heart. It’s one of those parts of the body you never hear about until it becomes a problem. In the case of a pericardial effusion, the problem becomes the relative stiffness of the pericardium; add fluid around the heart, the pericardium doesn’t give way, so the volume loss is up to the heart to deal with. This means the heart fills with less blood, and has to cope with less filling volumes and pressure; want to keep up the same circulation volume with a smaller output, the heart has to deliver more beats. This works for a while, but it’s the low-pressure right heart that loses out ultimately; when the pressure inside the pericardium exceeds the returning venous pressure, it’s a vapor lock. No blood goes in, so none goes out. You can see the problem.)

The intensivist feels it’s time to intubate the patient, and says ‘if [the patient] crashes, we’re going to need to drain the effusion”, and gets no argument from me. Of course, you know what happens next.

The patient has an uneventful intubation, but the addition of positive-pressure ventilation results in PEA (pulseless electrical activity). Of course the big spinal needles typically described for the needle aspiration of a pericardial effusion are nowhere to be found, but there’s a nice substitute in every resus bay: the introducer needle for a central line. So, using that needle I start the pericardiocentesis.

Needle pericardiocentesis in the ED has been described several ways, but the end result has the end of the needle inside the pericardium but outside the heart. I’ve done it before, and it’s either a very satisfying minute wherein a volume of blood is released and the patient gets immediately and gratifyingly better, or, not. My preferred approach is a subxyphoid (under the bottom of the sternum) approach, trying to visualize where the tip of the left scapula would be (if you could see through people), and aiming the needle there, pulling back on the end of the syringe while advancing.

All in the room were surprised when, instead of blood, we got back a thin, milky-white fluid, and a lot of it. My first thought, given a very recent surgery, was infection, and I then blurted out the signature line of this post: “Get me culture stick!” This while I’ve got a needle next to the heart and CPR is ongoing. (In a tribute to the professionalism of the staff, I got the culture stick in less than 30 seconds).

After looking at the fluid pouring from the needle we decided it wasn’t infectious, but was, rather, chylous, opening a whole other bag of worms (a possible injury to the thoracic duct somewhere). The chest surgeon made an appearance, used our disposable suture scissors to re-open the surgical incision, and put gushed the end of the fluid. The patient, of course, had a full recovery of pulse and blood pressure, and went off to the OR for another drain, and to see if the source of the chyle could be found.

So, beloved nurses, it goes both ways: you get your Lifesaving Foleys, and I get my Lifesaving Culture Sticks

MedGadget Sci-Fi Contest: Please Meet the Winner!

Medical Sci-Fi Contest: Please Meet the Winner!

And now, the moment of truth… The winner, is A’Llyn Ettien with a story called Immigrants, a tale of ethical dilemmas of child bearing and parenting in the potentially bleak realities of the future.

I was again flattered to have been a judge, and to have read the excellent entries. Many thanks to MedGadget for having this contest, and for the fine folks at for the prize (an iPhone), and to all the contestants, every one of whom write better than yrs trly.

Follow the link and read the top three. It’s worth your time.

How to Tell Off a Drug Rep

Read it and chuckle:

Letter to a Drug Rep : PANDA BEAR, MD

KevinMD on; oh, and a bad example of defensive medicine

Defensive medicine is indeed a problem. This isn’t the example that tells that story. Oh, and Kevin looks pretty good on TV.
Defensive Medicine: Cautious Or Costly RICHMOND, Va., Oct. 22, 2007(CBS)

It started as a simple stomach ache, but Alexandra Varipapa, a sophomore at the University of Richmond, decided to go to the emergency room.

There, doctors ordered a full CT scan, a radiation imaging test, which found a harmless ovarian cyst. She never questioned the CT scan, CBS News correspondent Wyatt Andrews reports.

Wow, she walked in and just got a CT scan! Oh, wait, she also got a history and a physical exam, but you wouldn’t know that from the slant of the article.

But her father did – when he got the $8,500 bill, $6,500 of which was that CT scan.

“I was pretty flabbergasted,” said Robert Varipapa, himself a physician.

Varipapa says his daughter’s pain could have been diagnosed far more easily and cheaply with a $1,400 ultrasound.

“A history, a pelvic examination and probably an ultrasound,” he said. And he would have started with the ultrasound.

Aah, a doctor relative with a retrospectoscope. Stepwise testing works just fine in the clinic, but in the ED we need to do a lotta things in a hurry:

  • rule out the horrible thing
  • get a diagnosis, or exclude the killer diagnosis
  • get the patient out of the ED to make room for the next patient

But the hospital defends the CT scan, saying an ultrasound might have missed something more serious.

“It would not have ruled out appendicitis obviously, it would not have ruled, necessarily, out a kidney stone,” said Dr. Bob Powell, ER medical director of Bon Secours St. Mary’s Hospital.

Varipapa agrees, but asks why not start simple – and do the CT scan only if necessary?

“Well it’s my opinion this is defensive medicine,” Varipapa said.

Well, you may be right that it’s defensive medicine, but that doesn’t make it incorrect, or bad medicine. A better question would be the 6K charge for a CT scan, but bashing the ED is a lot easier. Frankly, this is not a terrific example of defensive medicine, but is a good example of a) the different thought processes between clinic and EM doctors, and b) a cautionary tale of current ED costs.

Kevin looked very reasonable and professional (and wasn’t wearing his pajamas)! Here’s his CBS video. I recommend it, mostly to see Kevin before he moves to Hollywood.

Update: TBTAM weighs in, on the side fo the ED!

BBC NEWS | Health | Optimism ‘no bearing on cancer’

BBC NEWS | Health | Optimism ‘no bearing on cancer’

The power of the mind has been overestimated when it comes to fighting cancer, US scientists say.They said they found that a patient’s positive or negative emotional state had no direct bearing on cancer survival or disease progression.


SWAT Docs save officer’s life in Dallas

From the Dallas Morning News:

A Dallas police lieutenant shot in the neck during a Wednesday morning raid was expected to survive, thanks largely to two doctors on the SWAT team he led.

The doctors said they did not dwell on whether Lt. Carlton Marshall would live or die. Instead, they fell back on their training, mentally checking off what they knew must be done. Stop the bleeding. Get him oxygen.

As cries of “Officer down!” went out over police radios, the two SWAT team doctors headed toward the side of the house. Drs. Eastman and Metzger are physicians at Parkland Memorial Hospital and UT Southwestern Medical Center. They join the SWAT team on missions as often as several times a week….

Seconds after Wednesday’s gunshot, the doctors met SWAT team members dragging Lt. Marshall around toward the front of the house. The doctors crouched in the grass over the lieutenant.

Blood gushed from his neck and his airway was clogged; the doctors knew he could not get oxygen. Dr. Metzger held the lieutenant’s head in his hands while Dr. Eastman cut a hole in his neck, allowing him to breathe.

I’d have to guess they did a field cric, but it’s hard to know. At any rate, it’s a save!

I’ve been interested in Tactical Medicine for a long time (I got very interested after Columbine), and good for these two docs, and a speedy recovery is wished for the officer.