Archives for November 2007

Doctor Anonymous: Change of Shift: Vol 2, Number 12

Doctor Anonymous: Change of Shift: Vol 2, Number 12
Welcome to Change of Shift, the best of the nursing blogosphere!

Graveyard shifts can bring on the actual grave?

In the ‘I never would have believed it’ category:

Overnight shift to be classified as ‘probable’ cancer cause

LONDON, England (AP) — Like UV rays and diesel exhaust fumes, working the graveyard shift will soon be listed as a “probable” cause of cancer.

It is a surprising step validating a concept once considered wacky. And it is based on research that finds higher rates of breast and prostate cancer among women and men whose work day starts after dark.

Next month, the International Agency for Research on Cancer, the cancer arm of the World Health Organization, will add overnight shift work as a probable carcinogen.

The American Cancer Society says it will likely follow. Up to now, the U.S. organization has considered the work-cancer link to be “uncertain, controversial or unproven.”

The higher cancer rates don’t prove working overnight can cause cancer. There may be other factors common among graveyard shift workers that raise their risk for cancer.

Hmmm. First thoughts: I’ve always wondered why we have to have a 24 hour world.  Also, insurance rates to rise on night shift workers.

I took care of a lawyer the other day

Lawyers are (probably) people too, and they get injured like the rest of us. I made a comment a while back on Kevin, MD (which I’m too lazy to search for right now) that, IMHO, lawyers are reticent to announce that they’re lawyers in the ED.

A few months ago saw a patient with a small laceration on a digit; after a digital block I left to do something else, then returned once the finger was good and numb to close the wound. I like to chat with patients during suturing; it is mildly distracting to the patient, and me (suturing is dull after the first thousand lacerations or so):

The conversation, as I remember it:

  • me: So, how’d this happen, again?
  • pt: Caught it between a dresser and the wall; I’m moving (out of state).
  • me: Aah. Moving for a new job?
  • pt: No, same job, different headquarters; kind of a promotion.
  • me: Good for you. What do you do?
  • pt: …I’m a lawyer…an Oil and Gas Lawyer, I don’t do any medmal.

That last part shot out of the patient’s mouth so fast, and loud, the patient in the cubicle across the hall started laughing.

We both laughed mutually, at the humor of the discomfort of his statement, and that his reaction caused laughter in others.

The finger was closed, and that was the end of the interaction, but it was amusing. And I probably won’t be sued by an Oil and Gas lawyer; at least, not by him directly.

Olive View ED Triage Death: MI

For background (and some interesting comments from interested parties) see How in the World does this happen? and More on the LA death:

Via the LATimes:

Untreated Olive View patient died of a heart attack

By Jack Leonard
Los Angeles Times Staff Writer
November 28, 2007
An L.A. County coroner’s spokesman confirmed Tuesday that a 33-year-old man who collapsed and died last month after waiting more than three hours at Olive View-UCLA Medical Center to be treated for chest pains had had a heart attack.
The county-run hospital in Sylmar had failed to administer a simple test to check whether Christopher Jones was having a heart attack when he walked into the emergency room Oct. 28.

Within days of Jones’ death, the county Department of Health Services announced that it was taking steps to fire the triage nurse responsible for evaluating Jones. State investigators are continuing to review the case to determine whether the hospital provided adequate treatment.

Craig Harvey, operations chief for the county coroner’s office, said Jones died from a blood clot and coronary heart disease. Pathologists also found that he had an enlarged heart.

There’s more, but it’s mostly a rehash of things already discussed (i.e., get an EKG machine and use it if your ED triages chest pain to the waiting room).

So, now we know.  And it’s fully as bad as feared.

Concentrated Navel Gazing

That’s a term for blogging about blogging, or in this case, blogging about the actions behind the scenes of the blog.

I just added SpamKarma2 due to an increasing (and tedious) amount of comment spam to this nearly-anonymous blog. I tell you this so that, should your comment get bounced, I sincerely want you to tell me. Hit the ‘contact’ form and a) email me your comment and b) to let me know f it’s working against me / us.

Now back to the irregular, unscheduled programming.

Updated: now disabled. It caused some terribly bizarre behavior, and is off.

Update2 (11-28@2230): Back on.  The weirdness from last night was reported to be ‘server overload’ that had nothing to do with Spam Karma.  So, again, lemme know if it does something untoward.

Grand Rounds 4.10 | Prudence, M.D.

Grand Rounds 4.10 | Prudence, M.D.

It’s up!

A day of Emergency Medicine?

Today was the first day back to work after a four day holiday. The patient acuity was high, which was a nice change:

  • The Septic Senior, with a-fib at 200, a systolic of 70, on digoxin and coumadin,
  • the Trauma Transfer, with the as-billed bleeding liver lac and free abdominal air, but also including the the undisclosed spleen lac,
  • the Arrest in the Ambulance Bay, who died despite all our efforts,
  • the Killer Back Pain, with the Type B aortic dissection,
  • the Altered Mental Status, with some dehydration and a seizure disorder on the side…

And those were in the first two hours. I really believe that some people ‘hang in there’ through the holidays, and then pay the piper for the privilege.

And, those who are sent to remind us to be humble, and maybe a little miserable.  The patient who, when presented with their diagnosis (really, irrefutable given the history and testing), says

  • “I don’t agree”.
  • me: Yes, it is. That’s what all the tests are for.
  • pt: “No. I have an Uncle who was a doctor, and I have my own Merck Manual, and I don’t think that’s right.”
  • me: Ummmm, okay …

All in all, a good day to be an Emergency Physician.

MedBlogs Grand Rounds 4:9

Mexico Medical Student
Grand Rounds 4:09¡Bienvenidos a Guadalajara, Jalisco, México! I will be your host and guide through this week’s best of the medical blogosphere.

Well done, Enrico!

I cut off a finger the other day

…and I’m still thinking about it.

The patient had been struck on his dominant index finger with a big pipe, twice. The force of at least one of the impacts blew out a big chunk of the bone of the finger, and the arteries (and apparently nerves along with them), but left the skin behind. By ‘blew-out’ I mean there was a big laceration on both sides of the finger, but it looked like a (pale, dusky, insensate) finger.

A conversation with the hand surgeon confirmed what I already knew: this finger was no more, and a ‘completion of amputation’ was in order. What I didn’t know: that was my job. (He was nice about it, and would follow the patient up in the office, but had to get to the OR).

Now, I’m not green anymore, and have completed a lot of digit amputations before but they were, frankly, utterly cosmetically deranged fingers. They looked a lot less like fingers than ground chuck, and it’s not hard to rationalize removing devitalized tissues and closing the wound. I do it pretty well, thanks.

This was different, at least superficially. It looked very much like a finger, and while intellectually I knew it was never to be a finger again, there’s a deeply ingrained taboo that prohibits me from causing permanent damage. Only after telling myself several times that this was actually no longer a finger was I able to take the sharp implement and cut off most of a finger. An index finger, a pointer, the one used for dialing a phone, scratching an itch, beconing, exploring a nostril, and a million and one other uses.

Into the basin went the limp digit (no bony support), and the closure was as good as I could do. The patient was amazingly calm about the whole amputation-thing, and actually said when I first saw him “…I know you’re gonna have to cut it off…” and showed me another amputated digit from a prior experience.

I don’t want to do that again, though.


The guy with the patient today wearing a t-shirt emblazoned:

“Let me drop what I’m doing and help you”

I wanted to point it out, or point and laugh, but I just ignored it.  Until now.

CNN profile of two physicians in training, and their debt projection

Holy cow:

Young doctors in debt

CNNMoney.comChris and Meg Reis are on their way to long medical careers. Now it’s time to deal with $500,000 in student loans.

By George Mannes, Money Magazine senior writer

November 16 2007: 11:47 AM EST

(Money Magazine) — It’s Wednesday evening and Megan Reis can’t remember when she last saw her husband Chris. Small wonder. Since Sunday morning, Meg has worked more than 60 hours at Advocate Hope Children’s Hospital, the Chicago-area facility where she is training in pediatrics.

Chris, meanwhile, has put in a 24-hour day followed by a 12-hour one at the nearby Loyola University Medical Center, where he’s learning anesthesiology. Meg guesses she hasn’t seen him since Saturday.

Such are the lives of medical residents: med school graduates getting years of on-the-job training, putting in brutal hours for salaries that, on an hourly basis, work out to a little more than they could earn stocking the shelves at Costco.

It’s all supposed to pay off, of course. Once they become full-fledged doctors (attending physicians, in the trade), they’ll have six-figure incomes, more reasonable hours, a respected occupation and work that they love.

Chris and Meg live frugally, work hard and are making the kind of investments in their future that would make any parent proud. But they’re also on track to finish their medical training in the next few years with a staggering $700,000 in debt.

I have some debt, but thanks to the Navy (and all of you, thanks) it’s a whole, whole lot less.

Does anyone else think this is an excessive amount of debt, even given rising costs?  Seems like a lot more than I’m used to seeing quoted.

UroStream: What’s up?

Keagirl uses the ladies room in her ED.  She had a surprise.

UroStream: What’s up?


More Dead Blogs

It was time to have a look at all my blogs in the ‘medical’ sidebar, for currency (generally, two plus months of inactivity is enough to consider your blog dead).

Added to the dearly departed:

17 more. I read all the time that ‘there’s a blog started every second’, and it takes most bloggers about 3 months to give up, for a variety of reasons.

I’m sure there are a lot of other active medblogs, but if I’ve not linked them, I don’t know about them.

Aggravated DocSurg: To CT or Not to CT? Another Salvo

Aggravated DocSurg: To CT or Not to CT? Another Salvo

Common things being common, anyone who has spent a little time perusing medical blogs has read a few posts about the value, or lack thereof, of CT scans in the evaluation of suspected acute appendicitis. I’ll outline my opinions below (Opinions? Moi?), but there has been another salvo fired in this skirmish, this time aimed against the “CT everyone” crowd.

Your ED’s mileage may vary, and the “CT everyone” crowd is usually the surgeons.  The ED Docs would love to avoid ordering them.

Great American Smokeout is today

20% of American adults smoke, a statistic that’s not going down.

From the CDC:

Smokers who use effective cessation aids such as clinician assistance, pharmacotherapy approved by the Food and Drug Administration, and behavioral counseling (e.g., quitlines) can increase their likelihood of quitting permanently (3). All 50 states, the District of Columbia, and certain U.S. territories have quitlines that can be reached at 800-QUIT-NOW (800-784-8669). Other interventions that increase cessation include implementing sustained media campaigns, reducing patient out-of-pocket treatment costs, increasing the price of tobacco products, and establishing smoke-free environments (4).

The Great American Smokeout (from the American Cancer Society). Quit today, and don’t start if you haven’t already.