Archives for January 2008

Movin’ Meat: Shave a doc for kids (bumped)

Update: Time for you (yes, you) to give some bucks to Shadowfax, who’s going to go Schick-bald to raise money for children’s cancer research. I’ve perused the list of donors to date, and there’s a couple of medbloggers in there, but not nearly enough.

So, bloggers, commenters and lurkers all, please consider giving some small donation to this worthy cause.

Here’s an effort I can get behind: scalping Shadowfax:

Movin’ Meat: I’m a Beautiful Man

Here’s how it works: You click the link and pony up a couple of bucks. I shave my head and post the pictures here for all the world to see. Children’s cancer research gets the money. You get the warm satisfying feeling of positive karma spreading through your body. We all win.

I made a donation, and hope you will, too.

Prius start problems

From a friend who’s a pilot:

 I am in Atlanta right now.  I told Hertz as I usually do when I travel alone to just give me a compact, “whatever everyone else does not want to rent.”  So I get to KPDK and they have left me a Prius.  I thought I could just get in a start it and pull it over to the Baron and unload my equipment.  15 minutes and 3 different places in the car’s manual later I finally figured out the 5 steps to get it started, which was only complicated by the fact that when it started it doesn’t sound like a car running which only added to my confusion.

Laugh if you may, dude, because I know that is what you are doing right now.

I think that car should require a type rating…

Actually it is a great idea and fun to drive.  I like the power source display.  Closest thing to a glass cockpit I’ll ever see…

I can understand his confusion, it’s not like most other cars as far as ‘starting’ goes.  Heh.

I got a present today

At work this evening there was a nice assortment of different coffees on the docs’ table, with this attached to the top:

I appreciate it (and thanks, Nurse 1961). I’ll try them out.

Still just one cup a day though.

Don’t treat the old and unhealthy, say doctors – Telegraph

Aah, the Panacea of Socialized medicine: the eventual realization that you can’t pay for everything for everyone, then rationing ensues.

Don’t treat the old and unhealthy, say doctors – Telegraph
Doctors are calling for NHS treatment to be withheld from patients who are too old or who lead unhealthy lives.

Smokers, heavy drinkers, the obese and the elderly should be barred from receiving some operations, according to doctors, with most saying the health service cannot afford to provide free care to everyone.

Fertility treatment and “social” abortions are also on the list of procedures that many doctors say should not be funded by the state.

The findings of a survey conducted by Doctor magazine sparked a fierce row last night, with the British Medical Association and campaign groups describing the recommendations from family and hospital doctors as “out­rageous” and “disgraceful”.

About one in 10 hospitals already deny some surgery to obese patients and smokers, with restrictions most common in hospitals battling debt.

Can’t wait for socialized medicine here. UPDATE: Yes, that’s sarcasm.

Scrub Fashion: A Polite Request

In the medical field, way way before my time, doctors wore coats and ties, nurses wore starched bleached-white uniforms, and all was right with the world (I’ve seen the movies). Times change.

Now everyone wears scrubs at work, and I get why: easily cleanable, comfortable, and usually they help to cover an array of bodies that are better left unseen (and I include myself in that category).

At least, that’s how it used to be. I don’t know what’s changed in the last few years in the scrub design world, but scrubs are now, well, ill-fitting, or more specifically too revealing. Frankly it looks like a plumbers’ convention in the hospital these days, and crack is what some of the patients take, not something any co-worker wants to see, or should wish to display. I’ve seen all the multicolor thongs and undies I ever want to.

Yes, this makes me an old coot, and I’m okay with that, lets all just endeavor to keep our underwear choices a secret at work.

Historical Medical Photography – Medgadget –

Historical Medical Photography – Medgadget –

MedGadget has a post to Flickr photo bucket pages from the National Museum of Public Health.  I’ve looked through the first, and it’s an eclectic collection of photos, from Civil War paintings to Vietnam.

I expect these to start adorning medblogger posts very soon…

Flickr Set 1…
Flickr Set 2…
Flickr Set 3…

The Cheerful Oncologist : Goodbye to ScienceBlogs

The Cheerful Oncologist : Goodbye to ScienceBlogs

It is time for The Cheerful Oncologist to sign out. I have decided to take a holiday from writing and therefore am cutting the cord from ScienceBlogs. I send thanks to those readers who put up with my malarkey over the past three years. If the fair maiden Blogorrhea, the muse of web logging, returns to bewitch me at some point I may start again, but until then I place my pen down and say to all, “God Bless.”

Another terrific medical blogger decides to walk away.  His comments are closed, which is a pity.  He’ll be missed.

MedGadget 2007 Medical Weblog Awards

The 2006 Medical Blog Awards

The winners (all but one) have been announced!

Go there, and have a look.

Scientifically Proven: 24 days

That’s how long it takes for a demented elder to be found on the floor of their live-alone apartment, be brought to the ED and have their life saved, somewhat dramatically.

It includes the time spent in the hospital being seen by several top-flite specialists and excellent, caring nurses.  Time to eradicate infections, ameliorate cardiac dysrhythmias, reverse renal dysfunction and begin their rehabilitation.

It also includes their transfer to a rehabilitation hospital and ultimately their discharge home.

To the same apartment, to be found on the floor, and be brought back.

There are no words.

iowahawk: A Public Service Message

iowahawk: A Public Service Message
A Public Service MessageI have to say I was heartened by the response to my investigative piece on the national crisis in journalist violence. As you know, whenever a public crisis is identified, the first steps in a solution are (a) a non-profit foundation, and (b) posters!

This is some humor for the three of you that are checking the blog this weekend.

MedBlogs Grand Rounds 4:17

» Grand Rounds: Briefing the Next US President « Brain Fitness Revolution at SharpBrains

Dear Mr or Mrs Next US President,Thank you for visiting Grand Rounds, the weekly collection of the best health and medical blog posts, in the midst of your very busy schedule.

I’m late, he wasn’t.  Good GR!

Forcing Care on Patients

Yesterday there was a Associated Press news item about a lawsuit involving an Emergency Physician and a forced rectal exam:

Man: NY Hospital Forced Rectal Exam

The Associated PressNEW YORK (AP) — A construction worker claimed in a lawsuit that when he went to a hospital after being hit on the forehead by a falling wooden beam, emergency room staffers forcibly gave him a rectal examination.

Brian Persaud, 38, says in court papers that after he denied a request by NewYork-Presbyterian Hospital emergency room employees to examine his rectum, he was “assaulted, battered and falsely imprisoned.”

His lawyer, Gerrard M. Marrone, said he and Persaud later learned the exam was one way of determining whether he had suffered spinal damage in the accident.

Marrone said his client got eight stitches for a cut over his eyebrow.

Then, Marrone said, emergency room staffers insisted on examining his rectum and held him down while he begged, “Please don’t do that.” He said Persaud hit a doctor while flailing around and staffers gave him an injection, which knocked him out, and performed the rectal exam.

Persaud woke up handcuffed to a bed and with an oxygen tube down his throat, the lawyer said, and spent three days in a detention center….

Hospital spokesman Bryan Dotson said, “While it would be inappropriate for us to comment on specifics of the case, we believe it is completely without merit and intend to contest it vigorously.”

Today it was linked to on the WSJ Law Blog, linking to Slate’s ‘Explainer’ column, the best part of which is this:

Slate MagazineThe idea of consent as a patient’s right goes back at least to 1914, when Benjamin Cardozo (who would later become a Supreme Court justice) ruled in a New York case that “[e]very human being of adult years and sound mind has a right to determine what shall be done with his own body.”

I have absolutely no problem with that answer, and it also lays out the situation in which I am ethically and professionally compelled to act against the wishes of my patients, the patient not of sound mind who refuses potentially lifesaving examination and treatment. 

Here’s my typical ‘against their will’ patient (who’s not there for a psych diagnosis, different story): Adult male brought in from a motor vehicle accident with some moderate damage to the car, usually tachycardic and normotensive, with signs of trauma externally (small lacerations or contusions) but nothing that makes anyone in the room immediately concerned.

Then comes the mental status examination, and the problems start.  The patient is ‘altered’, which can be described a lot of ways but for me  boils down to ‘not right right now’.  Yes, it could just be alcohol or drug intoxication (most people will, initially, cooperate and tell you what they’ve taken, but not all) but even if they cop to the drugs and booze, it that really all that’s going on?  Does this patient have a head injury causing their slurred speech, their restless combativeness and their unwillingness to cooperate, or not?

There are a couple of ways to find out, and at this point in this patients’ care they’re both fraught with problems: wait and see (and hope for the best), or examine and treat to exclude life and limb threats against their verbalized wishes (to guard against the worst).  This is where “First, Do No Harm” becomes a work in progress, balancing the risks of sedation (or infrequently sedation, paralysis and intubation, which are real but small) to facilitate a medical evaluation to exclude badness versus the also small but real risk the patient has a severe injury being masked by alcohol or drugs, which waiting to diagnose could spell disaster.

I’ll tell you that I’ve done both, and that’s where the professional judgement comes in, deciding based on training and experience who to watch and who to press ahead with.  It’s not an easy decision, and it’s much much harder to go against any patient’s verbal desires, but if I’m concerned enough I do it.  Frankly I’d much rather work up 100 patients with an altered mental status against their will than miss the patient with a life threat that I ascribed their altered sensorium to alcohol or drugs, and it was just a confounding problem.

Here’s the patient who personifies the issue (a mixture of real patient experiences to obscure it, but all this has happened with my personal patients): adult male, 275# (all muscle) brought in cuffed after a car chase with the PD.  Wrecks car, has a 4 inch lac across the forehead, and is diaphoretic with a HR at 130.  Patient is alert, answers most questions, denies drugs (the PD says he’s a frequent cocaine user, they’ve arrested him before), moves all extremities, but won’t allow any interventions.  Nice nurses try their best to bond (I only really bond well with older vets and LOL’s) and he’ll allow his BP, but that’s it; no IV’s, nothing.  Speech is direct but goal-directed (toward leaving), and none of us can talk him into letting us do anything.

My problem as the treating EM doc: do I let him walk out?  His lac will eventually heal, but I’m very very worried about head injury and the real possibility of internal bleeding from his accident.  If he has any of those, it’s terrible for him if I let him go (and not good for me either, I’d get to try that career change I talk about).  Yes, all this weird behavior and the abnormal vitals can be explained by cocaine use, but am I willing to risk his life on that assumption?

No.  We tried five adults holding an arm while giving 5mg of Vitamin H (Haldol) with 10mg of Versed, and he was still wide awake an struggling, no way we’d get a CT done.  This was only the second time in my career I’d used IM sux to knock a combative patient down (quadruple your IV dose), and it worked; his intubation and workup proceeded very smoothly.  He benefited from not struggling with other adults, decreased BP and heart rate, and we sewed up his lac while he was out.

I’d like to tell you we found a big bleed and saved his life, but this is reality.  His CT’s were normal, Trauma washed their hands of him as a cocaine ingestion, so when he woke up in the ER 4 hours later (we were sedating him while intubated) he was calm and cooperative.  He apologized to all of us profusely, told us he’d been taking cocaine heavily ‘and I get out of control sometimes’.  He went home, safe.  I slept well, because though it was a risk to go against his wishes, it was a much better choice than letting him go, for both of us.

I’m not well-versed enough in the jargon of ethicists to use their terms, but doing right for patients very occasionally means not doing what they tell you they want. 

It’s rare, and it happens.

Hat tip to reader Chris, and many thanks to my commenters.  I’m not gone, it’s just a slump.

Thank You and Goodbye « Hallway Four

Thank You and Goodbye « Hallway Four

Hallway Four signs off, and it sounds like she’s in my head:

…I’m going to call it quits. Nothing bad has happened that has led me to this point, it just seems like the longer I work in the ER, the less I have to say about my job. I don’t know what this means. I still have good cases and amazing patients and funny stories, but for some reason I feel less and less inclined to write about them now than I did a year ago.

Hallway Four will be missed, and after a suitable period of mourning, will join the Dead Blog blogroll.

It’s been five days since I last posted, and that was a link to Grand Rounds.

MedBlogs Grand Rounds: Vol 4:16 – Grand Rounds – Vol 4., No. 16

Grand Rounds – Vol 4., No. 16Welcome to this weeks edition of Grand Rounds, the week’s best from the medical blogosphere.

And if you haven’t been to our new site before, welcome to PathTalk, a community blog for all things pathology. We’ve only been around for a few months, and have taken a short hiatus recently, but hope to ring in the new year with more content from a specialty that is relevant to all of our medical colleagues out there.

Nice, succinct, easy to read.

2007 Medical Weblog Awards: Start voting!

Remember the rule of electoral success: Vote early, vote often!

2007 Medical Weblog Awards Sponsored by The Polls Are Open!

The 2006 Medical Blog Awards
After a careful analysis and consideration, we are excited to present to everyone the group of finalists of the 2007 Medical Weblog Awards. But first, a couple of notes.We would like to thanks everyone for nominating so many great medical blogs for consideration. Literally dozens of candidates in each and every category were named. As we personally know, each blog is someone’s labor of love, and it is not an easy work to maintain. So as editors of Medgadget we took the job of selecting the finalists very seriously.

And, of course, many thanks to ScrubsGallery for sponsoring these awards!