Movin’ Meat: Market Economics in Action

… All of a sudden, we started seeing large numbers of herion users, many of them “novice” injectors, still using their veins. Most of them were pretty frank that they had only recently started using heroin, and few of them had any record of ER visits for drugs in the past. So, amateur economist that I am, I started systematically asking the heroin users how long they had been using, whether and what they had used before, and why they changed. …

via Movin’ Meat: Market Economics in Action.

Excellent post about economics in action, as seen by an Emergency Medicine physician.

Nice one.

FWIW, Fort Worth is mostly a cocaine town, with a smattering of meth and black tar heroin only once or twice a year.  AFAIK, our Rx drug problem is hydrocodone (sorry about that word, spam filter, you’re about to get a pounding).  I think Oxycodone and its ilk being Schedule II in Texas, requiring different State prescription pads, has kept that class abuse down (some).

Interview with Dr. Flea « ScienceRoll

Interview with Dr. Flea « ScienceRoll.

Interesting interview with Flea, an early medblogger and the definition of beware what you blog.  Read the interview for the lowdown on that…

He’s wrong about not blogging anonymously.  I think he means not to blog like you’re anonymous, which is a different thing…

Anyway, good for Berci for getting the interview!

AMA Policy on Social Media

New AMA Policy Helps Guide Physicians’ Use of Social Media

For immediate release:
Nov. 8, 2010

SAN DIEGO – Millions of Americans use social networks and blogs to communicate, but when those users are physicians, challenges to the patient-physician relationship can arise. New policy adopted today by the American Medical Association (AMA) aims at  helping physicians to maintain a positive online presence and preserve the integrity of the patient-physician relationship.

It’s not surprising there is some guidance on social media from the AMA.  I suppose the only surprise is that it took this long.

Follow the link above to read the policy, which I find remarkably reasonable.  I have some litle heartburn about this one:

(e) When physicians see content posted by colleagues that appears unprofessional they have a responsibility to bring that content to the attention of the individual, so that he or she can remove it and/or take other appropriate actions. If the behavior significantly violates professional norms and the individual does not take appropriate action to resolve the situation, the physician should report the matter to appropriate authorities.

Plenty of thoughtful people disagree with things I’ve written (and a few unthoughtful folks disagree with everything), but I’m not a fan of giving AMA blessing to harass. 

Yes, there’s some things written out there I’m not a big fan of.  I take it as a sign of strength that we can disagree but not make a federal case of it.

And, for you aspiring to get into a professional school, f) is not just for practicing physicians:

(f) Physicians must recognize that actions online and content posted may negatively affect their reputations among patients and colleagues, may have consequences for their medical careers (particularly for physicians-in-training and medical students), and can undermine public trust in the medical profession.

You’d have to go a long way to damage the medical profession, but it takes one facebook post to damage yours.  “Dude, I was so wasted when I…” doesn’t instill confidence in you or your judgement.  Just putting that out there.

So, rare kudos from me for the ever-shrinking AMA.

Another satisfied ABEM Diplomate

I get emails after bemoaning the inefficient / laughable requirements being imposed by ABEM for continuous certification, and while I thank them for writing I’m not interested in being the Lonely Critic who Wails at ABEM.

So, allow me to publish (with their permission) someone elses’ lament at the current state of ABEM:

Thank you so much about your column about ABEM! It is making me feel like I am not the only one going thru this. We have 150 hours of CME required now, 4 through my state, 8 through my insurance, and now I find we can’t count the LLSA’s as continuous ed! Plus the articles in LLSA are horrible.

I took my CONCERT this year and the scores still aren’t out 8 weeks later for a computerized test. Someone needs to rise up against ABEM, they are not our advocates. I felt like maybe ACEP can help but I don’t think they can. ABEM I think is run by a lot of ivory tower guys who work 4 shifts a month in a University Hospital with the residents doing all the work. Thanks again for your columns!

One of my colleagues recently took the recertification test, which is now computer-based, and his description was less than flattering. “It’s like they scanned a photograph of a slide, and then uploaded that for the test”. He’s also about 8 weeks out from the test, and awaiting his scores…

I don’t want to be the anti-ABEM forum (is EMED-L still around?) but when I get emails like this it tells me I’m not alone in wanting ABEM to perform better. Significantly better.

The NNT | Quick Summaries of Evidence-Based Medicine

The NNT | Quick Summaries of Evidence-Based Medicine.

I think I blogged this before, but didn’t describe it much.  Allow me to rectify that mistake.

theNNT.com is an ever expanding site which boils down high quality reviews of medications and interventions, and presents its recommendations in a very much more approachable grren/yellow/red/Warning triangle format rather than some ratio.

While I won’t use this as a single source to change my practice I’m going to have to do some more research on some ofht eh shibboleths of our age ( Octreotide for variceal bleeding, PPI infusions for Upper GI bleeding, etc) are just two of the studies that fly in the face of current practice.

An aside: while inhaled corticosteroids for asthma aren’t beneficial in the review, what it doesn’ tell you is that the Feds think it does, and will grade your asthma care on how many of your asthma patients get a prescription for them.  So, be aware.

Graham is behind this, and good for him.

Scientists turn skin into blood in medical breakthrough; could help cancer treatment | The Australian

STEM cell researchers have found a way to turn a person’s skin into blood, a process that could be used to treat cancer and other ailments, according to a Canadian study published today.

The method uses cells from a patch of a person’s skin and transforms it into blood that is a genetic match, without using human embryonic stem cells, said the study in the journal Nature.

via Scientists turn skin into blood in medical breakthrough; could help cancer treatment | The Australian.

Wow.  Very cool.

I wonder if, hopefully, someday, this could be a replacement for random blood donation?

How to make Oral Rehydration Therapy fluid

Doc Gurley (who’s been going to Haiti since at least the first earthquake relief started) wrote a post today about cholera (currently hitting Haiti hard).

She found there were very few YouTube videos about how to make Oral Rehydration Therapy (ORT) fluid, which is the mainstay of cholera treatment.  Simply put, if you can replace orally what you’re losing from the far end, you get to live.  It’s cheap, it’s easy, but you have to know what to do for it to work.

ORT is super cheap and amazingly easy to make.  Thanks to Doc Gurley, there is now an illiterate (as in language independent) how to video: Recipe for Life!

While it seems graphic, I think it makes perfect sense.  Here’s hoping it helps!

Per Doc Gurley, swipe the video!  Repost it everywhere!  She says Haitians have cell phones, and the more universal this knowledge is the more likely it is to help.

Online doctor ratings aren’t very helpful – USATODAY.com

By Kevin Pho

When I ask new patients how they found me, frequently they say on the Internet through search engines such as Google.Out of curiosity, I recently Googled myself. Numerous ads appeared, promising readers a “detailed background report” or a “profile” of me. Among the search results was information about my practice, whether I was board certified, had any lawsuits against me, and reviews from online doctor rating sites. Thankfully, most were favorable, but some were not.

via Online doctor ratings aren’t very helpful – USATODAY.com.

Kevin, MD, who else?

Great work Kevin!  (I shook his hand once, might have been my brush with fame).

Army finds simple blood test to identify mild brain trauma – USATODAY.com

FREDERICK, Md. — The Army says it has discovered a simple blood test that can diagnose mild traumatic brain damage [TBI] or concussion, a hard-to-detect injury that can affect young athletes, infants with “shaken baby syndrome” and combat troops.

“This is huge,” said Gen. Peter Chiarelli, the Army vice chief of staff.

via Army finds simple blood test to identify mild brain trauma – USATODAY.com.

Yes, it is, if it pans out.  There’s so little actual information in this it’s hard to get excited about it, but let’s say they’ve isolated a ‘brain injury’ protein.

First, it would have uses outside TBI, though that in and of itself might be useful.  I don’t want to poo-pooh this test for TBI, but there are already rules for returning to contact sports (and combat has to be the ultimate in contact activities), so what’s the purpose here?  (I forsee more Purple Hearts, which is fine…).

Stroke?  TIA? Seizure?  Pseudotumor cerebri, as a strain indicator? What if this is the test that allows us to diagnose meningitis without doing lumbar punctures?  I’m all in on that front…

Let’s hope this pans out, for all our sakes.

Knowing when it’s That Time

Knowing when to stop trying to save people is hard, especially when that’s how you’re trained, and innately wired.  It’s been a frequent theme on this blog.

Movin Meat has a good post on the subject today (weeks ago, just found this in my drafts folder), and it’s remarkable for two reasons.  First, it’s a well written account of doing the right thing, even though that’s much harder than the easy thing, and secondly, the power of convincing medical writing to influence the actions of physicians.

Movin Meat specifically cites thinking about the recent Atul Gawande piece in the New Yorker, which helped him make sure the option of how to die was presented to the patient and family.  That’s good writing, and it’s something the world could use more of (as long as it’s not preachy, or gratuitously political).

The World Death Rate is steady at 100%.  There’s nothing at all comforting, comfortable or holy about dying on the vent in the ICU.  Talk with your family about what you do, and don’t want.

Tumortown | Culture | Vanity Fair

Still and all, this is both an exhilarating and a melancholy time to have a cancer like mine. Exhilarating, because my calm and scholarly oncologist, Dr. Frederick Smith, can design a chemo-cocktail that has already shrunk some of my secondary tumors, and can “tweak” said cocktail to minimize certain nasty side effects. That wouldn’t have been possible when Updike was writing his book or when Nixon was proclaiming his “war.” But melancholy too, because new peaks of medicine are rising and new treatments beginning to be glimpsed, and they have probably come too late for me.

via Tumortown | Culture | Vanity Fair.

An excellent writer describing his cancer experience.  Not to be missed.

ACEP Scientific Assembly 2010 wrapup

I was a little concerned about whether I’d like going to the big yearly ACEP meeting, as I went to a couple of the spring conferences and found them lacking in experience, but the last of those was last several years ago.

This time I decided it was the right thing to do, and hoped I’d be able to socialize a bit.

Mandalay Bay was very nice, if laid out Texas-sized.  It was a 10 minute brisk walk (all indoors) to the three story conference center, which was nice and cool despite the reportedly radioactive heat outside.  There were a lot of exhibitors, and they were knowledgeable and professional.

First, the personal highlight, meeting the EM medbloggers!  I got to meet Shadowfax of Movin’ Meat, Nick of Blogborygmi, Graham of Grahamazon (and now The NNT), Symtym, Richard of his epononymously named effort, and WhiteCoat of Whitecoat Rants (who I thought had acromegaly, as opposed to Shadowfaxes’ remembrance of him as a little person…).  (We tried to take his picture but apparently he’s natively pixellated…).  We had individual and group meetups, and except for being remarkably better looking than the other attendees you couldn’t pick us out of a crowd.  Mark and Logan Plaster of EP Monthly were of course very nice (and flattering), and I also got to meet Edwin Leap, but I’m not sure he knew who I was as I didn’t use my pseudonym…

I also enjoyed the Fresno residency get-together, catching up with resident friends and faculty.  There’s something about those friends – hadn’t talked to some in years, and we picked up like we’d last talked 30 minutes before.  It’s probably the shared intense years, but it was remarkable.

Surprisingly, a few people at the meeting had heard of my blog, and one, who was also twittering from the same conference sought me out to have our picture made together!  It was interesting, fun, and humbling.

Speaking  of twitter, I tweeted the meetings I attended (I was tired and bagged the Friday morning meetings), and I guess I went a little tweet-nuts: according to @takeokun I had 281 tweets for the Tuesday, Wed and Thursday meetings.  I tried to post the highlights of the meetings; you can take from that number there were an awful lot of highlights!  For my tweets, which are part of my normal twitter stream look here, and for all 826 tweets from the Scientific Assembly, look for them under their hashtag: #sa10.

I wanted to hone-down the true practice-honing pearls, but there are so many I’ll just throw out the ones that come from the top of the mind:

  • single unit blood transfusions are now perfectly fine, the ‘two-unit rule’ is dead
  • hip dislocation reduction: use the Captain Morgan technique. Stand beside the bed, fix the pelvis to the bed, put your foot on the bed, put the patient’s affected-limb calf over your leg (right up to the knee), and reduce by flexing your ankle.
  • nursemaid’s elbow reduction: hyperpronation, not the supinate-flex manouver.
  • to more easily reduce an ankle dislocation, flex the knee first
  • in ITP, you can give Rh POS patients rhogam (the antibodies coat the platelets and help prevent splenic sequestration and destruction)
  • 90% of pts held in both ED hallway & upstairs hall preferred upstairs. “we think the other 10% liked being able to go smoke”
  • “medicine is acting for ugly people” – Greg Henry
  • Key clinical picture in thyroid storm is a tachycardia way out of proportion to their fever.
  • Lid lag in hyperthyroidism: see the sclera when pt looks down, think hyperthyroidism.
  • In thyrotoxicosis can use Li instead of iodine if they’re intolerant, as it has the same mech of action.
  • “if the patient sees nothing and the doctor sees nothing, think retrobulbar neuritis”.
  • “before you write anxiety as a diagnosis, remember, people get real anxious just before they die”.
  • “I don’t understand why you would pay money to have someone rub your back; I understand why you’d pay to rub your front.” Greg Henry.

You get the idea…

I had fun, and will be going next year.  We need to get more attendees twittering the meetings they’re in.  (My iPad was the perfect tool for the job).  EM docs, get ready for next year, and get ready to twitter while you’re there!

ER doctor on probation after suspected DUI arrest – San Jose Mercury News

ER doctor on probation after suspected DUI arrest

The Associated Press

Posted: 09/30/2010 09:08:07 PM PDT

IRVINE, Calif.—An Irvine emergency medicine doctor has been placed on five years probation by the state medical board for reporting to work shortly after she was arrested on suspicion of drunken driving.

Board documents say she showed up drunk for her overnight shift at the La Palma Intercommunity Hospital emergency room about two hours later.

via ER doctor on probation after suspected DUI arrest – San Jose Mercury News..

I gotta think a) that’s NOT going to help this doctors’ case and b) that’s not going to be good for their career…

Tuesday at ACEP Scientific Assembly 2010

I’m here, but all my blogging is over on Twitter.

If you’d like to follow, I’m here: http://www.twitter.com/gruntdoc

Why a doc might want to blog anonymously

Yesterday came another of the tiresome ‘all doctors should blog using their own names, not anonymously’ blog posts, with the predictable reasons cited: nobody will take the anonymous blogger seriously, and because I’m a doctor and I said so.  Never underestimate the Physicians’ belief that what they believe is correct, even (especially) if it’s out of their sphere of training.

If you’re a doc in private practice, trying to build a practice and make a name, use your name, and have fun.  If you have a burning desire to change the world, and feel that you have deep points to make the need to be taken seriously, use you name.  Embrace being googleable!

However if you’re a hospital-based doc, or you’re blogging to entertain yourself, you mom and 9 people with nothing to do, there’s no real reason to use your true identity, and several not to.  Your hospital, contracting company or hospital might not like the idea you’re blogging, even if you never say anything bad about your colleagues or the joint.

I tell everyone who asks how to start blogging to start anonymously, as a) you’re going to be new to it and might type out something you’ll want to disown, and anonymity can help you avoid repercussions of the permanently-cached world, and most find they have 6 posts burning in their brain, get those done, get bored and quit.  A pseudonymous blog is really easy to quit.  (Allegedly, I have yet to try myself).

I fit paragraph 3 here, by the way, and have no pretensions to change how the world works, and absolutely never want anyone who reads this blog to think it’s medical advice (hint, it’s not).  Also, you have to take my word for it I’m a doc, and it’s not all that important to me anyone think I am a doc when reading my posts.  Am I a doc?  Yes.  Do I care to drop the pseudonym to prove it?  No, why would I?

And the sadly obligatory: if you’re blogging pseudonymously to say bad words about your boss, denigrate your patients (beyond pointing out the usual irritations), because your mom didn’t love you and you need therapy, or you just love to type f-bombs, reconsider.  There’s no such thing in the long run as anonymity on the internet, and you’ll be found out if there’s enough motivation.

So, there are many ways to be a doc, and many ways to blog.  It’s not a one size fits all world.  Just do it the way you want.