I’m good at intubating (the procedure by which a tube is passed through the vocal cords into the trachea to assist ventilation). I’m not the world’s expert, and I haven’t written a book about it, but I know what I’m about. I was trained by people who knew what they were doing, and I (and my patients) owe them a debt of gratitude. (Lotta I’s there, sorry).

Very occasionally, I get to help out my partners in Emergency Medicine practice when they’re in a bind with this procedure, and I do.  It’s always fun, and a little gratifying, to ‘get the tube’ when a colleague (and their patient) is in trouble.

As Ron White says, “I told you that story so I could tell you this one…”

Pride goeth before the fall.

I have come to learn that one of the worst sins of a physician is Pride. This is strictly different and separable from confidence, in that confidence is a normal and rational belief in ones self and abilities whereas Pride is based in ego, irrespective of confidence. Or logic, for that matter.

The worm turns, and I’m the one who cannot get the tube in the trachea. I’ve preoxygenated, sedated, RSI’d, and taken 3 tries. I’ve changed tubes, blades (the laryngoscope has differently sized and shaped blades), and patient positioning which are among the things that should be adjusted in the event of intubating failure. The good news? This patient can be oxygenated and ventilated easily with the bag valve mask. The bad? I’m now no closer to getting the airway secured with a cuffed tube than I was when I started.

This is where not having Pride came in: I asked for help. The Prideful EM doc (or the one in solo practice, and I respect the heck out of all of you) will keep trying, and will eventually help the patient and assuage their ego (or their situation) by getting The Tube. This can come at a cost to the patient in airway trauma or worse, and it’s desirable to avoid that.

My colleague physician came in, smiled, and helped my patient and me out of a bind. Colleague made it look ridiculously easy, with a first attempt intubation. Just like I’ve done before…

He was amazingly humble, and didn’t rub my nose in my failure to intubate. I truly hope I’ve been as nice to my colleagues in the same situation. Really, he was as nice as a human could have been while pulling chestnuts from a fire. Mine, to wit.

And I surprised myself by asking for help with a procedure I’m normally good at. No Pride, no Ego, just what’s good for the patient. I’m getting this Doc thing.

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Nearly a quarter of the Texas population lacked health insurance in 2010, according to the most recent data released by the American Community Survey, which the U.S. Census Bureau conducted. That’s more than 5.7 million Texans.It’s likely that someone you know — and probably one you wouldn’t have guessed — doesn’t have health insurance. More than half of the uninsured are employed. More than a third have an annual household income above $50,000. And more than 1 million have college experience or post-secondary degrees.

via Interactive: Who Are the Uninsured in Texas?.

Very nicely done.

If I get a lesson from this, it’s “Stay in School. kids!” (If you live that long).

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Permanent repeal of the flawed Medicare payment formula known as the Sustainable Growth Rate just got a lot more expensive….

via Doc Fix Just Got More Expensive – Margot Sanger-Katz – NationalJournal.com.

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So: the 2011 winner of the worst quackery award is: battlefield acupuncture. This bizarre practice, invented just 10 years ago, offers a trifecta of ills:

It offers no medical benefit and carries a real risk of harm for some patients.

The U.S. government is wasting tens of millions of dollars per year on it, and plans to increase its spending next year.

The patients are wounded combat veterans who have no choice about where to get treatment.

In battlefield acupuncture, the “doctor” (no competent doctor would do this) sticks needles into the patient’s ear to relieve pain.

via The Worst Quackery of 2011: Battlefield Acupuncture – Forbes.

Incredible. And infuriating.

(Found on Twitter, but I cannot recall who tweeted it).

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…peddling the same tired phenomenon of magical thinking regarding the diagnostic miracle of highly sensitive troponins…

via Emergency Medicine Literature of Note: Yet Another Highly Sensitive Troponin – In JAMA.

Nice! Go and read.

via @nickgenes on that Twitter thing…

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Recently, the Centers for Medicaid and Medicare Services announced a scheduled cut in Medicare physician fees of 27.4% for 2012. This cut stems from the sustainable growth rate (SGR) formula used by the physician-payment system. …
To illustrate the level of inequity in this system, we broke down the national spending for Medicare physician services by state and by specialty and determined which states and specialties have contributed most to the SGR deficit between 2002, when the program was last balanced, and 2009. Although SGR spending targets are set on a national level, we computed state targets by applying the SGR’s national target growth rate to each state’s per capita expenditure, using 2002 as the base year. Our analysis is an approximation, because, unlike the SGR, we do not adjust for differential fee changes. …

We compared the state targets for the years 2003 to 2009 to actual state expenditures and added the annual difference between these figures to get a cumulative difference between the state’s spending and the SGR target. This cumulative difference was then divided by the 2002 per capita expenditure to determine the percentage growth since 2002.

via The Sources of the SGR “Hole” — NEJM.

Here are the graphs, and my attempts at explanation, and the questions I have: 

Hmm. First, was a rebalancing done on the numbers of citizens in these states between 2002 and 2009?  Texas was a net in-migration state during this time period, NY was a net out, and Florida was a mixed bag (source: Brookings .pdf). Hmm. (And, Alaska was mid-pack throughout). I’ve never understood regional variations in billing.

The By Specialty graph:

And, my half-joking explanations, in the slides:

Yeah, okay, that’s EM gloss. Our costs went up, and our volume went up, and now everyone either wants or gets a CT scan. That’s not a huge surprise.

Interesting, nonetheless.

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1. I’m most interested in EM. Given that I have no prior military service/experience, am I basically going to have to do a GMO tour to get this specialty?

Well, it depends on a lot of factors. Your branch of service is probably the biggest determinant (AF is best, Navy is historically worst at going from Internship straight to residency without a GMO tour), but there are several reasons you might not want to go straight to residency.

Honestly, residency is easy compared with being a GMO, at least the first year of a GMO tour. I finished a Basic Surgery Internship, and went to the fleet as a Battalion Surgeon (honorary doc title). I could spit out the Ddx of hypersplenism but had no idea how to treat musculoskeletal back pain, an ankle sprain, or PFPS. I’ll get into the rest of this later.

2. Did you do a GMO tour? If so, how was it?

Yes, GMO for 4 years. Fortunately for me it was between conflicts. To plagarize some guy, it was the best of times, it was the worst of times. Seriously, if I could have my GMO job 1/2 time and my real job 1/2 time I’d be a very happy person, and a happy doc.

3. What made you ultimately decide to stay in military post-active duty or leave for private practice?

I wasn’t a career type, and I knew I wanted to work in the real world. At the time new EM grads were going to boats, and while they’d be very useful there were there a shooting war, it would be a punishment tour otherwise.

4. What kind of leadership opportunities did you have in military medicine that you feel would have been impossible/unlikely in civilian medicine?

I got to lead, really lead, some excellent Navy Corpsmen, I got to advocate for some Marines and Sailors who needed it, and I got to go places nobody gets to these days. (2 trips to Iwo Jima, try booking that on Kayak).

5. Would you have decided to still do HPSP if the scholarship amount was significantly smaller? (ie, <50% what it is).

It was that then, I did it because I wanted to serve and it served by desires and interests. In general, if you’re considering HPSP just to pay the bills you won’t be a happy camper, and you’re signing on the line for a lot of years.

6. Is it possible to find out how many GMOs the Navy needs? (Currently, there are rumors that the Navy is going to change the GMO program).

No idea. But, don’t consider GMO time punishment, or time lost, it’s just something different, and I still think of (parts of it) fondly. The bonus of being a GMO and re-applying to a military residency? Time in Service is weighted on your app. So, if you want to be a brain surgeon but were bottom of your class, after a few GMO tours you’d most likely be in (YMMV).

Best of luck with your decision, and please let me know how it goes!

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The idea of putting maggots into open flesh may sound repulsive, but such a therapy might be a quick way to clean wounds, a new study from France suggests.

via Maggots Clean Wounds Faster Than Surgeons | Wound Healing | LiveScience.

I kid. I think this is a good idea, and it’s natures’ way of saying ‘cleanup on aisle three’. Patients not infrequently will be brought to the ED with awful, non-healing wounds infested with maggots.

We typically kill them off, more because a) the staff is completely grossed out and b) if you’re living at home and have maggots in your wounds, let’s just say your personal hygiene is deeply suspect. Rank, in fact. Needs a decon level bad.

However, there is a legitimate role for biological wound cleaning; I have a WWII surgical book with a chapter in it on growing your own sterile maggots. It’s not an ER thing, but it’s yet another tool in the armamentarium of bad wounds.

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Thanks to a $374,000 taxpayer-funded grant, we now know that inhaling lemon and lavender scents doesn’t do a lot for our ability to heal a wound. With $666,000 in federal research money, scientists examined whether distant prayer could heal AIDS. It could not.

The National Center for Complementary and Alternative Medicine, or NCCAM, also helped pay scientists to study whether squirting brewed coffee into someone’s intestines can help treat pancreatic cancer (a $406,000 grant) and whether massage makes people with advanced cancer feel better ($1.25 million). The coffee enemas did not help. The massage did.

…

“Some of these treatments were just distinctly made up out of people’s imaginations,” said Dr. Wallace Sampson, clinical professor emeritus of medicine at Stanford University. “We don’t take public money and invest it in projects that are just made up out of people’s imaginations.”

via Studying alternative medicine with federal dollars – latimes.com.

For those who are curious about homeopathy:

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FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull

Helps to determine if immediate CT scan is needed

The U.S. Food and Drug Administration today allowed marketing of the first hand-held device intended to aid in the detection of life-threatening bleeding in the skull called intracranial hematomas, using near-infrared spectroscopy.

via Press Announcements > FDA permits marketing of the first hand-held device to aid in the detection of bleeding in the skull.

But then, wait, said I, is it any good? Apparently Not:

The FDA granted the de novo petition for the Infrascanner Model 1000 based on a review of data comparing results from 383 CT scans of adult subjects with Infrascanner scan results. The Infrascanner was able to detect nearly 75 percent of the hematomas detected by CT scan. When CT scans detected no hematoma, the Infrascanner detected no hematoma 82 percent of the time. The Infrascanner Model 1000, however, is not a substitute for a CT scan.

Anyone considering purchasing one of these based on those numbers? If so, I’ll sell you a random number generator for 1/2 of what they’re asking.

Stated another way, this device will miss more than 25% of intracranial hematomas that are present, and will tell you it’s there when it’s not 18% of the time.

Not ready for prime time. I feel bad for the detailers who are sent out to see this thing, and worse for the patients it’s used on.

Brought to my attention by @EMNews on twitter. (In case you missed it, I’m getting a lot of my bloggable stuff from Twitter. I don’t blog most of what I comment on. Imagine what you’re missing! Get to twitter, and follow me @gruntdoc).

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