Happy Birthday to

…Gruntdoc!  This is the Fifth Anniversary of a blog started on a lark,and continued due to lack of imagination.

Thanks very much to all of you for reading, and I hope to keep going for a long time.


My 4th birthday, for a retrospective of the design.

I wonder if I get to meet John Malkovich now…

Irishdoc on Intern hours

Is there a doctor in the house?: The Hours

Make sure and read to the end, then ask if this is particularly safe.

I remember vividly trying to survive the drive home post-call several times as an intern. I never fell asleep, but I did drive for miles with the parking brake on because I’d forgotten I’d set it, and was so sleep-addled I didn’t recognise it.

Change of Shift 1:18

PROTECT the AIRWAY ? Blog Archive ? CHANGE OF SHIFT, Vol. 1, No. 18

CHANGE OF SHIFT, Vol. 1, No. 18

Well, I’ve been luck enough to reprise my first time hosting Change of Shift on December 14, 2006, and though there were slightly fewer submissions this time around, the writing does Change of Shift justice and is testament to the amazing people out there working long shifts and then coming home only to do more work by blogging about their experiences.

An aside: sites like this make me glad I have a java color-killer (makes black text on a white background), the second down on this page.

A different style of Concierge Medicine

…this time from an Emergency Medicine perspective:

Vail Daily: Doc HollywoodResortMed now employs eight Vail-area doctors and four more in the Aspen area, and their 24/7 service hits the road in three specialized Jeeps. Far from the classical house-call doctor’s black bag, these Jeeps come armed with everything an emergency doctor needs, including IV fluids, meds, oxygen and even a hyperbaric chamber, when necessary.
“We can distinguish between what is routine and what is truly an emergency – with our equipment and training, chances are good we can handle 99 percent of problems in a hotel room or home,” Davis said. “It’s a dramatic shift when you think about it. A guest comes to the valley, and they spend a lot money to be in a resort property. The idea of replacing those moments with a hospital stay or time in a waiting room is not good. This is a good substitution. The idea of watching TV in their comfortable hotel room when the doctor comes to them became very appealing once guests became aware that the service exists.”

It’s written by one of their entertainment reporters, which (I suppose) explains all the name dropping, though I’d have thought discretion would be the better part of valor in such a business.

Change of Shift 1:15



Frying pan to fire

Today the charge nurse approached me with an unusual question: “Did you prescribe ‘marinol‘ to a patient”?

me: No.  I’ve never written a prescription for it in my life.

Charge Nurse: “What is it, anyway?”

me: It’s THC, the active ingredient in marijuana.  Why?

CN: “There’s a parole officer on the phone, who says that one of their parolees tested positive for marijuana, but they have a prescription for marinol from you to explain it.”

me: Nope.  Not from me.


The prescription was faxed to us.  Yes, it’s written on one of our current Rx pads, yes my name is circled.  No, it’s not my hand writing or my signature, and the DEA number is way off (and doesn’t follow a basic convention every pharmacist would look for, and which I won’t give away here).

CN: “The parole officer wants something written out that this prescription wasn’t written by you.  They wanted it typed on letterhead, but I said we were a little busy for that.” 

me: (Again noting how our charge nurses are smart and save me a lot of work): Okay.  Handwritten note disclaiming the forged prescription goes off to the Parole Officer.


Now this parolee has two problems, at least: testing positive, and having a forged prescription for a Schedule III drug.

Merry Christmas

To you and yours!


(Photo originally here; be sure to check out the captions in the comments).

Speculation in a Vacuum

I have no knowledge of what has befallen Senator Tim Johnson (D, SD), and there’s a disturbing vagueness to the lack of released diagnosis to date.

From the CNN article, the only part to describe the clinical picture:

Johnson spokeswoman Julianne Fisher said the senator was in the Capitol on Wednesday morning conducting a conference call with South Dakota reporters when “his speech pattern slipped off.” (Listen to Johnson’s difficulty speaking during a WNAX radio interview — MP3, 749 kb)

Fisher said the senator was able to walk back to his office in the Hart Senate Office Building, then began having problems with his right arm. He thought he was all right, she said, and went to his desk, but came out a few minutes later and “it was apparent he needed help.”

Several hours later he’s in the OR.  Subdural hematoma springs to mind given the description of both a speech and one-sided arm difficulty, but only time will tell.

Update @ 8:31AM:

A U.S. Capitol physician says Sen. Tim Johnson underwent successful brain surgery for an arteriovenous malformation, a condition which causes arteries and veins to grow abnormally large.

That would do it, as well.

Nanomedicine Gel to Stop Hemorrhage

I’ve been reading about nano this-and-that, and now there’s some progress in my field: bleeding that Needs to Stop.

New Scientist Tech logoSwab a clear liquid onto a gaping wound and watch the bleeding stop in seconds. An international team of researchers has accomplished just that in animals, using a solution of protein molecules that self-organise on the nanoscale into a biodegradable gel that stops bleeding.

If the material works as well in humans, it could save thousands of lives and make surgery far easier in many cases, surgeons say.

Molecular biologist Shuguang Zhang, at the Massachusetts Institute of Technology in the US, began experimenting with peptides in 1991. Zhang and colleagues at MIT and the University of Hong Kong in China went on to design several materials that self-assemble into novel nano-structures, including a molecular scaffold that helps the regrowth of severed nerve cells in hamsters (see Nano-scaffolds could help rebuild sight).

Their work exploits the way certain peptide sequences can be made to self-assemble into mesh-like sheets of “nanofibres” when immersed in salt solutions.

In the course of that research they discovered one material’s dramatic ability to stop bleeding in the brain and began testing it on a variety of other organs and tissues. When applied to a wound, the peptides form a gel that seals over the wound, without causing harm to any nearby cells.

Ed Buchel, who teaches general and plastic surgery at the University of Manitoba, in Winnipeg, Canada, sees equal potential for treating trauma and burns. “If this works as well on humans as it does on rats, it’s phenomenal,” he says.

Still, they caution that extensive clinical trials are needed to make sure the materials work properly and are safe. The MIT researchers hope to see those crucial human trials within three to five years.

Their research will appear in the 10 October 2006 edition of online journal Nanomedicine.

This is a far-horizon thing, but if it works as described it’d help, for a zillion or so patients and their doctors.

via Slashdot

Change of Shift #8

is up, here: cooltext190913551.jpg

Too much testosterone kills brain cells: It’s Official

via CNN:

Health NewsWASHINGTON (Reuters) — Too much testosterone can kill brain cells, researchers say, in a finding that may help explain why steroid abuse can cause behavior changes such as aggressiveness and suicidal tendencies.

Tests on brain cells in lab dishes showed that while a little of the male hormone is good, too much of it causes cells to self-destruct in a process similar to that seen in brain illnesses such as Alzheimer’s.

This is one of those truisms of Trauma: Testosterone is a Neurotoxin.  Now it’s been proven. 



The Patient of the Year

(This is not meant in any way to disparage my patient.  I post this so you get an inkling of the challenges facing the terrifically good-looking but otherwise ordinary Emergency Physician during a shift).

A patient presents to the ED, from an assisted living center.  The Chief Complaint on the triage form says ” ? ”  I’m game.  Into the cubicle we go.

“Tell me the story”, I say.  Blank look.  Look again at the triage form.  ‘Patient is deaf’ it says.  Also, ‘history of schizophrenia, and CHF’.  Ooh.  No medication list. 


So, a good PE is completed, and a lot of pantomime is done.  The interpreter is called.  And, a wait ensues for said interpreter, though the lab workup continues.

The interpreter comes, sleepy but competent.  After a while signing with the patient, I get something unexpected: ‘this isn’t making any sense’.  What do you mean?  ‘I mean the answers have nothing to do with the questions, and there’s a lot of things that make no sense’.

Ask if the voices are louder than normal.  ‘Yes’, and the interpreter is relieved, as now it’s all making sense, at least for them, if not for the patient.  Does patient think their voices are out of control?  ‘Yes’ says interpreter, clearly relieved that things make sense now.

Labs are returning, and it’s not good news.  Elevated troponin could (probably does) indicate cardiac injury.  ?Chest pain? is asked, and there is no answer that makes sense, per the interpreter.  The EKG looks like the chest xray: wide and abnormal, but nothing that makes the clinician panic.

To say the consultants were thrilled with this admission would be an understatement, but not one griped. Amazing.

Coffee May Protect Against Alcoholic Cirrhosis

From Medscape today came several comment-worthy news items, but this is the headliner, and (potentially) effects the most people:

June 13, 2006 — Coffee may be protective of cirrhosis, particularly alcoholic cirrhosis, according to the results of a cohort study reported in the June 12 issue of the Archives of Internal Medicine.

“A minority of persons at risk develop liver cirrhosis, but knowledge of risk modulators is sparse,” write Arthur L. Klatsky, MD, from the Kaiser Permanente Medical Care Program in Oakland, Calif, and colleagues. “Several reports suggest that coffee drinking is associated with lower cirrhosis risk.”

In this study, 125,580 multiethnic members of a comprehensive prepaid healthcare plan who had no known liver disease supplied baseline data at voluntary health examinations from 1978 to 1985. Through 2001, 330 of these members were diagnosed as having liver cirrhosis, including 199 members with alcoholic cirrhosis and 131 subjects with nonalcoholic cirrhosis, confirmed by medical record review. ….

[technical details omitted]

These relative risks for coffee drinking were consistent in different subgroups. Tea drinking was not related to alcoholic or nonalcoholic cirrhosis. Cross-sectional analyses revealed that coffee drinking was related to lower prevalence of high aspartate aminotransferase and alanine aminotransferase levels. The odds ratio of 4 or more cups per day (vs none) for a high aspartate aminotransferase level was 0.5 (95% CI, 0.4 – 0.6; P < .001), and it was 0.6 for a high alanine aminotransferase level, (95% CI, 0.6 - 0.7; P < .001). Inverse relations were stronger in those who drank large quantities of alcohol.

“These data support the hypothesis that there is an ingredient in coffee that protects against cirrhosis, especially alcoholic cirrhosis,” the authors write. “The absent relation of tea drinking to cirrhosis might mean that the relation is less likely due to caffeine than to some other coffee ingredient.”

(emphases mine)

I’ll drink to that!

In the Foothills of Medicine, by Dr. Robert McKersie

In the Foothills of Medicine

I was offered a complimentary copy of Dr. Robert McKersie’s Book "In the Foothills of Medicine", as long as I’d write a review of it. I thought this to be a fair trade, and probably poor judgement on Dr. McKersie’s behalf, as I’m not a professional book reviewer, I’m just a grunt doctor.

It’s an interesting study of becoming a doctor (FP), who came to medicine later in life after a time of being a teacher. His written communication skills are terrific, and he’s also a good storyteller. There are many excellent vignettes of his patient care experiences, and patients who touched him. There’s also a painful chapter about love, a lover and loss that makes me appreciate how brave he was to write about it, and include us in his life.

Dr. McKersie is also involved in Himalayan HealthCare, wherein he travels into the mountains of Nepal and practices medicine there. It’s quite a different life and practice from that we’re used to in the US, and his descriptions (almost) make me want to participate. Clearly he enjoys these working vacations, and it shows in his writing.

The cost of medicine, and a desire for some sort of universal health insurance (and frequent readers know about my feelings there) is a very frequent theme in the book, and frankly it’s a bit of a distraction. On more than one occasion, having involved us in the compassionate care of a patient, there’s ‘money’ sticking its head into the story; in a couple of the stories it’s valid, but in several it’s just jarring. I think one, or maybe two of these mentions would have made the point, and frankly I began to scan ahead to see where the ‘money’ paragraphs were so I could just skip them.

In all, a good book, and I hope he keeps writing. He has a skill for it, and a natural openness into his life and practice that’s good for physicians and patients alike.

Dr. McKersie has a web site, where you might also purchase his book, or read about his other interests. 

CNN: Hospital slapped for transplant bump


Let one patient skip to top of waiting list; rightful recipient dies

LOS ANGELES, California (AP)St. Vincent Medical Center received a rebuke from the national organ-donation network for allowing a patient to skip to the top of the waiting list for a new liver in 2003, bypassing others who were sicker.

It was the first time the United Network for Organ Sharing publicly sanctioned a member.

"It sends a message about the overall importance of patient safety and regard for the public health," the network’s executive director, Walter Graham, said Thursday.

St. Vincent admitted in September that its doctors had improperly arranged for a Saudi man to receive a liver intended for a higher-priority patient. Federal inspectors also found that the hospital removed the rightful recipient from the waiting list without telling him that it was doing so. The man later died.

The rebuke requires the hospital to alert about 4,000 of its patients about the discipline, but it doesn’t prevent it from performing other organ transplants or taking on new patients. Graham said the network stopped short of asking the federal government to suspend St. Vincent’s other transplant programs because it didn’t think patients were in imminent danger.

St. Vincent issued a statement saying it would challenge the sanction in court. The hospital, which closed its liver transplant program in November, argued the action was unjustified because it is now complying with transplant rules in its heart, kidney and pancreas programs.

Most private insurers have already removed St. Vincent from their lists of preferred providers or stopped referring patients there.


Unless you’re a Saudi.