31 March 2011

Annals of crappy medical journalism part XLIV

Going to the Huffington Post for medical information is perhaps comparable to going to Vito Corleone for advice on income tax compliance.  Another prominent blogger refers to is as "that hive of scum and quackery," a lovely and accurate epithet for a media outlet which provides refuge and cover for anti-vaccationists, homeopaths and practictioners of reiki and other such pseudoscientific twaddle. I avoid the HuffPo like the plague.  But, like a moth to the flame, sometimes I can't help myself, and when a facebook friend (and former blogger) pointed to this contrarian article, my interest was piqued and I had to check it out.

Is High Blood Pressure Overtreated? Dr. Dennis Gottfried, Associate professor, University of Connecticut Medical School

First of all, I don't know Dr Gottfried, and I don't want to cast aspersions on him professionally. He might be a faith healer and snake-handler, or he might be a prominent researcher and expert in the field. I have no idea, and other than his questionable judgement in being affiliated with the HuffPo, I don't want to make any judgement on him as a physician or a scientist. 

The media and communications, part, however, is pretty aggravating. As a general-interest publication, the HuffPo is trafficked primarily by people who are, in the medical context, patients. Which means that when they consume medical news they tend to personalize it -- "How does this article relate to me?" It's also true, perhaps unfortunately, that for most news articles, many people read only the headline and the lede and maybe the final paragraph. 

So the take-home message of this article most health consumers will get is this: "Diagnosing and treating hypertension is clearly sound preventative medicine; but, as with so many areas of health care, too much of a good thing is often not good!" and this: "What these studies do show is that lowering blood pressure excessively with medications can be dangerous. The national belief that more and newer in health care always represents improvement is not only expensive, but dangerous. In medicine, too much of a good thing can be bad." Which are absolutely awful messages to send to the general public! It's a public health imperative to educate people of the importance of identifying and controlling high blood pressure, and this article sends a confusing and conflicting message to patients that maybe it's actually a bad thing to control their blood pressure!

Now it's true that the article pays lip service to the importance of controlling blood pressure for most people. But that's a nuance too easily lost, especially when it's in direct opposition to the central thesis of the article -- that too much treatment of blood pressure is bad. It's also true that the author does a nice academic-style review of some recent studies which do, in fact, support this central thesis. But there is a major qualifier which is actually pretty difficult to extract from this article: the applicability of the thesis is solely to a very small selected population of people who already have been identified as vasculopaths. That's a huge caveat, and one which absolutely needs to be clearly and prominently identified in the key parts of this article, especially since it is directed at the general public.

There is a huge difference in the way a physician and a patient read this sort of thing.  A health care provider will (hopefully) evaluate the argument and the data and consider which of the many patients he or she cares for it might be applicable to. The population in discussion is reasonably well identified in this article, and I think most doctors would be able to internalize and use this information clinically. But for general audiences, this is terrible, since most people/patients who read this (who are problby more likely to have HTN than the average reader) may not pick up on the narrow applicability of this study and draw the wrong conclusion as it relates to their own health, that taking their meds or controlling their pressure is maybe not as important as their doctor said, and maybe even harmful. This is all the more possible since the discussion of the research is pretty dense and academic. (I had to read it a couple of times to make sure I had a grip on it, and I am accustomed to reading medical literature.) People have a hard time making sense of conflicting and changing medical science, and this article, written as if for a professional audience but presented in a general publication, only exacerbates that public health challenge. As an editorial in Circulation, I'd have little argument with this piece. As an article in the "Personal Health" section of a mass-market website, it does a grave public disservice.

Take home message: know your audience and make sure your message is geared to be clear and accessible to them.

Seattle Weather

From the incomparable The Oatmeal:

 

Worth clicking through to see the rest.

Regional Variations

I miss China White.

That may seem to be a weird thing to say, but there it is.   I did my residency training back in Baltimore.   Baltimore was at that time in the grips of a terrible heroin epidemic (still is, as far as I know).   The form of the drug distributed there was the highly purified stuff called China White, and its use was incredibly widespread.   It was easily soluble and thus ideal for intravenous use, and we saw the consequences of IV injection constantly -- accidental overdoses, HIV infection, endocarditis, and, most commonly, pyogenic abscesses.

Oh, the abscesses we saw!   They were magnificent things!   Hot and red, exquisitely painful, immediately subcutaneous, often massive and under tension, ready to spurt liters of pus as soon as you touched the scalpel blade to skin.   There was a trick to lancing them with a minimum of fuss -- bringing the yankauer suction in right along with the knife, making a tiny stab wound just big enough for the tip and immediately plunging the sucker into the abscess to evacuate all the pus without creating a huge mess (or a huge stink).   Incredibly satisfying, both in terms of the sheer volume of pus you could get out, and the patients' abject relief and gratitude for the decompression and resolution of pain.  And they healed rapidly enough that the patient could be injecting back into the same site within a week or two.

Amusingly, the anethetic was almost always the worst part of the whole procedure.   They would writhe and holler and weep at the mere approach of the needle.   I recall one man flinching away from the syringe, saying, "I'm afraid of needles."  Incredulous, I asked him, "How on earth can you be afraid of needles?  You inject heroin every single day of your life?"   He responded, in a moment of clarity, "Mostly I'm afraid of needles that don't have heroin in them."

I could write for hours about the bizarre complications we saw of the IV drug use.  The guys who used to shoot centrally -- in their groins and necks.  The x-rays with fifty broken-off needles in the neck (this was caused by patients shooting in the IJ, and nodding before withdrawing the needle, which would then snap off).   The guys who would escape from the hospital with central lines in place and come back with three different organisms growing out of their bloodstream.  The guy who dropped his lung trying to shoot subclavian, and then came back a week later having done it again.

My personal favorite was a young man who came in complaining of headaches.   They had been occurring daily for a week or two, and they sounded migrainous in their nature, but he had never had migraines before.   He freely admitted using IV heroin and cocaine -- speedballing them, which was kind of unusual in that region.   As so many other "shooters" had, he too was out of peripheral veins and had taken to shooting into his jugular.   
"You know the funny thing, doc," he told me, "is that lately, I have had real trouble getting that vein, too, so I've been shooting into the pulse vein in my neck."
I was staggered.   "You've been shooting heroin and cocaine together into the pulse vein?  You mean the carotid artery?"
"Yeah, I guess that's what you call it."
"How long have you been doing this?"
"About two weeks."
"And how long have you been having the headaches again?"
"Now that you mention it, about two weeks."
"OK, I have an idea for you -- it may sound a little crazy but hear me out -- why don't you stop shooting heroin and cocaine into the pulse vein in your neck?  I think that might fix your headaches."
"I dunno, doc," he responded with a straight face, "I was hoping you could just give me a pill for the headaches."

But on the West Coast, they apparently can't get the China White.  Instead, they get an inferior grade of less-pure heroin generally referred to as "Black tar."   Black tar is viscous and difficult to inject.  IV use is quite uncommon -- at least long-term IV use is, since the black tar scleroses the veins rapidly.   The good news is that needle sharing (and thus HIV) is apparently less common out here.   The bad news is that the consequences of intramuscular injection are just nasty.

Instead of the easy and satisfying subcutaneous abscesses, there are these deep abscesses in the muscle bellies.   If the abscess manages to track to the fascial planes, then it travels up and down the affected extremity.  The whole limb gets hot and swollen and tense.   I have seen compartment syndrome from this, though uncommonly.  More often, it needs to be opened and drained in the operating room.   The depth requires the limb to be filleted open, compared to the smaller incisions for the subcu abscesses, and the fact that the muscle bellies need to be opened up guarantees a bloody, messy procedure, which takes a long time to heal.

Worse, the IM injections predispose to necrotizing fasciitis and other bizarre infections.  We've seen several cases of honest-to-goodness botulism over the last few years.   Freaky stuff, and not for the faint of heart.   At least the complications of the China White were well-known, simple to spot, and easy to manage.

Seriously, there've got to be some entrepreneurial distributors out there who can bring China White to the West Coast, right?  Get to work on it!

That's a joke (I think).

 

Originally published April 2009

30 March 2011

Happy Doctor's Day!

From the incomparable Medium Large's feature on why cats are not doctors:



Worth checking out the rest.

At my hospital we got nice little LED flashlights, for some reason.

The suburban lottery winner

I'm lucky enough to work at a place in a lower-to-middle class suburb, which doesn't see too much penetrating trauma. Sure, we have a knife & gun club, like any other town, it's just that ours are a bunch of wussies, relatively speaking. It's rare to have a savage, prolonged beat-down like we saw in the inner city where I trained. There was a ritual there, so I am told, that if you wanted out of a gang you had to subject yourself to a beating which was called a "punkinhead." Each gang member would get to take a couple of shots at your face, and they would hold you up to ensure every member got their licks in. By the end, your face was swollen up to the size and shape of a pumpkin. If you survived, you were out of the gang. I don't know if that was true, but I do know we saw a lot of inner-city youths with incredible facial injuries from these beatings. Where I am now, a fat lip or busted jaw is about the worst we see. And the gunshot wounds in the city were astonishing. On a summer weekend night shift, half a dozen was not uncommon. Chest tubes and thoracotomies became boring enough that we let med students and interns do them (supervised, of course). Now, in our lower-middle class suburban paradise, if we see three gunshot wounds a month, it's unusual, and we probably see as many wound from hunting accidents as we do from actual homicide attempts.

So it was a Big Deal when the medics called to let us know that there had been an outbreak of gunfire at a local nightclub and we should expect multiple casualties. Fortunately, we're all trauma trained and ready and we scurried around preparing for the victims to roll in. I was pretty proud of our response: in five minutes, we had three resuscitation room ready to go.

We were sadly disappointed by the first few victims to roll in. (Did I say disappointed? I meant relieved.) They were fine: flesh wounds only, minor extremity injuries. But, the medics warned us, the next one coming (which happened to be mine in the queue) was hit directly in the left chest. They shook their heads when I asked how bad she looked and said there was a lot of blood at the scene. It sounded bad.

Sure enough, when they got there, the impression was scary. A young woman, flat on the gurney, pale and terrified with a shirt saturated with blood hanging off the sides where the medics had cut it, and one burley paramedic straddling the gurney compressing a trauma dressing against her chest in an attempt to stanch the bleeding. 

We jumped into action. Exposure, IV access, vitals, all that good stuff. I talked to her and she was alert: she told me she had no idea what had happened. She heard some pops and felt something hit her and she fell down. She was healthy, with a three-month old baby and was scared that she was going to die. I reassured her as best I could and we went to work. Sure enough, just above her left nipple was an entry wound. We couldn't find an exit wound or any other injury. A chest x-ray was done to track the bullet in her torso, to see if there was blood in the lung or a collapsed lung or the bullet had crossed to the other side of the chest. Strangely, there was nothing at all. No bullet present, and no evidence of injury. We x-rayed her neck and abdomen, searching for the bullet: nothing. Incidentally, her vitals were fine, and her color had improved after some rewarming and reassurance. Finally, I expored the wound. Bloody (as you would expect in a lactating breast) but it didn't seem to penetrate more than a couple of inches, and that on the outside of the chest. 

Then one of the techs, going through the heap of bloody clothing discarded in the corner, triumphantly produced the bullet. It had apparently stopped after hitting her chest, and fallen out into the lining of her jacket.

And that was it. We washed her wound out, dressed it, observed her a couple of hours and repeated the chest x-ray, and she went home. First time I've ever had a Discharge Diagnosis of: "Gunshot wound, left chest."

The police later explained that the patient's location had been at an extreme range from the shooter, so we figured the bullet's energy was mostly spent by the time it hit her. There was also an icky possibility that it had passed through another victim before hitting her, which would also have attenuated its energy enough that the superficial injury would make sense.

So that's life at the suburban trauma center. Even our gunshot wounds are weak. But wow was she lucky. As she left, she turned and told the nurse that the next thing she was going to do was to buy herself a lottery ticket.

24 March 2011

I want to be a cyborg


We are living in the future, now. I want a robotic exoskeleton. 

 

Pretty awesome adaptive technology for the handicapped, too. So cool.

23 March 2011

Death Panels Forever!

One of the truisms in Left Blogistan, where I frequently hang out, is that "reality has a well-known liberal bias." Fortunately, that matters less to those unfettered by actual facts, a point illustrated today by Senator (yes, really, a US Senator) Ron Johnson who, in a Wall Street Journal op-ed piece performed a reprise of 2009's Lie of the Year: Death Panels wherein bureaucrats ration care:

ObamaCare and Carey's Heart

My daughter probably wouldn't have survived in a system where bureaucrats stifle innovation and ration care.

Some years ago, a little girl was born with a serious heart defect: Her aorta and pulmonary artery were reversed. Without immediate intervention, she would not have survived. [...] If you haven't guessed, this story touches my heart because the girl is my daughter, Carey. And my wife and I are incredibly thankful that we had the freedom to seek out the most advanced surgical technique. The procedure that saved her, and has given her a chance at a full life, was available because America has a free-market system that has advanced medicine at a phenomenal pace.

I don't even want to think what might have happened if she had been born at a time and place where government defined the limits for most insurance policies and set precedents on what would be covered. Would the life-saving procedures that saved her have been deemed cost-effective by policy makers deciding where to spend increasingly scarce tax dollars?

Yes, that dystopian future where we stand aside an allow infants to expire from treatable illnesses would be terrible. It is, incidentally, not the dystopia which we currently inhabit. The dystopia now is one in which 46 million americans do not have access to routine care, and those infants born to parents unlucky enough to be uninsured may receive heroic lifesaving care on a charity basis -- or maybe not, depending on the whims of chance and the severity of their illness. Most hospitals will perform heart surgery on an otherwise dying infant and eat the cost (or retroactively enroll them in medicaid), but if your child has, for example, moderate severity cerebral palsy, good luck getting him or her the intensive physical therapy, occupational therapy, and speech therapy that will be needed to get her functioning at her best possible level. You need insurance to get thigs like these, and sometimes to get lifesaving treatment -- and getting more people insurance is the whole point of the PPACA.

That's the world as it is, until 2014 anyway. It was a terrible decision to defer implementation of the PPACA (aka "ObamaCare") until then, but that's water under the bridge. So am I to take it from Sen Johnson's testimony that at that time we will suddenly be in a situation where the government will be imposing limits on what lifesaving procedures must be covered by insurers? You may be surprised to learn that the answer is ... yes! The funny thing, the insidious lie at the heart of Sen Johnson's heart-tugging testimony, is that the government is setting minimum standards for coverage, not maximum standards. In fact. several republican governors have criticized the standards set by the PPACA as being too high.  Previously, your private insurance, purchased in your behalf by your employer probably had a lifetime limit of how much it would cover -- likely $2 million, though policies vary. If your kid happens to be a cardiac kid, you can blow through that in just a couple of operations and ICU stays. ObamaCare outlaws these lifetime coverage caps, and sets mininum standares as to what insurers must cover, and cost-effectiveness is not part of the equation. Also, ObamaCare bans insurance companies from discriminating against children with pre-existing conditions.

"But wait!" A chorus of commenters are ready to retort, " What about the CER death panels, where the government will pick and choose which therapies to cover?" It is true that this research is going to be done, and likely that it will be utilized in reimbursement decisions in the future. However, the C stands not for "cost" but for "comparative" in which we will try to determine which of multiple treatments for a given disorder is the best. And yes, in a world where health care consumes 16% of GDP, cost should be a component of rational, value-based purchasing. But that assumes that there are multiple accepted treatments for a given condition, and does not in any way imply, as Senator Johnson falsely insinuated, that patients' lives will be weighed and valued by bureaucrats. But like many opponents of the PPACA, Johnson seems to be railing not against what the bill is, but against the bogeymen of what he fears it could someday be. 

Bottom line: the PPACA leaves the commercial, employer-sponsored insurance that about 58% of americans have untouched. It leaves medicare and medicaid essntially untouched, but possibly marginally more efficient. For those on the individual market, it will make insurance radically more accessible. And for those currently uninsured, it either opens the individual market to them, opens the individual market with subsidies, or puts them on medicaid. That's it. Nothing which would prevent a commercially-insured child from getting her heart fixed. 

Oh, and as an aside, Sen Johnson cites some cherry-picked and misleading statistics about the cancer care in the US compared to other countries. I would refer you to The Incidental Economist for an evisceration of that talking point. 

22 March 2011

Internet Detritus

It was a productive day filtering lots of random/amusing stuff on the Internet. 

 

Probably untrue:

iPad2: Wife said "no," Apple said "yes." But in Comic Sans?

 

The 55 best Simpsons newspaper headlines

Historic pictures of opthalmologic disorders. Seriously icky.

 

 

Hideaki Akaiwa is the Badass of the Week, and for good reason:

Hideaki Akaiwa, concerned for his family, rushed out of his office in time to see his city completely submerged under an obscene ten feet of water that buried everything from houses to businesses. He ran to the high water mark and stared helplessly into the sprawling lake that once used to be his home.

But it gets even worse. Hideaki's wife of twenty years was still buried inside the lake somewhere. She hadn't gotten out. She wasn't answering her phone. The water was still rising, the sun was setting, cars and shit were swooshing past on a river of sea water, and and rescue workers told him there was nothing that could be done – the only thing left was to sit back, wait for the military to arrive, and hope that they can get in there and rescue the survivors before it's too late. With 10,000 citizens of Ishinomaki still missing and unaccounted for, the odds weren't great that Hideaki would ever see his wife again.

For most of us regular folks, this is the sort of shit that would make us throw up our hands, swear loudly, and resign ourselves to a lifetime of hopeless misery.

But Hideaki Akaiwa isn't a regular guy. He's a fucking insane badass, and he wasn't going to sit back and just let his wife die alone, freezing to death in a miserable water-filled tomb. He was going after her. No matter what.Regardless of how he came across this equipment (borrowing, stealing, buying, beating up a Yakuza SCUBA diving demolitions expert, etc.) Hideaki threw on his underwater survival gear, rushed into the goddamned tsunami, and dove beneath the rushing waves, determined to rescue his wife or die trying. I'm not exactly sure whether or not the dude even knew how to operate SCUBA equipment ... Hideaki wasn't going to let a pair of soul-crushing natural disasters deter him from doing awesome shit and saving his family. He dove down into the water, completely submerged in the freezing cold, pitch black rushing current on all sides, and started swimming through the underwater ruins of his former hometown.

Surrounded by incredible hazards on all sides, ranging from obscene currents capable of dislodging houses from their moorings, sharp twisted metal that could easily have punctured his oxygen line (at best) or impaled him (at worst), and with giant fucking cars careening through the water like toys, he pressed on. Past broken glass, past destroyed houses, past downed power lines arcing with electrical current, through undertow that could have dragged him out to sea never to be heard from again, he searched.

Hideaki maintained his composure and navigated his way through the submerged city, finally tracking down his old house. He quickly swam through to find his totally-freaked-out wife, alone and stranded on the upper level of their house, barely keeping her head above water. He grabbed her tight, and presumably sharing his rebreather with her, dragged her out of the wreckage to safety. She survived.

Yowza.

Lion parents can be jerks, too.

Admit it -- you laughed, didn't you?

21 March 2011

The Graveyard

Bongi is an amazing writer, and if you haven't, I strongly urge you to read his latest post, titled "The Graveyard."

I imagine that a huge number of doctors know exactly what he means. I remember being told by a surgeon, while I was in medical school, that "you're not a real doctor until you've killed someone." I thought at the time (and still think) that there was a puerile bravado behind that admonition, but there is also a grain of truth. I have my own graveyard. Curiously, not all of its inhabitants are dead. They are the cases where I screwed up, or, charitably, cases that went bad where I feel that maybe I could've/should've done things differently.

The missed SAH

The missed DVT/PE

The missed AAA

The missed Aortic dissection

The missed MI

I remember them all, clearly and in detail. I remember which room each one of them was in while they were in the ER. (seven, eleven, ten, nine, five) I remember what they looked like. I remember what the ECGs looked like. Like Bongi, I tend to blame myself even when the lawyers and quality committees have exonerated me. I should count myself lucky that after ten+ years in practice the body count is so low (at least as far as I know). Rationally, I can see that these cases were not my fault, and in fact I am comfortable defending them, if I had to, which I am glad to say that I have not. But I carry the scars. The Aortic aneurysm died in front of me after a three-hour battle for stability. The dissection I found about the next day when I came back to work (she survived, miraculously). The horror of realizing that you were wrong in your assessment of this patient, and he or she died because of it is really something. It changes you. You carry it with you, on some level, every single day.

This is, I think, what the surgeon meant when he said "you're not a real doctor until you've killed someone." I thought he was full of bravado and being cavalier about the fact that your patients will die sometimes; I thought he was glorifying the toughness that some surgeons so revel in. Maybe he was; I don't know. But I have learned this -- it changes you, and until you have to go home and lay in your bed and consider how that person died and whether it was your fault, it's hard to understand. But it is true, that you are not really a doctor until you have confronted and surmounted that moral burden. Some never do. Some practice in terror of that moment, and some leave the profession because they cannot bear that moral responsibility. Some become jaded and cynical and try to blind themselves to the consequences by dehumanizing their patients (a failing particularly easy for ER docs to succumb to). Most of us don't talk about it -- especially surgeons, which is one reason to highly commend Bongi for putting it out there so starkly. I play at being cavalier in the ER; it's a facade, my clinical persona. But the memory of these cases where I was so catastrophically wrong also keeps me humble (yes, really) and keeps me alert to the possibility that I might just be wrong again, reminds me to keep an open mind. I like to think this is wisdom, hard earned.

I don't want to seem in any way like I am looking down on my colleagues in specialties with low mortality rates. They're doctors as much as I am. I always hated the "It's a black thing, you wouldn't understand," or the idea that you couldn't really understand what it is to have kids until you have your own. I don't like that sort of exclusionary thinking. But wisdom comes in part from experience, and experience forms us. So I won't say that someone cannot understand the weight of this responsibility until they have gone through it. But I will say that I am a different person now for having done so, and I understand things differently for it.

Well done, Bongi, for illustrating it so eloquently.

18 March 2011

Happy Match Day

Good Luck to all the med students who will be finding out their fates today!

 

A nice reminiscence from ScutMonkey.

17 March 2011

Uisce beatha -- Water of Life

 

Happy St Paddy's Day!

And remember, if your beer is light enough to dye green, it's too light to drink today! Have a Guinness instead.

16 March 2011

The Value of the Physical Exam

I've remarked in the past how rarely I ever learn anything useful from physical exam. It's one of those irritating things about medicine -- we spent all that time in school learning arcane details of the exam, esoteric maneuvers like pulsus paradoxus, comparing pulses, Rovsing's sign and the like. But in the modern era, it seems like about half the diagnoses are made by history and the other half are made by ancillary testing. Some people interpreted my comments to mean I don't do an exam, or endorse a half-assed exam, which I do not. I always do an exam, as indicated by the presenting condition. I just don't often learn much from it. But I always do it.

The other day, for example, I saw this little old lady who was sent in for altered mental status. There wasn't much (or indeed, any) history available. She was from some sort of nursing home, and they sent in essentially no information beyond a med list. The patient was non-verbal, but it wasn't clear if she was chronically demented and non-verbal or whether this was a drastic change in baseline. So I went in to see her. I stopped at the doorway. "Uh-oh. She don't look so good," I commented to a nurse. As an aside, this "she don't look so good" is maybe 90% of my job -- the reflexive assessment of sick/not sick, which I suppose is itself a component of physical exam. But I digress. Her vitals were OK, other than some tachycardia*. Her color, flaccidity and apathy, however, really all screamed "sick" to me. Of course, the exam was otherwise nonfocal. Groans to pain, withdraws but does not localize or follow instructions. Seems symmetric on motor exam, from what I can elicit. Belly soft, lungs clear. Looks dry. No rash. 

Sigh. Probably another case of urosepsis. Sorry, I mean UTI with sepsis. Boring, and unsatisfying. Let's scan her and cath her and lab her and see what shows up. Let me just take a look at her legs and make sure there's no cellulitis or anything there. Nope, but boy she really groaned when I moved that leg, didn't she? Weird. Seems that left hip hurts her when I push on it. Did she fall out of bed? Maybe she's got a broken hip. Is there a bump on her head? That would explain the altered mental status. Nope. So I flip up her gown to look at the hip better, and I was surprised to see a bright red rash all around her leg and pannus (she was quite large). Huh. Here we go -- she has a rip-roaring cellulitis. That would explain the altered mental status quite nicely. Good. I'd better take a look at her backside, though. She might have a pressure sore there that could be the source, and we have to document that it was present on admission. The nurses glared at me a bit, but we got a team together and rolled her on her side so I could examine her sacrum. No pressure ulcer, and I was about to let them roll her back, when I noticed something -- "Hey, what's that?"

It was a little dark area, like a bruise, just the size of a quarter, on the back of her thigh.  But it wasn't quite like a bruise -- it was too sharply demarcated, and too dark, almost black. I poked at it, but she didn't groan, and the skin was intact.  Weird. It was involved in the cellulitic area, though. 

I didn't like it. So as I put in the orders I decided to add on a CT scan. Shortly afterwards, the labs started to come back, and it was clear this was looking serious. White count of 22,000. Glucose 950. Creatinine 3.5.  All bad. Then the call from the radiologist**. I pulled up the images:

necfasc3

necfasc2

necfasc
Uploaded with Skitch!

There was extensive air all through the soft tissues of the thigh, tracking to the perineum and the abdominal wall. Aha! Now this made perfect sense. She had necrotizing fasciitis, commonly known as the "flesh eating bacteria!" This is a true surgical emergency, and indeed she got a very big surgery. The whole area involved simply had to be excised, and in such a sick patient, that's a huge operation, with a very high mortality. When the famliy eventually showed up, I prepared them with the "she may very well not survive" talk. (And, yes, it turned out this was a dramatic change from her baseline level of function.) To everyone's great surprise, she did pull through the surgery (and the repeat surgeries), and last I saw was getting prepped for discharge to rehab.

The take home point here, really, was that the physical exam, while a rote and generally unrevealing exercise, simply cannot be skipped. This lady had no crepitance -- the crackling underneath the skin that is classically the hallmark of subcutaneous gas. I think she was just too fat, and the thigh too tense, and maybe the air too widely disseminated. If I had not taken the time to look at her backside, I would never have seen the black spot that clued me into the fact that this was more than a routine cellulitis. Had I sent her to the floor on antibiotics, she would have died. This is not at all to be taken as a recantation of my original thesis: in 99% of cases, I learn little to nothing from the exam. She just happened to be in the 1% that actually had a critical finding, which proves the corollary to my thesis, that despite the seeming pointlessness of exam, you still have to do it. 

 

 

* pro tip for Emergency Medicine interns: respect tachycardia.

* pro tip #2: the radiologist never calls to discuss the fortunes of your local sports team, or a pleasant surprise he experienced in the market. It's always Somethign Bad when the radiologst deigns to speak directly to the emergency physician.

15 March 2011

Surgeon performs self-appendectomy (50 years ago)

Wow. I didn't know this ever actually happened:

Antarctica, 1961: A Soviet Surgeon Has to Remove His Own Appendix

I worked without gloves. It was hard to see. The mirror helps, but it also hinders -- after all, it's showing things backwards. I work mainly by touch. The bleeding is quite heavy, but I take my time -- I try to work surely. Opening the peritoneum, I injured the blind gut and had to sew it up. Suddenly it flashed through my mind: there are more injuries here and I didn't notice them ... I grow weaker and weaker, my head starts to spin. Every 4-5 minutes I rest for 20-25 seconds. Finally, here it is, the cursed appendage! With horror I notice the dark stain at its base. That means just a day longer and it would have burst

 

More complete case report here in the BMJ.

11 March 2011

The iPad and Medicine

The folks over at iMedical Apps had a point-counterpoint the last couple of days, on whether the iPad or Droid tablet devices would come to dominate the medical industry. Here's the argument for the Droid, and here's the iPad's case. I'm not sure there will be a clear "winner" in the sense that Windows has come to have a near-exclusive lock on the desktops within health care enterprises. Rather, there will be co-existence, with some developers/vendors choosing one platform and others, well, you get the idea.

It is clear, however, that currently Apple has the inside track, and in some cases that can be decisive. The iPad is already in existence, mature both from hardware and software perspective, widely distributed, and insanely popular. The Droid counterparts do not yet exist, per se. Honeycomb, the Android 3.0 software, is just now being released, and the Xoom, which may in the end be a worthy competitor, was just released with a still-incomplete feature set. The early adopters in healthcare, including many major insitutional players, are already deploying iPads through their organizations, and developing the software that can run on them. The race is not won based on the start, but an early advantage in the market (and in the mind-share of developers) can have long-term consequences.

OS integrity is another factor that may be a significant advantage for the iPad. From reports (I've never used Droid at length), the OS is buggy and highly crash-prone, whereas the iOS is a mature platform which is ultra-stable. And the walled-garden approach that Apple favors, which admittedly closes the platform to some developers, also provides better integration and interoperation of third-party apps. The relative lockdown of the platform and the resultant stability might also be a factor in the decision for hospital IT departments to go with the iPad.

Enterprise support is one area where Apple has notoriously failed over many years, and may be its achilles heel in this competition. While the iPad OS does contain a number of enterprise-friendly features, it's not clear that the purchasing departments for hospitals will overcome their long-help antipathy for Apple, and not clear whether Apple will develop the support systems necessary to really compete in the corporate environment.

Lord knows which way things will go. It's not clear to me that any tablet device will become as indispensible as some evangelists believe it will. Neither the iPad nor any competitor excels as a data input device to the standards that would be necessary for bedside charting. It may be a handy reference device to carry on rounds, to access and review clinical data, but even then, the ubiquity of desktop terminals in the hospital environment renders that less critical. If you gave me a tablet device which was fully integrated with my EMR, I'm not sure I would have much use for it in the ER. For practitioners who rove all over the hospital I can see it being more useful, but pending the development of EMR portals which are wildly superior to any that exist now, I am dubious that a table will ever be the primary input device for clinicians' charting.

08 March 2011

Annals of Crappy Journalism, part XXVII

So I saw the headline in my inbox today as part of my daily "news" update from ACEP:

and I thought to myself, "what in hell is going on in California?" I mean, I know it's all locusts and rivers running red with blood what with the budget crisis and the balance billing law and the mandatory nursing ratios, but I thought someone for sure would have told me that 20% of their patients were now walking out of the ER without being seen. I mean, I know people who work in California, and none of them have mentioned that they are living in a post-apocalyptic end time. So I clicked through to the article linked, a place called "Healthday.com":

Fortunately, there was a citation, of sorts, to the current article published in the Annals of Emergency Medicine (subscription required). I eagerly clicked over and read the following:

We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%.

So... median 2.6%? That's, uh, not too bad. We do better. Yay us? But it's not 20% either. So what's the deal with the breathless headlines? Oh, I see, 20% was the max, at ONE hospital. Yeah, that's pretty bad. But it doesn't quite jibe with the breathless headlines implying the problem is state-wide, does it?

So, it's a decent article, better than the dreck they often publish as "research," but I can summarize it fairly easily: blah blah blah, poor people at underfunded hospitals get shitty service, notify the press! It's completely unsurprising, an example of the category of EM literature I refer to as "proving the intuituvely obvious." There is an interesting corollary that they did not comment on -- that funded patients are much more likely to leave without being seen than uninsured/medicaid patients. This is in part because funded patients have higher expectations of customer service, and in part because funded patients are more likely to have other avenues to access care (i.e. a primary care doctor or specialist). But I digress. Yes, it's an important article because it does quantify the existing problem. But healthday's writer (or, more precisely their editor who wrote the headline) completely failed to understand the statistics and now this inaccurate statistic is being spread all over. And I'm annoyed.

Yeah, I know, I'm about six weeks away from yelling at the kids to get the hell off of my lawn.

07 March 2011

Austerity rules, baby!

I'm hoping to be able to get back into blogging a bit now that life is edging back ever-so-slowly towards normal, albeit an uncommon and rarely used sense of the word "normal." The new normal, anyway.  I haven't been quite absent from the blogosphere over the past few weeks and months; I've still managed to keep up a brisk skim of posts and headlines. I would read something interesting and think, out of reflex, "Oh, that's gotta go on the blog," but then I'd get distracted by a shiny object and forget about it.

So I'll start with something easy and near to my heart; it combines Emergency Medicine, economish, and politics. You may have heard about the budgetary tussles ongoing in DC. The newly-elected tea partiers in the House are pushing their leadership to reduce the deficit by cutting some $61 Bn from non-defense discretionary spending this year. Now, this may surprise some of you, but I have a modicum of sympathy for this. I've always been a budget hawk and I thought Clinton's greatest legacy was the budgetary surplus he bequeathed on the nation. Sadly, the current plan is puerile -- extend tax cuts and write off the revenue component of balancing the budget, ignore defense spending, and indiscriminately slash spending across the board. It's pathetic. And that's just in conception, in the abstract -- bear in mind that real, specific cuts in spending are way tougher to swallow than the theoretical cuts the cognoscenti talk about.

Consider, for example, Poison Centers.

There are 57 of them nationally. Turns out they're funded by the states, federal funding, and charitable donations. I did not know that. I just assumed that they would always be there, like I assume that when I call 911 a professional dispatcher will pick up the phone. In our state, a couple of years ago, the Governor slashed the funding for the poison center, in a desperate effort to produce an all-cuts balanced budget. This nearly shut the service down altogether, and it was only through a last-minute partial reprieve and a reduction in services that the service remained open at all. If I recall correctly, the medical director is working without a salary still.

So now, I see this in the lame-stream media (NYT):

PENNY AND POUND FOOLISH: Cutting Poison Control

PRESIDENT’S F.Y. 2010-11 REQUEST: $29 MILLION

HOUSE VOTED: $2 MILLION

Eliminating nearly all the money for poison control centers would save $27 million — not even a rounding error when it comes to the deficit. Yet it is so foolish that it perfectly illustrates the thoughtlessness of the House Republican bill to cut $61 billion from the budget over the next seven months.

The nation’s network of 57 poison control centers takes four million calls a year about people who may have been exposed to a toxic substance. In three-quarters of all cases, the centers are able to provide treatment advice that does not require a visit to a hospital or a doctor, saving tens of millions of dollars in medical costs.

While a single visit to an emergency room can cost hundreds or thousands of dollars (often paid for by the government), a call to a poison center costs the government only $30 or $40. A study in the Journal of Medical Toxicology estimated that the poison centers saved the State of Arizona alone $33 million a year. Louisiana eliminated its centers in the 1980s but restored them when it realized how much money they saved.

The centers, which collect poison reports, can also act as an early warning system for pandemics or large toxic exposures, allowing a quick response.

The federal government pays about 20 percent of the cost of the centers, with states, cities and philanthropy picking up the rest. Many strapped state and local governments have cut back their financing, and experts say that the virtual elimination of federal money would force many centers to close and sharply damage the effectiveness of the national network.

History repeats itself as farce, and tragedy.

The take-home point, of course, is not that budget cuts are inherently evil or to be avoided. It's that they're hard. Federal money goes to services which are essential (or at least in this case, cost-effective). Federal money goes to services that are popular. Federal money goes to services with a powerful constituency. If the budget is ever to be balanced, it will require hard and unpopular choices, including tax increases, cuts in services, cuts in defense and possibly cuts in entitlements. But to just go through the budget and essentially zero-out critical services is either unserious or nihilistic, either of which would, sadly, be a reasonable description of the process we are seeing to date.

Oh, in case Google brought you here because you searched for for the Poison Center phone number: it's 1-800-222-1222