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1209717_19610439The focus of this web site is medicine. In this blog, you’ll read about patient stories. The situations have been changed to be HIPAA compliant. Factual statements may or may not be true. I may change ages, gender or presenting complaints about patients. I may even entirely make up complete patient encounters from my fertile imagination. Trust me, if you think I’m writing about you, I’m not. There are billions of people in this world and readers send me stories about patients all the time. It isn’t you.
You’ll also read a lot about health care policy. I may throw in posts about life lessons, computers, and will even throw in family stories once in a while. If you’re looking for articles about politics, sports, or celebrities, you’re in the wrong place – unless the topics have some relationship to medicine.
If you want to add a guest post or to cross-post something from your blog, or if you have a patient story you want me to write about, e-mail me. See more information in the “About Me” page.

Healthcare Update — 12-6-2013

A couple of interesting articles on how changing our microbiome may help cure our ills. Fecal transplants have been shown to cure patients suffering from Clostridium difficile infections. Seres Health is testing the first pill containing live bacteria to treat C. difficile and is developing other live bacterial treatments for “inflammatory and metabolic diseases.” Latest battle against antibiotic resistant organisms pits viruses against resistant bacteria. A protein called “0.4” … I’m calling it “.4” to tick off the Joint Commission … was found to kill many of the bacteria resistant to antibiotics such as clostridium difficile, N. gonorrhea, and one of the superbugs called carbapenem resistant Enterobacteriaceae. Now we just need to make sure that the viruses and/or proteins don’t make humans sicker than the bacterial infections. No, it’s not your menstrual period. When woman was involved in car accident, police officer noted that she was bleeding from her vagina. Initially, the woman stated that she was on her period, then an investigation at the jail showed that she had a broken crack pipe and a capped syringe in her hoo hah. She was brought to the ED, evaluated and released. The police actually booked the broken crack pipe into evidence. I’m just going to sit back and smile about all the comments I could make right now, but the winner in the comment section to the article was “Now THAT’s a crack pipe.” Some people would call it a waste of good vodka, but one commenter to a medical column noted that a spray containing half vodka, half water, and a few drops of orange essential oil works well for itchy rashes. I almost erased this this entry after asking myself why the hell I even care about what some random reader thinks will cure itchy rashes, but then I started thinking about a Russian surgery resident who used to smell like vodka and used to harass Mrs. Whitecoat and tell her “You look EXCELLENT” just about every day before I married her and it just made me laugh. So you have to suffer through my word association memories. Sorry about that. And if you decide to spray some diluted Stoli on your pits and it does work, drop me a note. Miracle surgery. First face transplant patient speaks out about his success. Seeing this transformation is remarkable. How many patient harms are associated with hospital care each year? If you believe the Institute of Medicine rhetoric, that number is as high as 98,000. However, this new research says the 98,000 number is a gross underestimate. These authors state that 400,000 patients per year die from “preventable harm” and that 4 million to 8 million patients suffer “serious harm” related to their hospital care. Putting these numbers into perspective, CDC data states that there were 35.1 million discharges in the US in 2010. I’m assuming that there were roughly that many admissions, since you can’t be discharged without being admitted. That would mean that one in every hundred patients discharged from a hospital dies from a “preventable harm” and that up to one in every four patients discharged from a hospital has a preventable “serious harm.” If this is true, then the obvious answer is to outlaw the practice of medicine. It kills too many people. If you’ve ever published a paper with Elsevier, think twice before trying to make it available to others. Elsevier is sending takedown notices to authors who try to make their work available to the public. Read your submission agreements carefully … and consider publishing your papers somewhere other than Elsevier. Some obligatory UnAffordable ...

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What’s the Diagnosis #18

A 51 year old male presents with chest pain and exertional dyspnea for the past 24 hours which began a week after having a trimalleolar ankle fracture repaired. Chest x-ray shows a right middle lobe infiltrate. WBC is 18.2. CPK is 180 (normal). Troponin is 0.9 (cutoff for acute MI is 0.64). EKG is shown below (you can click on the image for a larger view). What’s the diagnosis? What is the treatment? Answer will be posted in the comments section in a couple of days. —————————— I’m making full blog posts available to the RSS readers and newsfeeds to make them easier for subscribers to read … without having to visit the blog. Want to help support this blog? Check out the new 2014 Tarascon Pharmacopeia. Tarascon Pocket Pharmacopoeia 2014 Classic Shirt Pocket Edition If you have trouble with the print size like I sometimes do, then you can also preorder the Tarascon Pocket Pharmacopoeia 2014 Deluxe Lab-Coat Edition Although printed a couple of years ago, I also keep this book in my pocket as well Tarascon Pediatric Emergency Pocketbook (Rothrock, Tarascon Pediatric Emergency Pocketbook) I put packing tape over the covers of the books and wrap it around to the inside surface of the covers to keep the books in good shape. This blog gets a small percentage of every purchase you make on Amazon when you visit Amazon’s site through these links. Thanks!

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Giving Thanks 2013

From www.morguefile.com (http://mrg.bz/URAZp9)

I worked in the ED last night and woke up a little while ago. I get to go back to work tomorrow morning. But today I get to spend relaxing with my family, watching a good movie by the fire, drinking cider, and eating turkey. In our home, we try to use Thanksgiving as a time to reflect upon the things in our lives for which we are thankful. We make all the kids write down a few things that they are thankful for and we talk about them at the dinner table before eating. The younger kids are always thankful for their personal possessions and their family. I try to expand upon specific ways that I’m thankful for our family in order to get everyone to think about what it means to be a family. I tell them how thankful I am that they are growing up to be such amazing young adults. I love to see how they develop empathy and help other people and animals. I love to see their good grades and hear from their teachers how they wish they had a class full of kids just like mine. This year we decided to do something special to help other families. We’re driving to one of the areas damaged by the tornadoes a couple of weeks ago and are bringing as many donations and supplies as will fit in our trucks to help some friends whose homes were destroyed and damaged. I also decided to get a bunch of inexpensive MP3 players, load them up with old radio broadcasts from radiolovers.com and give them to some of the elderly patients in the hospital after my shift tomorrow. May not be the latest iPad, but hopefully it will make some people smile. I looked through my other Thanksgiving posts from throughout the years and was going to link to them, but many were taken offline with my old blog. I dug up my first, and favorite, reflection on Thanksgiving and have posted it below. Enjoy the time with your friends and families … and have a safe and happy holiday! Oh, and just like it wouldn’t be a real Christmas without thinking about the Red Ryder BB gun, it wouldn’t be a real Thanksgiving without being able to view the “greatest turkey event in Thanksgiving day history” courtesy of WKRP in Cincinnati. ——————————– Giving Thanks Initially posted November 23, 2007 There are many things I have to be thankful about this year. Since my family is away visiting relatives while I stay home to work in the ED, we can’t go around the table and tell each other what we are thankful for, so I’ll post my thanks this year for the world to see. I am thankful for my family. Twenty years ago in my wilder years I probably would have laughed at someone who said that. It was all about me back then. But now the smile from my child’s face and a kiss on the cheek can instantly erase a whole day’s worth of frustration at work. Sometimes I lay awake at night in bed just watching my wife sleep and thinking how lucky I am to have her with me. Even as I sit here typing this alone, I know that I am not alone. I can’t imagine the torment that families go through being away from their loved ones who are serving our country overseas. I pray for the fast and safe return of each and every one of our brothers, sisters, mothers, fathers, sons, daughters, and those who have no family ...

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Diabetic Eye Problems

One of my goals in updating this blog was to create some informational posts to help patients understand common medical problems. When the National Eye Institute e-mailed me about posting an article on diabetic eye disease, I thought it was a good opportunity to do another such post. Diabetic retinopathy is the most common cause of diabetic eye problems and is a leading cause of blindness in adults. Diabetic retinopathy affects a significant proportion of patients with diabetes: 38% of diabetic patients in this study, 26-36% of diabetic patients in this study, 27-36% of diabetic patients in this study, and 28% of patients over age 40 with diabetes (about 7 million people) according to NEI estimates. If you think of the eye as a movie projector, the outside world is the movie being projected (the large red arrow in the first picture below), the lens is the camera lens (yellow in the picture), and the back or the eye (the retina) is the movie screen (grey area to which the three red arrows are pointing). Diabetic retinopathy is caused by damage to the blood vessels in the retina throughout the back of the eye – which damages the “screen” upon which our brains view the world around us. The resulting image to our brains (as shown in the second picture from the National Institute of Health) is blurry with multiple blind spots – as if someone had burned holes in the “movie screen.” Treatment of diabetic retinopathy involves first controlling one’s glucose levels. If good blood sugar control isn’t sufficient, doctors can use a laser to coagulate some of the damaged blood vessels in the back of the eye. After laser surgery, the back of the eye has many small laser burns (see the white spots on the third picture) which limits the overgrowth of blood vessels. This is a simplistic explanation of a complex problem and an eye doctor can explain it in more depth. The bottom line, and the point that the National Eye Institute wanted to make, was that regular eye exams in diabetic patients can help find and treat any diabetic vision problems at an early stage when the prognosis is better. The message from the National Eye Institute is below. Set Your Sight on Healthy Vision if You Have Diabetes If you have diabetes, your doctors most likely have told you to keep your blood sugar under control through diet, exercise, and proper medication. But did you know that you also need a dilated eye exam at least once a year? A dilated eye exam is when an eye care professional dilates, or widens, the pupil to check the retina in the back of the eye for signs of damage. All people with diabetes, type 1 and 2, are at risk for vision loss, but certain groups are at higher risk: African Americans, American Indians/Alaska Natives, and Hispanics/Latinos. The longer a person has diabetes, the greater the risk of diabetic eye disease, which includes the following: •       Cataract (Clouding of the lens of the eye) •       Diabetic Retinopathy (Damage to the retina) •       Glaucoma (Damage to the optic nerve) In November, when National Diabetes Month is observed in the United States, the National Eye Health Education Program (NEHEP) of the National Eye Institute (NEI) recommends that all people who have diabetes reduce the risk of vision loss from the disease by having a comprehensive dilated eye exam at least once a year. “Half of all people with diabetes don’t get annual dilated eye exams. People need ...

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Healthcare Update — 11-25-2013

Also see more healthcare related news from around the web at my other blog over on EPMonthly.com American College of Emergency Physicians threatens board certification of any physician who provides medical care in a non-emergency setting. If that fake headline left you scratching your head, so should this one: American College of Obstetricians and Gynecologists threatens board certification of gynecologist who treats men for anal cancer. Even though the diagnosis and treatment of anal cancer in men is similar to the diagnosis and treatment of cervical cancer in women, and even though ACOG’s decision will significantly affect studies on treatment of anal cancer, ACOG sees no “compelling reason” to change its mind. After all, ACOG has been “no Y chromosomes allowed” since 1935. All specialties should be outraged at ACOG’s decision. Most hospitals require board certification of their physicians, so physicians in many cases are forced to be members of the specialty societies in order to practice within hospitals. The more that physicians simply comply with misguided and arbitrary specialty society requirements, the more that we allow those special interests to control the medical care that we provide to our patients. ACOG’s decision not only usurps the determinations of state medical licensing boards, but it also smacks of misandry and homophobia. Did influenza vaccine kill this 19 year old? One day after getting influenza vaccination, the patient developed vomiting, headaches, chills and shaking. A week later he went into a coma and later died from “brain swelling” of undetermined etiology. Patients gone wild in a Long Island emergency department. The brawl in a parking lot wasn’t enough. When the victims were taken to Eastern Long Island Hospital, they went at it again and injured some of the emergency department staff in the process. Philip Howard from Common Good discusses in interview with Medscape how “crazy laws” trap physicians in malpractice system and how current system is not system of justice, but is instead a “system of extortion.” Pensacola Florida Naval Hospital closing its 21,000 visit per year emergency department and turning it into an urgent care center to save money. Will close at night and will no longer accept ambulance runs. Hospital spokesman justifies the move by stating that the emergency department has a “relatively low patient volume”. Tough Mudder race involves obstacle course where often wet and sweaty participants are shocked by live wires up to 10,000 volts. A race in the Philadelphia area resulted in 38 participants going to the emergency department – half of those visits were due to electrical shocks. Doctors at one hospital said that an 18 year old patient “essentially had a heart attack, inflammation of the heart” from receiving 13 shocks during the race. Taking things too far? ACEP’s @DrHowieMell is also quoted in the article. It was recently the 50th anniversary of President Kennedy’s assassination. One of the more captivating accounts of what happened when President Kennedy was brought to the emergency department was written by Jimmy Breslin. As patient volumes increase by 23%, UK’s St. Helier Hospital is telling patients to stay away from the emergency department unless they have a real emergency. Last year, the hospital treated a record number of patients, so it doesn’t look like the warning is going to work. $2.4 million verdict against emergency physician when gastric bypass patient complaining of abdominal and back pain is released from the emergency department and dies the following day from a bowel obstruction. Damages in medical malpractice claims continues to rise. Average payout for medical malpractice cases has increased from $300,000 to $500,000 between 2006 and 2012. Maryland, a ...

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“You’re Next”

By Birdstrike MD I saw a story in the news about something that happened to an ER doctor.  It reminded me of something that had happened to me before, so I started writing about it.  Then my imagination got a little bit carried away.  So, let’s just say parts of this story are absolutely true, and other parts are, well…just read along.  I walk in for my ER shift.  There’s a letter in my department mailbox.  It’s a hand written letter from a patient.  I open it, “Hey doc!  I just wanted to thank you for taking care of me last week.  It was one of the low points of my life and I really had hit rock bottom.  You’re the first one to talk to me like a human being.  You convinced me to get help.  They finally let me out.  Thanks, again.  You saved my life.  You’re a great doctor.  We should hang out sometime.” Sincerely, Jerry —– Cell: XXX-XXX-XXXX” I remember the patient.  I admitted him for severe alcohol intoxication, depression and suicidal thoughts about 2 weeks ago.  It’s not that often that you get to start out a shift with a “thank you” letter, albeit with a bizarre request at the end to “hang out sometime.”   In this ER game, you take every pat on the back you can get, because they don’t come every day. I walk to the pit to see my first patient.  First up is, “Broken wrist.”  I walk into the room and it’s him, Jerry, the letter writer.  “Hi, Jerry, what can I do for you today?” “This,” he holds up his mangled right hand and wrist.  “I got pissed off and punched a wall.” “Wow, you sure did a number on yourself.  What happened?” I ask. “Did you get my letter?” he asks. “Yes.  Why do you ask?” I wonder aloud. He stares at me silently, and uncomfortably long.  “Oh, I don’t know,” he trails off, staring through me.  “Just fix me up, and we’re good.” I walk out of the room.  That was weird, I think to myself.  I put in an order for x-ray of the hand and wrist.  I put that plate up in the air to spin, and move on to: Chest pain, Migraine, “Can’t see,” Sprained knee, “Menstrual,” “Sick still,” Split lip, “Vag drip.” Jerry’s x-ray is done.  Wow.  He’s completely shattered his wrist and 4th and 5th metacarpals in his hand.  I haven’t seen a one this bad in a long time.  I walk into his room.  “Jerry, you’ve badly fractured your hand and wrist.  You’ll probably even need surgery.  I’m going to call the orthopedic surgeon.” “No.  I want you to fix it.  You owe me, big time,” Jerry says. “No, you don’t understand.  It’s badly fractured.  You need a surgeon for this, a specialist,” I explain. “Did you hear me?  I said, ‘NO ’,” he says, gritting his teeth so hard they could shatter. After years of seeing anything from little old ladies to psychopathic criminals, it takes a lot for a patient to truly bother me, but this guy is truly disturbing in a way that’s hard to describe.  It’s time to get out of this room.  “That’s the way it has to be for you to get the best care,” I say and walk out of the room. As I get to the door, he yells, “This s—t is your fault mother f—-r!  You should have called me back.  I left my cell number on the letter for a reason.  YOU shattered my hand and wrist.  This is because of ...

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