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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.

Chief Violetté and the Headless Trauma

By Birdstrike M.D. It was intern year of my Emergency Medicine residency.  I was on my trauma surgery rotation and working at least 100 hours per week (pre-ACGME regulations). To say that I was burned out and sleep deprived would be an understatement.  It was three weeks into residency and I had done nothing but change dressings on my Chief resident’s patients’ putrid decubitus ulcers, run to get gauze packets, perform rectal exams, “RETRACT!”, and be the butt of senior resident jokes.  I had learned so few real skills in procedures or anything else that I was seriously ready to quit at this point, but in way too much student loan debt to do so.  I can’t tell you how many times I prayed for this guy to end up blind, impotent and in an adult diaper.  My supervising resident, Chief “Violate” … I’m sorry, let me rev up my French accent, Chief Violetté was infamous for getting his first two surgical residencies shutdown due to his generally abusive nature, not to mention his penchant for being an exquisite jerk at the perfect moment.  At his program’s ACGME site visit, when he was asked why he logged 168 work hours three weeks in a row during his first surgery rotation, his response was,“I wanted to work 170 hours, but when I got to 168, there were no more hours left in the week!”  I must say, despite being a bastard with no equal, old Chief “Violate”(as I will refer to him from now on), made me take my game to another level. It’s Saturday night.  I’m on call.  I’m dead asleep, and let’s just say I’m feeling a little “pukey” and abso-friggin’-lutely exhausted from having a little too much fun the night before at the local nursing school graduation after-party.  I hear this insanely loud pounding on my call room door and our medical student is screaming, “Wake up!  Wake up!  The Chief’s got an intubation for you!  He wants you in the trauma bay in 30 seconds!!” In a deep circadian haze, I run down to the trauma bay,  and Chief Violate grabs my ear, pulls me into trauma room 1 and says, “I’ve got a procedure for you, big boy.”  I look down at the patient on the stretcher and see a pair of boots, blue jeans, a belt, a man’s tattooed chest, a perfectly normal neck and … a bloody stump of a partial-head pouring out blood like a lawn sprinkler.  As my sphincter tone increases rapidly to diamond cutting levels, the Chief puts a Mac 3 in my left hand and a 7.5 ET tube in the other, pushes me to the head of the bed and says, “You’ve been whining about not getting any good procedures, so cock, lock and get ready to rock, tough guy!” To everyone’s shock and amazement, the guy is alive!  He’s conscious!  Choking on blood he screams, “Finish me off!  Finish me off, and put me out of my misery, you bastards!”  Apparently, instead of pointing the shotgun at the back of his throat towards his brainstem which would certainly have been instantly fatal, he put it in his mouth and pointed upwards, tearing off his upper teeth, maxilla, nose, eyes, forehead and frontal skull, leaving the key parts of his brain intact. As my heart rate creeps up to near SVT levels, the Chief painfully flicks my ear and says, “What the hell are you waiting for?  Intubate him, All-Star!  Don’t worry.  This will be the easiest airway of your life.”  Only having intubated sedated animals and rubber dummies ...

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Jim Dwyer New York Times Pediatric Fever Article Debate

This is probably a record length post for me, but I thought it was important to respond to Mr. Dwyer’s comments to a post written on this blog regarding the article he wrote that appears in the NY Times. I had planned to leave my comments after his, but they became too long and involved and I also wanted to paste a couple of pictures from Mr. Dwyer’s article, so I instead decided to answer his criticisms in a post. If any of you were wondering, I was not the anonymous physician who authored the previous post on Mr. Dwyer’s article. I spent most of my afternoon creating this response because Mr. Dwyer’s original article was somewhat frustrating to me, but I found his justifications and explanations for what was contained in his article to be misleading. UPDATE See additional commentary about Mr. Dwyer’s articles here and here. ———————————————————- Dear Mr. Dwyer, When re-reading your article, I absolutely agree with Rory’s wish that no other child – and no other family for that matter – should have to go through what Rory went through. He sounded like a great kid and he obviously had a close family and a bright future. As you also mentioned, Rory’s uncle was a friend of yours, so I can imagine that this incident affected you more than most other investigations you have performed. This topic hit home for me as well. My daughter nearly died from an invasive pneumococcal infection when she was younger. She was hospitalized for a week in a university medical center on triple antibiotics. Very scary times and we thank God that things turned out well. So let’s go through your article and responses you made to the criticism about your article so that we can determine how to prevent kids from dying from sepsis due to invasive organisms. JIM DWYER COMMENT: 1. You say that the stop sepsis campaign is for tracking severe sepsis. That misstates both the nature of the campaign and my citation of it in the article. The campaign’s goal is to aggressively identify sepsis and begin treatment within an hour. (The tracking of cases you cite is secondary.) To begin the process of identification, the initiative created a triage screening tool which gives a list of 8 signs and calls for additional investigation if a patient has three of them. As I wrote, Rory Staunton had two when he came into the ER. He had three when he was leaving. (BTW — his heart rate over a period of two hours ranged from 131 to 143. That’s in the article, too.) In the distribution literature with the screening tool, there is no distinction between pediatric and adult patients. Whether or not you think the values are relevant to a 12 year old, 5’9″, 169 lb boy, Rory was assessed for possible sepsis in triage. Let’s look at the sepsis criteria according to the checklist that you posted. Then let’s apply them to children. 1. Pulse greater than 90. In children up to 2 years of age, a pulse rate less than 90 is considered too slow. In other words, ALL children up to 2 years of age should have a pulse rate greater than 90. 2. Respiratory rate greater than 20. In children up to 5 years of age, a respiratory rate less than 20 is considered too slow. In other words, ALL children up to 5 years of age should have a respiratory rate greater than 20. So now in children who have entirely normal vital signs for their age, right away you have ...

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Dear Diary

I’ve had an interesting couple of weeks. My trusty Palm Pre died on me after a good few years. When I brought it to the customer service center, the whippersnapper working there said “Whoa! That’s an old phone!” Thanks. Amazing how something that was so “cutting edge” a few years ago is now pretty much a piece of garbage. So I upgraded to the brand new Samsung Galaxy S3 and its Android tracking, er, um operating system. As soon as you activate the phone, you have to agree to allow a bunch of programs the ability to access your contact list, identity, phone calls, and location just to get the phone to work. You can’t remove the programs from your phone and you can’t limit their access. So then I researched a bunch of programs that would prevent other programs from accessing my information. And I installed a program that makes my GPS think I’m wherever I program it to be. Currently, I’m in the middle of the Gulf of Mexico. Overall, I have to admit that the phone is pretty nice. Screen is amazing. I can dictate text directly into the phone. Can do video chats with the kids. Can even control my computer at home from the screen on the phone. Kind of a learning curve on some of the programs, though. I’ll probably put up a few posts regarding my versions of the “best” Android programs to have on your phone. Speaking about phones, I saw someone pushing the envelope with cell phone etiquette at a restaurant recently. It’s not just that the person’s cell phone was turned on. It’s not that the cell phone was out on the table. The person actually brought a stand to set the cell phone on during dinner so that she didn’t miss that ever important text message (the picture was taken from across a restaurant, so don’t give me grief). Dogs are doing great. Had fun at the park the other day digging into the woodchips on the playground until someone yelled at me through the trees that they were “destroying” the playground. Destroying wood chips. Right. I was going to squat over one of the holes and smile at him, but figured that all that would do is get me arrested. Yes, I filled in the holes. I always fill in the holes. Went out with Mrs. WhiteCoat to a wine tasting event over the weekend. Had lots of fun and didn’t even purchase a bottle of wine. Met a guy who appeared intoxicated. We talked for a while and then he had to leave. He was driving. Offered to get him a cab, but he lived 40 miles away. Thought about calling the police, but then if he wasn’t drunk, I’d look like a jerk. Besides, he’d surely be gone by the time they got there and I had no idea what route he would be taking. So I watched him leave the event and wondered if I should have gotten physical with a stranger to keep him from driving. Then I wondered how I’d feel if he hit and killed someone. The whole situation bothered me the rest of the night. I got home and began brushing my teeth before bed. The toothpaste tasted funny. That was because it was my daughter’s facial moisturizer. Hey – it was dark and the tubes are almost exactly the same size. She’s lucky that she’s not grounded for … summer … for leaving that stuff in my drawer. For the past few days we’ve been dealing with another problem. The ...

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Jim Dwyer New York Times Article – Irresponsible Journalism?

By an Anonymous Emergency Physician The opinion piece below was written by an emergency physician regarding a New York Times article by Jim Dwyer (picture at right). The author did not want to be identified due to fears of retribution from either the NY Times or from the hospital at which the physician is employed. In addition to the points the author raises below, I would add these additional points of information: 1. The “Stop Sepsis” campaign cited in Mr. Dwyer’s article specifically stated that it is only to be used for tracking patients with severe sepsis and that “only those patients who are hypotensive after being given 2L of fluids or that have an elevated lactate should be entered in the data portal for this Collaborative.” Rory was not hypotensive and no lactate level was included in the labs pictured in Mr. Dwyer’s article. Mr. Dwyer never mentions any of these facts. The Collaborative does not allow access to links on this page describing its screening tools or to how it believes that a determination for ordering a lactate level should be made. I will also note that Mr. Dwyer responded to some of the more than 1600 comments to his article, including some of the issues raised below, in this follow up article. -WC UPDATE JULY 22, 2012 Also see an important update to this debate at this link. —————————————— The New York Times published an incredibly sad story about a 12 year old boy named Rory who went into the NYU emergency department, was diagnosed with gastroenteritis (a viral stomach bug), and who was dead two days later from septic shock.  Those are just about the only facts that are not in dispute.  The rest of the New York Times article seems to build a mountain of evidence as to why the emergency physician screwed up.  However, as is frequently the case, the truth is much more complicated than the media would have you believe.  There are lots of comments from other doctors using the almighty retrospectoscope and so many clinical inaccuracies discussed that this sad story is turned into a piece of sensationalistic journalism. This post is mostly for the non-medical people that read this blog to help you understand the medical issues a little better.  This is a scientific discussion of the main inaccuracies of the article followed by what possibly could have been done better.  I say “possibly” because I did not examine the patient and all of my information is through the New York Times article.  If you have already read the article and decided that the ED doctor screwed up and nothing can change your mind, then stop reading.  If you want a fair and evidence-based discussion of the article then read on. The article references the “Stop Sepsis” campaign and says that the vital signs that should have triggered an evaluation for severe sepsis.  The article says that Rory had initial vital signs of a temperature of 102, a heart rate of 140, and then points to the Stop Sepsis guidelines.  There are two problems with this: First, the Stop Sepsis guidelines are intended to be used in adults, not in children. Second, just because a patient has abnormal vital signs doesn’t mean that they have severe sepsis.  Most patients in a pediatric ED waiting room would meet these criteria and yet they don’t have severe sepsis.  The “Stop Sepsis” guidelines are a screening tool that can suggest sepsis but they have to be used in the right clinical context.  Most physicians see pediatric patients every day who meet the “Stop ...

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Healthcare Update 07-16-2012

Some inner-city New York hospitals have figured out how to save money in malpractice premiums … they “go bare.” Interfaith, Kingsbrook Jewish, and Wyckoff Heights all insure themselves for lawsuits and two of them have set aside no money for judgments. Lawyers call it “irresponsible.” Feeling suicidal? Text me about how you feel. Patients with emergency psychiatric issues prefer cell phone-based or computer-based interventions to the traditional face-to-face interactions. Text messaging, e-mail, and social networking sites were preferred over traditional interventions by 90% of patients for at least one psychiatric topic. Next up: A game titled “REALLY Angry Birds.” Dallas patient who went to pick up Norco refill for post-surgical pain arrested and forced to stay in jail overnight on suspicion of obtaining a controlled substance by fraud when pharmacist calls wrong physician to confirm prescription. Physician says he never wrote prescription. CVS isn’t commenting. How about just “oops”? Then there’s this doctor in California who was arrested for prescribing addictive medications to people with no legitimate need. One of the undercover officers brought copies of his x-rays to show him how severely his back had been injured. In reality, the x-ray was that of a German shepherd.

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The Individual Mandate For Dummies

This cartoon was sent to me in an e-mail. Overly simplistic, but illustrates the issue. Credit here.

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