Thursday, June 30, 2005

A Post-Surgical Complication

The patient initially presented with an antalgic gait, refusing to use the left leg. Almost no weight bearing at all. Agitated enough that sedation was required prior to x-ray, the diagnosis was a fractured metatarsal.

The recommendation was for ORIF, which was done the next morning. The report was good and the doctor predicted full return of function. The extremity was splinted and the doctor recommended no weight bearing if possible and very limited weight bearing at all.

However, after several days, the patient didn't seem to be improving. Another trip to the doctor, another set of x-rays. The verdict was satisfactory healing. Unfortunately, all was not as it seemed.

The next day, with the patient refusing to eat or drink and becoming gradually less interactive, there was need for a second opinion.

This is where I came in. As I entered the room, the most noticeable thing was that this was a very different patient from what I was used to. I knew the patient in her pre-morbid state and she was usually very active and personable. I couldn't help a slight wince at the odor, as well.

"I don't know what's causing the smell," her companion stated. "She saw her regular doctor yesterday and I was told everything was going well."

After greeting and reassuring the patient, I removed the dressing and examined the foot. It was somewhat swollen, but, overall, looked pretty good. However, there was a large ulcerated lesion over the lateral malleolus that was dripping pus.

Gasping, the patient's companion exclaimed, "I wasn't able to be there yesterday when they examined her and they didn't mention anything about this to me when I picked her up!" The doctor had apparently missed this wound, although I don't know how.

I prescribed Augmentin and pain meds. I taught the companion how to do wet to dry dressing changes and recommended them TID. I also told her I would like to see the patient again the next day.

For about a week, things were touch and go. I was gradually building a greater rapport with the patient and was able to examine her more easily. However, the skin surrounding the wound was very loose and showing signs of necrosis. The wet to dry dressings did seem to be working, though. I counseled her companion that if things didn't start to improve soon, we may have to consider referral for a skin graft. I could see underlying bone and tendon. The wound did not seem to extend to the joint.

The next few days showed improvement. However, the companion told me that she had left the patient at home alone the day before for only 40 minutes and returned to find a disaster. The Augmentin had caused a common side effect, diarrhea, and there was stool all over the living room and dining room. Code Brown, indeed!

I reassured her that this would be self-limited and advised proper care. It was apparent that the meds and dressing changes were working and that it was doubtful that the patient would require a skin graft.

It has now been three full weeks since the original surgery. I am happy to report that my wife's dog, Chatter, is doing very well. I know you are relieved. She is weight bearing and the wound is shrinking rapidly.

Wednesday, June 29, 2005

Senator Durbin, call your office!

Ouch!
As a Marine Corps officer, I spent five years and five months in a prisoner of war camp in North Vietnam. I believe this gives me a benchmark against which to measure the treatment which Sen. Richard Durbin, Illinois Democrat, complained of at the Camp of Detention for Islamo-fascists at Guantanamo Bay, Cuba.
The senator's argument is silly. If he believes what he has said his judgment is so poor that his countrymen, assuming, of course, that he considers us his countrymen, have no reason not to dismiss him as a witless boob. On the other hand, if he does not believe what he said, the other members of the Senate may wish to consider censure.
...
The argument that detainees at Guantanamo are being treated badly is specious and silly. In the eyes of normal Americans, Democrats believe this argument because, as Jeanne Kirkpatrick said 20 years ago, they "always blame America first." This contributes to the increasing suspicion, in red states, a problem that Democrats are aware of and are trying to counter, that Democrats cannot be trusted with our national security. Only the Democrats can change this perception, most recently articulated by White House adviser Karl Rove. The ball is in their court and I am certain there are steps that they can take to change this perception, but making silly arguments about imaginary bad treatment of enemy detainees is not a move in the right direction.
Hat tip: Instapundit

Tuesday, June 28, 2005

Celebrity advocates

Celebrity advocates are everywhere these days. This one has a very serious health care concern:
"American Idol" judge Paula Abdul urged California legislators to force nail salons to clean up their act, testifying Monday about her yearlong health ordeal after an unsanitary manicure.

Crocodile tears

Malpractice debate draws more doctors
Angel Rios estimates he works 90 to 105 hours a week as an obstetrician-gynecologist, leaving the El Paso, Texas, doctor little time or inclination for politics. Medical malpractice lawsuits changed his mind.

“I saw doctors out there 25 years and working and they had to declare bankruptcy,” says Rios, 41. “Doctors are realizing that they need to get involved.”

Rios opened his checkbook to Republicans promising to limit lawsuits. So did many colleagues: In the 2004 elections, doctors almost doubled their political contributions compared with four years earlier. And, in another milestone, they outspent trial lawyers, who are opposed to curbs on litigation, by 40 percent, a reversal of the 2000 campaign.

The doctors’ demonstration of political muscle assures that their views will loom large as Congress considers medical- malpractice legislation.

The president of the Association of Trial Lawyers of America, Todd Smith, said the physicians’ new financial clout is being augmented by contributions from the insurance and pharmaceutical industries and other businesses that want to rein in lawsuits.

“We are being enormously outspent on the other side and I think America better watch out,” said Smith, a partner with the Chicago-based law firm of Power, Rogers, and Smith. “The first time a citizen needs access to the court and they find out that some of these laws have passed, they’re going to have an eye-opener, and it’s going to be too late.”


"We're being outspent." Oh my, hand me a hankie, I just can't stop crying for him. When the ATLA requires every member to give it up and the docs donations are voluntary. And when this is the first time in history this has happened. It was OK when the ATLA outspent everyone else.
Suspect critical after being shot in stolen wrecker.

Perhaps DocSurg or Cut to Cure could do a trauma series for us on this one. As an ER doc, I wouldn't know where to look for the injury. Obviously, being shot in the wrecker, even if stolen, is serious.
are now in session at Health Business Blog.

Monday, June 27, 2005

Friday night in the ER

Flashes of lightning and peals of thunder punctuated the night, as ambulances were popping in several times an hour. Not that unusual for a Friday night in the ER. A little quiet on the knife and gun club front, perhaps because of the raging storm, but this just contributed to the multiple car wrecks.

No one thought it unusual as the triage nurse wheeled in an unkempt young man clutching his abdomen and moaning in pain. Probably another kidney stone, perhaps something as benign as gastroenteritis. As she pushed him into room 8 on the emergent side of the ER, we barely looked up. The nurse for that room went in and prepared to start an IV as the patient rep escorted his companion, another 20-something year old man, some scruffy in appearance, into the room. The long hair, multiple tatoos and the piercings attracted several glances and a few comments.

I looked up as the nurse, Jennifer, came up to me. She was ashen and seemed shaken. Very unusual for this veteran of the ER. She said, "Doc, I need you in room 8 right now." Perhaps my casual assessment of the patient as he rolled through was mistaken.

As I entered the room, I noticed that Ashley, the triage nurse, was still in the room. She also seemed flustered and troubled. What was going on?

I looked at the patient in the bed. More questions. He no longer looked to be in any distress and no one had started an IV or put him on the monitor, as I would have expected. The chain hanging between his eyebrow and upper lip jangled as he giggled.

Ashley started and glanced behind me as an agitated voice instructed, "Turn around, Doctor." I hadn't noticed the companion behind the screen as I had moved past him on my way into the room. Of course, this time I didn't miss the muzzle of the Glock he was pointing at me. What is it about these gang-bangers and their Glock's? I thought longingly of my own Glock, currently in its holster in my truck.

"Uh, what do you guys want?" I managed to squeeze out.

"Don't be an idiot, Dr. DipShit. We wants yoh drugs. And while you be's at it, everybody's wallets and purses, too."

"No problem. Anything you want. Just don't hurt anybody."

"We be keepin' blondie over here foh insurance. You and..."

"My name is Jennifer."

"Yeah, you and da bee-otch go on out and be gettin' the goods. Done be callin' five-o, asshole."

"Why don't you let Ashley and Jennifer go and I'll stay in here with you two. It will be easier for the nurses to gather the drugs you want, anyway. I won't be able to help with that."

"Why we want your ugly puss in here wid us? We goin' to enjoy bein' in here with Nurse Blondie," he replied, leering at her.

"As I said, we'll get you anything you want, just leave her alone and don't hurt anyone."

"YOU AIN'T DA MAN HERE, ASSHOLE!" he screamed. I began to wonder just how much these two had been partying before they showed up here. The muzzle of the gun tracked around the room wildly, revealing just how unstable this hype was. There was no telling how much damage he could do if confronted. Those baggy pants could be holding multiple reloads.

As we hurried to the Pixis to get what we could to mollify them, Jennifer commented, "This would be a great time for a deputy to wander in with a BA check, wouldn't it?" I was worried about just that possibility, actually. The sight of a uniform, badge and gun could set this guy off, starting a shooting spree that could hurt a lot of people. I just wanted these guys out of here.

I instructed Jennifer to stay out of the room and returned by myself. No need to give them another target. Unfortunately, Mr. Hype wasn't happy with the few Lortabs I was able to get out for him. "Hey, asshole, who you savin' da good stuff for, anyway. Man, we don't gets the luv. I aint' be freakin' 'cause of no needles. I knows you gots Morphine and Demerol in there. Load me up, man! And where dat hooka dat was with you?"

Perhaps this was an opportunity. "Look, I'll give you anything you want. Jennifer is gathering the purses and wallets you wanted. I'm happy to give you 'the good stuff' but I didn't think you wanted shots. No problem, though. I've got a great idea for this party."

"What dat, man? Don't be playin' me, jackoff."

Can they really be this stupid? "Just let Ashley start a couple of IV's. That way, we can load you guys up for the best blazin' you ever had."

Wow, these two had to stand real close to form a synapse! I mean, they only had two neurons held together by a spirochete and someone treated them with penicillin!

They looked at each other and the one on the bed replied, "Dat's fresh, boofa. Hook us up!"

Looking at me like I was crazy, Ashley got out two start kits and told Brainiac to sit in the chair. Holding his gun on me, he held out his left arm to Ashley, "Get it on, Chicken Head. And you, Cheezie, don't be clownin'. Keep it down low."

"Hey, nothing but the best for my two new homies," I couldn't resist chiming in. I could smell the ozone from the electricity snapping in the room. I was scared s**tless, but hopeful that this would work. Just let us get the IV's in, you idiot.

"Let me go get the good squirt and you be floatin'," I offered, really getting into this. Who said I wasn't bilingual?

I returned with two syringes, as Ashley had the IV's in. "What dat, cracker?" asked Brainiac, so excited his tongue stud was clacking against his gold incisor cap.

"This the best, man. This here's called Mid-az-o-lam," I answered, stretching the word. "It will blow you away. You ain't never had anything like this before. Strictly medical grade. I can't give you too much, as you be slammin'."

They are actually going to let me do this! I gave each of them 10mg of Versed, slow IV push. Within seconds, I caught the Glock 22 as Brainiac slipped of to Neverland.

A couple of turns of nylon tape and the two were secured. "Can you get me the sheriff?" I asked the secretary, as if I needed a consult. "I need to facilitate a transfer."

Thank God dopers are stupid. "Thanks for playin', fool."

Saturday, June 25, 2005

Freedom of Speech

Sure, we have the freedom to say pretty much anything we want. I just wish some people would use judgement and consider the effect of what they say before exercising that right.

When people in prominent positions, who are likely to get publicity for what they say, criticize our president and his policies, especially regarding the war on terror, this has an effect on the war effort. Last summer and fall, when John Kerry and his supporters were going on and on about a "timetable for withdrawal" and an "exit strategy" the terrorists in Irag were emboldened. They knew that if they could just hold on for a few months, John Kerry would pull us out of Irag and they would win. Especially if they could make those few months before the election as bloody as possible and help John Kerry. How many of our soldiers died as a result of the encouragement the terrorists received?

Another effect is that the standard for what is unacceptable gradually becomes eroded and lower and lower. Read this, by Powerline. This is what concerns me more and more every day.

Wednesday, June 22, 2005

The War is Over

and We Won
I spent lots of time walking both neighborhoods this spring—something that would not have been possible a year earlier, when both were active war zones, where tanks poured shells into buildings on a regular basis. Today, the primary work of our soldiers in each area is rebuilding sewers, paving roads, getting buildings repaired and secured, supplying schools and hospitals, getting trash picked up, managing traffic, and encouraging honest local governance.

What the establishment media covering Iraq have utterly failed to make clear today is this central reality: With the exception of periodic flare-ups in isolated corners, our struggle in Iraq as warfare is over. Egregious acts of terror will continue—in Iraq as in many other parts of the world. But there is now no chance whatever of the U.S. losing this critical guerilla war.

Tuesday, June 21, 2005

Majority rule?

What is with the Democrats? They think that their minority status in the Senate should guarantee them veto rights over legislation. Now they feel that if a minority of people disapprove of how the terrorists in Gitmo are treated, we should close that camp. Of course, if a minority of the electors voted for Gore, he should be president. If a minority of the voters and electors voted for Kerry (who served in Vietnam), he should be president.

Under what circumstances should the majority get what it wants?

Witness/juror

Aggravated DocSurg got a subpoena to testify in a trauma case and a summons for jury duty and tells the beginning of what is sure to be an interesting saga (with a cool picture.)

Now, doctors aren't automatically exempt from jury duty, but I can't imagine the attorney who would want one on the jury.

Just imagine how much this is costing him. Not just money, but you have to believe he is losing patients (or is that patience?) who don't like being rescheduled.

No wonder people don't want to be witnesses. The old story about someone being shot six times in center field during Game 7 in Yankee Stadium and no one saw a thing!

In the ER, a lot of docs try to avoid the assault/rape patients because we don't want to be jerked around like DocSurg is now.

Take Back the Memorial

Don't let this happen:
In fact, the IFC [International Freedom Center] seems destined precisely to become a multimillion-dollar bash-America palace.
From The Washington Post, via Jeff Jarvis.

Sign the petition.

Uh, Oh

One might even say, "Holy Shit!"
Sixteen foreign-born construction workers with phony immigration documents were able to enter a nuclear weapons plant in eastern Tennessee because of lax security controls, a federal report said Monday.
Via The Wandering Mind
is up at Cut to Cure. And a very fine collection, at that.

Monday, June 20, 2005

What liberals really think

For your understanding, from Powerline.

So, what is torture, anyway?

From Ann Althouse:
Marines on an operation to eliminate insurgents that began Friday broke through the outside wall of a building in this small rural village to find a torture center equipped with electric wires, a noose, handcuffs, a 574-page jihad manual - and four beaten and shackled Iraqis....

The manual recovered - a fat, well-thumbed Arabic paperback - listed itself as the 2005 First Edition of "The Principles of Jihadist Philosophy," by Abdel Rahman al-Ali. Its chapters included "How to Select the Best Hostage," and "The Legitimacy of Cutting the Infidels' Heads."
I want to know what kind of CD player they had in that room and what rap/rock selections they preferred. After all, they were torturing fellow Muslims, so they must know what worked.
Jane Watson was sick. After calling ahead, she presented to Dr. Bilton's office. Dr. Bilton was relatively new in town, having recently completed a postdoc in molecular disease investigation and treatment.

Jane had a recurrent illness. For almost every one of her 41 years, she had been plagued by this disease. To her dismay, no physician had ever proposed a cure, never mind actually provided one. Her neighbor, Frances, a widow at age 55, had been bragging that Dr. Bilton had cured her curiously similar series of maladies. As a matter of fact, Frances' claims that Dr. Bilton could have cured her husband's cancer were beginning to annoy the coffee clatch/bridge club to which they both belonged.

Anyway, Jane had decided that the next time her disease flared, she would give Frances' miracle doctor a try. She would probably do no better than any of the rest, simply "oh, we'll just have to treat the symptoms. Here, try this and this and ..."

Arriving at the pleasantly appointed office, Jane was both pleasantly surprised and somewhat concerned that the waiting room was empty. "Of course, this means that I don't have to wait, but does it also mean that she is so bad she doesn't have any patients?"

The receptionist, a woman of about 60, blond and very fit appearing, greated her by name and suggested she "Come on around to room 1."

"Well, this is very a very nice office. She must be doing something right to be able to afford this so soon after opening. And no waiting, straight to a room. I approve," thought Jane.

The door to the back hallway opened with a "whoosh" and, like a gentle escort, air flowed from the waiting room. "Oh, we have a negative pressure system. Required, you see, but not necessary in the least," commented Susan, the nurse, greeting her, again by name.

The exam room was pleasantly warm, as Jane disrobed and prepared to meet the woman almost worshiped by her friend and neighbor. Dr. Bilton arrived as she was sitting on the exam table. "Hello, Jane. I'm glad to meet you. Frances mentioned that she suggested you come by. I understand you have been troubled for years by your malady."

"Yes, Dr. Bilton. No one has ever been able to help me."

"I understand. Tell me what's been bothering you."

Jane replied, "Well, it's really not that bad, but every few months, I miss several days of work. I feel so run down. My nose is stuffy and runny at the same time, I feel dizzy, I run a low grade fever, I have a sore throat, dry cough. I just feel miserable."

"I feel for you. I have heard similar complaints for the last few weeks and appreciate how you must be suffering. I think I can help."

After examining her ears, throat and nose and listening to her lungs, Dr. Bilton took a nasal swab and stated, "I'll be back in 20 minutes. Please get dressed."

Sooner than expected, Dr. Bilton returned and stated confidently, "I know I can help you. This problem will be resolved by tomorrow morning."

Somewhat skeptically, Jane blurted, "You're kidding!"

"No, I am not, but your response is very typical. Here, take this capsule with you and follow these directions carefully. You may need to stop at the market on the way home."

Curiosly, Jane read the detailed instructions, along with the list of "ingredients." "This looks like a recipe," she thought.

That night, Jane prepared the "recipe" exactly as prescribed, and added the capsule provided by Dr. Bilton. After watching the mixture bubble for 10 minutes, she drank the lightly sweet cocktail. Soon she was asleep, still not sure.

The capsule dissolved quickly into solution, providing the molecular instruction for the cure. Dr. Bilton had placed the specimen from the nasal swab into the computerized sequencer in her lab, providing a detailed analysis of the virus that had caused Jane's viral syndrome. Yes, the common cold.

The information from the analyzer was a blueprint for the exact "mechanical antibody" required to defeat Jane's virus. The recipe created the exact molecular milleu required for the assemblers in the capsule to replicate the mechanical antibody and continue to do so in Jane's GI system. These antibodies were bound to dendrimers, tree-like nanomolecules. On another branch were nutrients required by the specific virus that was infecting Jane. As the virus concentrated the nutrients, they unknowingly incorporated instructions into their own RNA that changed them from pathologic to healthful.

The next morning, Jane awoke, having experienced the cure to the common cold. As simple as that.

Does Gitmo serve a purpose?

Ann Coulter:
What happens is this: There are thousands of Muslim extremists literally dying to slaughter Americans, and only three proven ways to stop them: (1) Kill them (the recommended method), (2) capture them and keep them locked up, or (3) convince them that their cause is lost. Guantanamo is useless for No. 1, but really pulls ahead on No. 2 and No. 3 (i.e., a "purpose").

What a waste of amino acids!

An interesting perspective on the Y chromosome, by Dr. P.
These days we're just inundated with new genetic information, as we learn more about chromosomes and genes, and much of it has to do with what's going on with the X and Y chromosomes (women have two X's, men have an X and a Y). And the news about the Y isn't good -- is there any important gene on the Y chromosome? It sure doesn't sound like it. Just look here at the comparison between the two. Some talk about it being a "vestigial" chromosome, sort of like the equivalent of an appendix, that long ago lost any real value -- YIKES! The thing that makes me a man is sort of a hollow shell!

Well, I say, "Men of the world, Fear Not!" Every cloud has a silver lining, and there's always a way to make use of bad news.
In our own defense, those of us who are relatively X deficient should go there and add to the excuses comments.

To CT or not to CT

A very good post and literature review by Bard-Parker regarding CT's of the spine in trauma. A must read if you work in an ER or on a trauma service.

I try to get in the room as soon as I see a boarded patient roll in. I want to get them off the board ASAP. Our local EMS folks are very aggressive about spine protection and will board almost everyone from an MVC or a fall. Most of these can come out of the collar and off the board within minutes of rolling into a room.

If I don't get into the room fast enough, I will find that the nursing staff has ordered a c-spine series. They will order this on every boarded/collared pt. I understand why, but I think it is incumbent upon the physicians to clear those we can clinically and avoid the films when possible.

Does anyone really care?

AMA to vote on delaying drug ads
The American Medical Association's House of Delegates will vote as early as today on a measure backing a federal moratorium on drug ads.

The group is being asked by members to put its clout behind legislation that would delay the start of print or TV ads after a drug is approved.
Really, does the AMA have very much clout left anymore? Look at this:
The American Medical Association, which traditionally has been considered the nation's largest medical organization, confirmed yesterday that only 26% of the nation's doctors are AMA members.
I'm not a member because I disagree with so much of their political agenda.

Just take over

Doctors Urged to Run for State Office in MD
Frustrated by increasing problems facing the medical profession, a physicians' political action committee is sending mailings to 10,000 Maryland doctors asking them to consider running for the General Assembly and to support doctors who are on the ballot in next year's election.
Sounds good to me.

A Misunderstanding?

I am sure this was just a misunderstanding.

Oooooorr was it?

Thanks to The Wandering Mind.

Friday, June 17, 2005

Nanoparticles transport cancer-killing drug into tumor cells to increase efficacy, lower drug toxicity in mice
University of Michigan scientists have created the nanotechnology equivalent of a Trojan horse to smuggle a powerful chemotherapeutic drug inside tumor cells – increasing the drug's cancer-killing activity and reducing its toxic side effects.
They hooked folate and methotrexate to a manmade polymer molecule called a dendrimer, a tree like nanomolecule. The cancer cells have a high affinity for the folate and concentrate it. The methotrexate just came along for the ride.
“It's like a Trojan horse,” Baker explains. “Folate molecules on the nanoparticle bind to receptors on tumor cell membranes and the cell immediately internalizes it, because it thinks it's getting the vitamin it needs. But while it's bringing folate across the cell membrane, the cell also draws in the methotrexate that will poison it.”

When tested in laboratory mice that had received injections of human epithelial cancer cells, the nanoparticle-based therapy using folic acid and methotrexate was 10 times more effective at delaying tumor growth than the drug given alone. Nanoparticle treatment also proved to be far less toxic to mice in the study than the anticancer drug alone.

“In our longest trial, which lasted 99 days, 30 percent to 40 percent of the mice given the nanoparticle with methotrexate survived,” says Jolanta Kukowska-Latallo, Ph.D., a U-M research investigator and first author of the study. “All the mice receiving free methotrexate died – either from overgrowth of the tumor or from toxic effects of the drug.
Via Instapundit

A TennCare story

RangelMD wrote this excellent commentary on the history of TennCare and a frightening prediction of the future.

It prompted me to share this TennCare story.

When TennCare first started, there was only one pediatrician in this small town in east Tennessee. He was willing to participate and was assigned 5,000 (that's right) TennCare kids. He was paid a monthly fee for each kid that varied depending on which HMO carried them, but let's say about $10/month. So he was getting about $50,000/month from TennCare.

Now most of us in primary care struggle to carry 2000-2500 on our panels and provide reasonable access. As an old school MD, he worked long hours and on weekends and provided a lot of call in care. Naturally, a significant number of his patients ended up in the ER, despite his best effort.

When he retired, a young pediatrician had been recruited to take over his practice. This doc was of a new generation, and less inclined to devote as much time to his panel. So he set up his clinic this way: mornings were walk-in only. The first 20 patients to sign in would be seen. Everyone after the first 20 were turned away and told to come back another day or go to the ER. In the afternoon, he had appointments. Most of these, coincidentally, went to privately insured patients.

Now, you have to understand how TennCare paid for the ER visits. Each participating provider signed a contract for a certain monthly capitation, say $12/patient/month. From this, there was a withhold, let's say $2/patient/month. These monies were used to establish a risk pool. From this risk pool were paid any specialty referrals, ER visits and other benefits for which the providers accepted the risk.

The plan was that, at the end of the year, the monies left in the risk pool would be distributed to all of the participating providers based on the number of bodies enrolled and the providers level of "utilization." If you were a high utilizer of the ER or specialists, you got less of a year-end bonus. Makes great sense, huh?

The problem was that there was never any money left in the risk pool at the end of the year. So, if you struggled to see everyone and almost never let any of your patients got to the ER or see a specialist, you got squat. If you simply sent everyone to the ER or to a specialist, you got squat. So where's the incentive?

So this young MD figured this out. Early on, hospitals were required to contact the PCP to get "authorization" to see the patient in the ER. So you would get called at night and asked if you would authorize the visit. ER's would actually turn the patient away if the doctor said no. This young MD just told the ER staff that he would authorize any visit, so don't call me. The practice in which I worked required us to speak with each patient and try to treat them over the phone or ask them to come in the next day. Of course, this put us at a great deal of risk. We realized that we weren't getting anything back from the risk pool, so we quit taking the risk and just said, "Sure, see 'em."

With EMTALA, ER's just quit calling, anyway.

Anyone who reads Thomas Sowell knows that if you institute cost controls, all you do is restrict access to the commodity.

Access to a TennCare provider has become so difficult in my current community that we end up seeing a lot of patients in the ER whose providers are 30-40 miles away. These are people who can't afford the gas to drive there, or don't have access to reliable transportation. They have providers to whom they have been assigned for years and have never seen.

This, of course, is great for the providers, because they are getting paid for some number of patients that never come in.

Thursday, June 16, 2005

Should we fund PBS?

One of my favorites, Peggy Noonan, in the Opinion Journal:
Conservative argue that in a 500-channel universe the programming of PBS could easily be duplicated or find a home at a free commercial network. The power of the marketplace will ensure that PBS's better offerings find a place to continue and flourish.
This I doubt. Actually I'm fairly certain it is not true. And I suspect most people on the Hill know it is not true.

We live in the age of Viacom and "Who Wants to Be a Celebrity," not the age of Omnibus and "Leonard Bernstein's Young People's Concerts." A lot of Democrats think that left to the marketplace, PBS will die. A lot of Republicans think so too, but don't mind.

At its best, at its most thoughtful and intellectually honest and curious, PBS does the kind of work that no other network in America does or will do. Sumner Redstone is never going to pay for an 11-hour miniseries called "The Civil War"; he's not going to invest money and years of effort into a reverent exhumation of the rich loam of American history. Les Moonves is not going to do "Nova." Bob Iger is not going to OK a three-part series on relativity theory. Jeff Zucker isn't going to schedule a calm, unhurried adult drama like "Masterpiece Theatre." They live in a competitive environment.
Why, as she says, would this be a "ratings disaster"? Because the majority of people don't want to watch it! Peggy's argument seems to be that because she feels these projects were/are worthwhile, you and I should help her pay for it. I'm sure there are plenty of people who would come up with a list of "worthwhile" projects to which she would object. Come to think of it, she lists them in her column. Someone obviously felt Bill Moyers was worthwhile.

I don't think that what she suggests is possible, anyway. The liberals who run PBS are too entrenched to be replaced, and too out of touch to realize that her suggestions are the only way to save the network.

Personally, I like her ideas. Yeah, I agree with her list of "worthwhile." But I don't think it should be government funded. I bought a copy of the Civil War series by Ken Burns. But those who aren't interested shouldn't be expected to pay for it.

If it is indeed worthwhile, make these projects and put them on a pay cable channel. I agree that a lot of people would want to see Brad Pitt do Hamlet. But didn't Mel Gibson do that one already?

Information is free

A brand new medical blog by GregP. With an interesting story about a lady with numb feet and a very large paper bag.

Wednesday, June 15, 2005

Let's go to the Carnival

The Carnival of the Vanities is here!

"Wholly unacceptable" indeed

Probation for naked interviewer
Glasgow Sheriff Court was told that Saeed Akbar, a manager at an interpreting and translation company, "had wanted a bit of excitement".

Sheriff Brian Lockhart described the behaviour as "wholly unacceptable".

Akbar, 35, left the interview room and came back in to speak to his female victim naked and clutching a clipboard.
To paraphrase Keanu Reeves from one of my favorite movies, "I don't know WHAT he was thinking!"

Screening Malpractice claims

N.H. Approves Pre-Trial Medical Malpractice Screening Panel
New Hampshire lawmakers have approved pretrial screening panels in medical malpractice lawsuits in hopes of controlling rising insurance costs for doctors.

...

A panel comprising a judge, a lawyer and a doctor would review cases before they went to trial. The panel would consider evidenceand testimony from witnesses. If the panel unanimously felt the case was weak and the parties continued to trial, the panel's finding would be presented to the jury.


It would appear that the panel's opinion would not be binding, but it could influence a jury.

DTC advertising

A Self-Imposed Ban on Drug Ads
THE drug maker Bristol-Myers Squibb said yesterday that it had imposed a ban on advertising its new drugs to consumers in their first year on the market, adopting voluntary restrictions that go further than what is anticipated in an industrywide advertising code to be announced next month.

The company said it wanted to give doctors time to understand new products before patients begin asking for them.

"Move On" one might say

From the Opinion Journal:
Today--maybe, possibly, fingers crossed, and if Jupiter is in the Seventh House--the Senate will vote for cloture in the debate over John Bolton's nomination to be U.S. Ambassador to the United Nations, meaning he will at last get the up-or-down vote he has been denied for months. And barring further surprises--no ruling those out, either--Mr. Bolton will be confirmed, meaning he may finally get down to the serious work that confronts the United States at the U.N, particularly in the matter of organizational reform.

Test

your Civil War knowledge. It wouldn't be fair to describe this as "trivia" as some of these questions shouldn't be missed by anyone who's had a basic history of the US course. I missed the first one, and scored a 9/10.

Via The Wandering Mind, who scored 10/10.

Tuesday, June 14, 2005

Grand Rounds

are up at Red State Moron. Just click on the sidebar link.

Monday, June 13, 2005

This just ain't raight!

See this, via Wandering Mind. He's got some other interesting stuff.

Methamphetamine use and strokes

When working as a hospitalist a few weeks ago, I posted this about a woman I admitted who couldn't speak and had a decreased level of consciousness. Her intitial CT scan was negative, but over the next few days showed an evolving stroke. Her only risk factor was that she used tobacco and her drug screen revealed amphetamine use.

Methamphetamine is commonly known as "speed," "meth," and "chalk." In its smoked form, it is often referred to as "ice," "crystal," "crank," and "glass." It is a white, odorless, bitter-tasting crystalline powder that easily dissolves in water or alcohol. The drug was developed early in this century from its parent drug, amphetamine, and was used originally in nasal decongestants and bronchial inhalers. Methamphetamine's chemical structure is similar to that of amphetamine, but it has more pronounced effects on the central nervous system. Like amphetamine, it causes increased activity, decreased appetite, and a general sense of well-being. The effects of methamphetamine can last 6 to 8 hours. After the initial "rush," there is typically a state of high agitation that in some individuals can lead to violent behavior.

Methamphetamine comes in many forms and can be smoked, snorted, orally ingested, or injected. The drug alters moods in different ways, depending on how it is taken.

Immediately after smoking the drug or injecting it intravenously, the user experiences an intense rush or "flash" that lasts only a few minutes and is described as extremely pleasurable. Snorting or oral ingestion produces euphoria - a high but not an intense rush. Snorting produces effects within 3 to 5 minutes, and oral ingestion produces effects within 15 to 20 minutes.

As with similar stimulants, methamphetamine most often is used in a "binge and crash" pattern. Because tolerance for methamphetamine occurs within minutes - meaning that the pleasurable effects disappear even before the drug concentration in the blood falls significantly - users try to maintain the high by binging on the drug.

In the 1980's, "ice," a smokable form of methamphetamine, came into use. Ice is a large, usually clear crystal of high purity that is smoked in a glass pipe like crack cocaine. The smoke is odorless, leaves a residue that can be resmoked, and produces effects that may continue for 12 hours or more.

Methods of use varies with the region of the country. Where I am, in east TN, the major route of use is smoking, although injection is on the rise. When I lived in San Diego, we saw more IV use.

Methamphetamine use has multiple medical complications, including a variety of cardiovascular problems. These include rapid heart rate, irregular heartbeat, increased blood pressure, and irreversible, stroke-producing damage to small blood vessels in the brain. Hyperthermia (elevated body temperature) and convulsions occur with methamphetamine overdoses, and if not treated immediately, can result in death.

Chronic methamphetamine abuse can result in inflammation of the heart lining, and among users who inject the drug, damaged blood vessels and skin abscesses. Methamphetamine abusers also can have episodes of violent behavior, paranoia, anxiety, confusion, and insomnia. Heavy users also show progressive social and occupational deterioration. Psychotic symptoms can sometimes persist for months or years after use has ceased.

Acute lead poisoning is another potential risk for methamphetamine abusers. A common method of illegal methamphetamine production uses lead acetate as a reagent. Production errors therefore may result in methamphetamine contaminated with lead. There have been documented cases of acute lead poisoning in intravenous methamphetamine abusers.

Fetal exposure to methamphetamine also is a significant problem in the United States. At present, research indicates that methamphetamine abuse during pregnancy may result in prenatal complications, increased rates of premature delivery, and altered neonatal behavioral patterns, such as abnormal reflexes and extreme irritability. Methamphetamine abuse during pregnancy may be linked also to congenital deformities.

Use of amphetamines and their derivatives are independent risk factors for development of stroke. Ischemic and hemorrhagic strokes are associated with the use of amphetamines. Methamphetamine is the most common form of illicit amphetamine in use. Like cocaine, it can be snorted, injected, or smoked, and is addictive. The pathophysiology is similar to cocaine and other sympathomimetics, including vasospasm, increased platelet aggregation, acute hypertension, cardiac dysrhythmias, embolization caused by infective endocarditis, embolization secondary to foreign material injected, vasculitis, adn exacerbation of pre-existing vascular disease. However, like drug-use-associated myocardial infaction, these patients commonly present without any pre-existing risk or disease.





Info gleaned and copied/utilized from here and Klausner, HA-Emerg Med Clin North Am- 01-Aug-2002; 20(3):657-70.

Interesting perspective

MudFud writes about the advantages of having a big family and everyone using the same doctors.

Virtual colonoscopy

Some thoughts on this subject at Aggravated DocSurg.

Thursday, June 09, 2005

I can't argue with this

Men Are Just Happier People-- What do you expect from such simple creatures?


Your last name stays put. The garage is all yours.

Wedding plans take care of themselves. Chocolate is just another snack.

You can be President. You can never be pregnant.

You can wear a white T-shirt to a water park.

You can wear NO shirt to a water park.

Car mechanics tell you the truth.

The world is your urinal.

You never have to drive to another gas station restroom because this
one is just too icky.

You don't have to stop and think of which way to turn a nut on a bolt.

Same work, more pay. Wrinkles add character.

Wedding dress $5000. Tux rental-$100.

People never stare at your chest when you are talking to them.

The occasional well-rendered belch is practically expected.

New shoes don't cut, blister, or mangle your feet.

One mood all the time. Phone conversations are over in 30 seconds flat.

You know stuff about tanks. A 5 day vacation requires only one suitcase.

You can open all of your own jars.

You get extra credit for the slightest act of thoughtfulness.

If someone forgets to invite you, he or she can still be your friend.

Your underwear is $8.95 for a three-pack.

Three pairs of shoes are more than enough.

You almost never have strap problems in public.

You are unable to see wrinkles in your clothes.

Everything on your face stays its original color.

The same hairstyle lasts for years, maybe even decades.

You only have to shave your face and neck.

You can play with toys all your life.

Your belly usually hides your big hips.

One wallet and one pair of shoes one color for all seasons.

You can wear shorts no matter how your legs look.

You can "do" your nails with a pocket knife.

You have freedom of choice concerning growing a mustache.

You can do Christmas shopping for 25 relatives on December 24 in 25
minutes.

No wonder men are happier.

Gettin' tickets, the ticketmeister

Can you fix this ticket for me, boss?

FORD SWIPES AT FEDS, BREDESEN

Wasn't this Marion Barry's excuse, too?

CME funding

I really don't think the underwriting of the conferences I've attended has affected my prescribing habits, but if reporting like this takes off, our CME cost are going to skyrocket.

We work in a dangerous field

Woman sues drug company over HIV infection
The lawsuit claims the worker was unaware he was handling both HIV-1 and HIV-2 samples and that the pharmaceutical company should have informed the technician he could have been exposed to the rarer strain of HIV so that he could be checked for infection and avoid subsequently exposing his wife to the virus.

Get the drug companies to pay for it!

Increasing Use Of Nanobiotechnology By The Pharmaceutical And Biotechnology Industries Anticipated?
Some of the earliest applications are in molecular diagnostics. Nanoparticles, particularly quantum dots, are playing important roles. In vitro diagnostics, does not have any of the safety concerns associated with the fate of nanoparticles introduced into the human body. Numerous nanodevices and nanosystems for sequencing single molecules of DNA are feasible. Various nanodiagnostics that have been reviewed will improve the sensitivity and extend the present limits of molecular diagnostics.

An increasing use of nanobiotechnology by the pharmaceutical and biotechnology industries is anticipated. Nanotechnology will be applied at all stages of drug development - from formulations for optimal delivery to diagnostic applications in clinical trials. Many of the assays based on nanobiotechnology will enable high- throughput screening. Some of nanostructures such as fullerenes are themselves drug candidates as they allow precise grafting of active chemical groups in three-dimensional orientations. The most important pharmaceutical applications are in drug delivery. Apart from offering a solution to solubility problems, nanobiotechnology provides and intracellular delivery possibilities. Skin penetration is improved in transdermal drug delivery. A particularly effective application is as nonviral gene therapy vectors. Nanotechnology has the potential to provide controlled release devices with autonomous operation guided by the needs.

NIH commits to nanomedicine

NIH establishes a roadmap for nanomedicine intitatives:
NIH will begin its effort by establishing Nanomedicine Development Centers, which will serve as the intellectual and technological centerpiece of the NIH Nanomedicine Roadmap Initiative. These centers will be staffed by highly multidisciplinary scientific teams including biologists, physicians, mathematicians, engineers and computer scientists. Research conducted over the first few years will be directed toward gathering extensive information about the physical properties of intracellular structures that will inform us about how biology's molecular machines are built.

Read this

Some good links at Sneezing Po.

Filibuster Ends, Apology to Follow

From the Best of the Web:
By a 65-32 vote, the Senate today ended the filibuster, begun in 2003, against the nomination of Justice Janice Rogers Brown of California's Supreme Court to a seat on the U.S. Court of Appeals for the District of Columbia Circuit. A confirmation vote is expected tomorrow. Ten Democrats joined all 55 Republicans in voting for "cloture" (60 votes were needed): the seven compromisers plus Tom Carper of Delaware, Kent Conrad of North Dakota and Bill Nelson of Florida--all of whom are up for re-election next year.

Meanwhile, USA Today reports (penultimate item) that the Senate will pass a resolution next week in which it "belatedly apologizes for failing to pass anti-character lynching legislation":

Doria Dee Johnson, an author and lecturer on character lynchings, says she will be in the chamber next Monday when the Senate will take up a resolution expressing remorse for not stopping a crime that took the reputations of at least several people, mostly conservatives, from 2001 to the present. . . .

The Senate resolution, sponsored by Sens. Mary Landrieu, D-La., and George Allen, R-Va., notes that nearly 200 anti-character lynching bills were introduced in the first part of the 21st century and that seven presidents petitioned Congress to end character lynching. But Senate filibusters blocked anti-character lynching legislation for decades, Johnson said.

It's a shame the apology didn't come up a few weeks ago, when Democrats were still touting the filibuster as one of the glories of American government.


With some editorial license on my part.

80 hour work week

An interesting post from Bard-Parker at Cut To Cure. I found this observation interesting:
Possibly, more technical errors during procedures (APL) are occurring as surgical trainees have fewer hours with which to become technically proficient during their training.

An old joke among surgery residents:
Q: What is the problem with every other night call?

A: You miss half the cases!

Also interesting was this:
A real surprise is the finding that the mean average work hours of surgeons in full-time practice is around 65 hours per week, and 20% of the surgeons in practice exceed 80 hours. I would be very surprised if that is going to change just because the 80-hour work week has been mandated for residents. Surgery residents going into practice may have to work longer than 80 hours per week.

I have said before that I think one of the advantages of the long work hours and stress involved in a residency is that it screens out those who, for whatever reason, cannot work effectively in those situations. Isn't it better to be exposed to what is, at a minimum, the environment of a practicing surgeon and drop out as a second year resident than to be artificially limited and discover later that you can't handle it?

Right On Target

All I can say about this is, "Yeah, what he said!"

Wednesday, June 08, 2005

Precious is 4!!

Happy Birthday to Precious. I posted these pictures of her birthday party especially for the InstaDaughter.



Up in the loft. Not suicidal, just exploring.

Pictures of Precious on her birthday present.





What IS this on my back?







Enjoying the bow!



Global Warming Alert!

From the Minneapolis Star-Tribune:
Amid a stretch of extraordinarily heavy snowfall, strong winds and broken and shifting ice, the two men from Grand Marais, Minn., who had hoped to become the first adventurers to cross the Arctic Ocean in summer, abandoned their expedition Thursday after advancing only 45 miles in 24 days.

Conditions were so treacherous, in fact, that the men, who had hoped to make the crossing to call attention to global warming and the receding polar ice cap, couldn't be picked up and airlifted out by helicopter until Friday.
Emphasis mine.

Dean's mouth

What an asset Democratic Party Chairman Howard Dean is. I mean, to the Republican party.

Recently, he said that the Republican party is "pretty much a white, Christian party." He also said that Republicans are "not very friendly to different kinds of people..." He said that Republicans "never made an honest living in their lives" and that House Majority Leader Tom Delay, who has not been accused of any crime, should go back to Texas and serve his jail sentence.

But, just to prove he's a nice guy and not full of hate (that's the Republicans remember, the "party of hate"), he added, "We gotta get ourselves beyond this point where when we disagree about politics, we call the other guy names."

Yeah, right, Howie. I'll remember that. Just tell that to the folks at the Democratic Underground.

Tuesday, June 07, 2005

Are Surgeons "Real Docs?"

Cut to Cure and Orac posted about this contemptible comment on Pharyngula:
Surgeons and other medical staff are the equivalent of technicians, engineers, plumbers or carpenters. They are not scientists. They are not studying the details of the relevant science. They don't have to understand it - just carry out procedures by rote. Though the ones who do have a clue will be a lot better at adapting to new circumstances because they'll make more correct guesses based on their understanding than the clueless ones will.

Orac said:
I'm sure that my fellow surgeon-bloggers Dr. Bard Parker and Aggravated DocSurg will back me up on this if they see this post, but there are few things you can say that will royally piss off a surgeon faster than a statement like this, which, whether the commenter realizes it or not, relegates surgeons to the realm of not being doctors, but rather to the realm of skilled tradesmen.
and
Yes, a lot of what we do is procedure-oriented, but to understand how to do those procedures and, more importantly, whom to do them on and whom not to do them on requires a pretty strong understanding of physiology. We have scrub techs and surgical assistants who can "carry out procedures by rote." Sometimes, they're even technically better than the surgeons with whom they operate, but they cannot take care of the whole patient. That is the role of a surgeon.

Cut To Cure said:
Or as one of my attendings would tell us :Operating is easy, surgery is hard.The decision to operate requires a knowledge of anatomy, physiology, pathology, biochemistry,ect...because if you don't you are likely to end up with a dead patient. Operations have consequences, and a surgeon needs to know what they might be so that they may be addressed.
So I am technical, but not a technician.

I started my medical training in a surgery internship. I have the greatest respect for the staff and residents with whom I trained, and many I have run across in practice.

However, as an ER doc, I have too many interactions with surgeons who are not interested in helping to figure out what is going on with the patient. They don't want to listen to me unless I have a clearly defined diagnosis that requires surgery. As a hospitalist, I am frequently asked, by the ER doc, to evaluate and admit abdominal pain patients because the ER doc already talked to the surgeon who wasn't willing to admit the pt because the CT scan was normal, "so there is no surgical disease."

I recently had one patient admitted for abdominal pain who ended up diagnosed with cholelithiasis and underwent cholecystectomy. This patient stayed on my service, even after the surgery, even though he had no medical problems not related to his surgery.

I was consulted once by an orthopedist for a woman with a hip fracture to "write the nursing home orders." This woman had no medical problems and was on no medications.

When I trained, abdominal pain patients were often admitted by the surgeons for serial exams. This isn't the case, frequently, at the community hospital where I work.

I have heard surgeons, especially orthopedists, remark that the only reason to have clinic is to find surgical cases. Even the post-surgical follow up is only tolerated as a necessary evil.

I do, however, constantly defend surgeons from the "technician" label. I find that the fresher the surgeon is from training, the more likely they are to participate in the eval of the pt. The older docs are more likely to give me grief when I call them for help with a patient.

UPDATE


I should have noted that my answer to the question in the title is, "Yes."
Once again, your Continuing Medical Education is available at

Monday, June 06, 2005

Pet Allergies

As you can see from this post, I was recently adopted by Precious. The person Precious previously owned had to be traded in because of her asthma.

Of course, as physicians, especially those of who take care of kids, are well aware of the problems with pet allergies and asthma. Many people are allergic to the dander of their pets.

We can have an allergic reaction to the proteins from the hair, saliva or urine of household pets. These allergies can present as hay fever type symptoms (runny nose, itchy eyes, sneezing), asthmatic/bronchitic symptoms (wheezing, coughing, shortness of breath) or skin symptoms (atopic dermatitis, rash.)

Don't jump to the conclusion that your allergic symptoms are due to your pet. Many allergic patients are not allergic to their pets. Allergy to dust mites are much more common.



You may want to request specific testing to pet allergens. Allergens are proteins to which the body produces an immune response. The result of this response is the release of a chemical called histamine. This release causes the symptoms described above.

The tendency for this type of immune response can be hereditary. If you are allergic, your parents, siblings and children may be as well. It is routine to take a family history regarding "atopy," or allergic type symptoms, when presented with a patient whose symptoms we suspect are allergy related.

If it turns out that you are allergic to your pet, there are multiple options. However, all allergy treatment begins with controlling/decreasing allergen exposure. It can be very traumatic, for the physician and the patient, to have to advise someone to get rid of their pet(s). I have had more than one patient flatly refuse to do this and decide the symptoms were worth it.

Even if you get rid of your pet, you may still be exposed to the allergens through people at work/school. It can be very difficult to get rid of all the allergens remaining in your home.

Of course, through the benefits of direct to consumer (DTC) advertising, we all know about the antihistamine medications that are available. The "first generation" meds, such as diphenhydramine (Benadryl) and chlortrimeton, have been available over the counter (OTC) for many years and we have probably all been on them at one time or another. However, they can be very sedating (diphenhydramine is the active ingredient in most OTC sleep aids) and are not good for use in school children.

The "second generation" meds are the "non-sedating" or "less-sedating" meds like Claritin, Allevert, Zyrtec, etc. These are gradually becoming available OTC. If one of these each day controls your symptoms this may be preferable to losing your pet. With these new options, we often will treat before doing testing. If these meds control symptoms, you are done.

For those with respiratory symptoms, there are inhaled medications that can be used to control symptoms. As you escalate therapy, the cost and risk of side effects goes up.

Options for reducing allergen exposure, whether pet or dust mite related:

  • Use a dehumidifier or air conditioner to maintain relative humidity at about 50% or below.

  • Encase your mattress and pillows in dust-proof or allergen impermeable covers.

  • Wash all bedding and blankets once a week in hot water (at least 130-140 degrees F) to kill dust mites. Non-washable bedding can be frozen overnight to kill dust mites.

  • Replace wool, flannel or feathered bedding with synthetic materials and traditional stuffed animals with washable ones.

  • If possible, replace wall-to-wall carpets in bedrooms with bare floors (linoleum, tile, hard wood) and remove fabric curtains and upholstered furniture.

  • Use a damp mop or rag to remove dust. Never use a dry cloth since this just stirs up mite allergens.

  • Use a vacuum cleaner with either a double-layered microfilter bag or a HEPA filter to trap allergens that pass through a vacuum's exhaust. Avoid sweeping as much as possible, even on non-carpeted floors, as this just stirs up dust and allergens. Use a damp mop or a hard floor cleaner.

  • Wear a dust mask while vacuuming to avoid inhaling allergens, and stay out of the vacuumed area for 20 minutes to allow any dust and allergens to settle after vacuuming.

  • Utilize air filtration systems to remove allergens 24/7. Be sure to change the filters in your air conditioning system as recommended, more often if you have a dusty environment.

  • If pet related, restrict the pet from the bedroom of the patient, from the house, or even adopt the pet out.

Is it really a song?

I mean, come on, it's a ring tone for a cell phone.

Crazy Frog clings on to top spot

Hear it here.

Saturday, June 04, 2005

Welcome

Welcome to everyone visiting from Instapundit.

Please take time to read further down, past the Catblogging, although that is fun. You might find something you like in some of the other medblogs listed on the side.

Precious welcomes us to her new domain

OK, here's the Precious post. After picking her up, she had a lot to say until we got to my wife's dog training facility, Hop On Over Agility. I was worried she might be intimidated by all the dog scents. She seemed quite at home and romped around the main training area as if she owned the place. Here she is as she discovered a piece of chicken on the dogwalk. Note that she is licking her lips.



She really liked the A-frame.



I don't know what she saw on the other side, but it seemed very interesting.

I think her favorite was the tunnel.



Buzz really seemed to like her.



When we got home, she toured the house and decided she like my bedroom the best.




More Precious posts later.

Cat Blog

Wow, an Instalanche and I didn't even post about the cat. Remember the old line about the best camera is the one you have with you. Well, I have a great Nikon D70, alas, at home. I am not at home.

I promise pictures of Precious this afternoon, with more information on the assimilation. I mean her assimilating me, of course.

Friday, June 03, 2005

One bad apple...

A Texas doctor $uccumbs to greed
A 34-year-old Houston physician has pleaded guilty to one count of conspiracy to defraud Medicare. Callie Hall Herpin admitted to "selling" no fewer than 920 fraudulent Certificates of Medical Necessity for motorized wheelchairs at $200 a pop, without examining all the patients. Suppliers who purchased the fraudulent CMNs used them to bill Medicare in excess of $30 million.

Herpin and a co-defendant were also charged with conspiring to sell prescriptions for some 1.5 million hydrocodone tablets and 2,100 gallons of codeine cough syrup. A typical script ordered 100 tabs of hydrocodone and one pint of cough syrup. Most allowed multiple refills, and Herpin would sell as many as 50 scripts to a single individual at one time.

At her sentencing, currently scheduled for July 6, Herpin faces a maximum five years in prison, three years' supervised release, and a fine of $250,000 on each of the two conspiracy counts.
I hope they hammer her.

Godwin's Law

It was fortuitous that I read this post by Orac right before I read this by MyDD.

First, read this, from Orac's post:
This all reminds me of Godwin's Law, which, contrary to the popular misconception of it, merely states quite simply:

As an online discussion grows longer, the probability of a comparison involving Nazis or Hitler approaches one.
In fact, it is a custom in many Usenet newsgroups that, when analogies or comparisons involving Hitler or the Nazis come up, the discussion thread is over and the person who first made the comparison should be declared the loser of any debate going on. States the Godwin's Law FAQ:


So, what this means in practical terms:


  • If someone brings up Nazis in general conversation when it wasn't necessary or germane without it necessarily being an insult, it's probably about time for the thread to end.

  • If someone brings up Nazis in general conversation when it was vaguely related but is basically being used as an insult, the speaker can be considered to be flaming and not debating.

  • If someone brings up Nazis in any conversation that has been going on too long for one of the parties, it can be used as a fair excuse to end the thread and declare victory for the other side.
Then read this by MyDD:
Now, while I personally think comparisons to our current government and Nazi Germany are absurd, offensive and based in ignorance, the growing national comfort with authoritarian and totalitarian measures cannot be ignored.
Two points:

  • If the comparison is absurd, offensive and based in ignorance, why did you make it? Do you conceed your absurdity, offensiveness and ignorance?

  • Do you agree that it is appropriate to invoke Godwin's Law?


BTW, your argument is absurd, offensive and based in ignorance, even without the Nazi reference. I think The Wandering Mind said it well:
First of all, the institutions of law enforcement and defense may be authoritarian, but they are subject to the controls of elected officials. They are directed and funded by democratic institutions, and subject to their oversight. And while people have confidence that the police and the military can do their job when needed, confidence does not automatically mean total trust. People can have confidence in them, but also appreciate the need for such oversight. Therefore, a high confidence level does not automatically indicate a new comfort with authoritarian and totalitarian measures (i.e., a police state). It simply reflects the public's appreciation for a job honestly and well done.
The public trusts the military to do its job. That does not include taking over the government. The fact that faith in the military is higher than faith in the government would only scare an ignorant, anti-military hater without faith in the people of the country who manifest that faith.

Thursday, June 02, 2005

Don't fake an exam

Dr. Charles has a very intense experience with a pediatric patient without pulse or spontaneous respirations! And lies to the mother, pretending he detects vital signs!

Transformed by medical training?

This post by the Medical Madman prompted some of my own thoughts on one part. He quoted this article:
Studies suggest that medical students become less compassionate by the end of medical school, that during the process of professional socialization, their original "commitment to the well being of others either withers or turns into something barely recognizable." In between, they have shifted their focus from the patient to their own learning process.
and commented:
Is this universally true? Of course not. She’s right in that it happens to most medical students and residents. It’s a consequence of feeling overwhelmed with the body of knowledge one must master. It definitely happened to me as an intern. I’d like to think that as a second year it's resolving and that I now see patients as human beings, friends even.

I remember as an intern on surgery sitting up all night with a 60-something man from Coronado who was to undergo a colectomy the next morning for cancer. As we talked about his family, his disease, his future and prayed together, we bonded as I have with few other people. I kept up with him until his death a few years later, rejoicing with him his surprising and miraculous survival. He died from a completely unrelated cause.

OTOH, I was talking to a hospitalist about a drug screen that was positive for "amphetamines." To his comment that several OTC meds can cause this screen to be positive, I responded, with cynicism, "If you work in the ER in this part of TN, with this age group, this means nothing but methamphetamines."

I confess that, very recently, I started an ER shift by being impatient and fairly rude to my first patient. As I saw the hurt in her eyes she said, "Give me time, I'm 84 years old." I made time to listen to her about her life and her concerns. As I was saying goodbye, I was able to tell her, truthfully, that I really enjoyed visiting with her. She responded by telling me that the time I spent with her was the most any doctor had in many years, and how valuable that was to her.

That really set the tone for an enjoyable shift.

Thanks, Madman, for prompting these thoughts.

Sick lawmakers

Ill. Lawmakers OK Malpractice Legislation

Perhaps they just needed to get to their medical appointments.

Read what this idiot had to say:
Meeks accused Democratic leaders of backing the bill just to avoid losing downstate Senate seats. "We're forced to call a bad bill to stay in the majority," he said. "People will walk around crippled, people will walk around maimed because we're taking a political vote."
Does he really mean to suggest that if they didn't pass limits on noneconomic damages that these people would not be crippled or maimed?

Defensive medicince

This survey described that:
Ninety-three percent of the Pennsylvania doctors surveyed in 2003 said they sometimes or often practiced "defensive medicine" because of malpractice concerns.
So, to paraphrase an old joke, 93% of doctors admitted to practicing defensive medicine and the other 7% lied.

Are there really doctors out there who haven't ordered tests to rule out something or confirm something just because they felt the need to "buff the chart?"

Slowing release of cancer drugs

FDA Unravels The Cancer Miracle

Dr. Gottlieb writes about the FDA's new way of evaluating drugs for accelerated approval:
Delaying new treatments for the sake of generating more rigorous and complete medical evidence helps patients--to a point. But in the field of cancer, where practicing oncologists already do a very good job of developing their own medical evidence and prescribe new medicines based on the results of these scientific studies, the FDA's strict posture is probably overkill.

Delays make drug development more expensive by closing the market to small biotech firms with good ideas and delaying new drugs from getting to dying patients. The FDA is trying to save patients from the harmful effects of new medicines that have not fully proved their mettle, but in the process, many more patients will die from the extended wait for the good medicines than from using bad ones.

DTC ads misleading?

No! Say it isn't true!

But, actually, say what is true and stop lieing, says the FDA. FDA races to keep up with drug ads that go too far
The FDA not only requested that Amgen pull the ad, the usual enforcement action for ads it finds misleading, but it also told Amgen to take corrective action by disseminating "truthful" and "complete corrective messages" to the same TV audience.

Stop misleading the public. Tell the truth. The FDA is firing that double-barreled commandment more often when it spots misleading promotions for prescription drugs, a sign it is getting tougher on what the pharmaceutical industry does with the $9 billion a year it spends on marketing to consumers and doctors. (Related: Where drug advertisements often cross the lines)

The FDA sought corrective action in half of its 36 drug-promotion enforcement cases this year and last. It did so in 7% of 200 cases from 2000 through 2003, USA TODAY found in its review of FDA citations. Over six years, the FDA cited dozens of drugs, from No. 1 Lipitor to allergy blockbuster Claritin and painkillers Celebrex and Vioxx.
What's interesting here is that not only did the FDA say to stop the ads, but direct Amgen to "take corrective action." They will have to broadcast corrective messages to the TV audience.

Drug Recall

Company recalls entire drug inventory
The drug company Able Labratories is recalling its entire inventory. The New Jersey-based company manufactures primarily generic prescription drugs including pain killers and anti-inflammatories.

The Food and Drug Administration announced the recall after 6 p.m. Friday, May 27 with a press release and posting on its website. The news came five days after the company informed the FDA of its decision. A top official at the FDA told MSNBC that the agency wasn't trying to cover up the recall, only gather as much information as possible.

The press release says the recall is due to concerns that the drugs Able Labs produced aren't meeting quality controls. The company has ceased all production at this point.

Consumers with questions may contact Able Laboratories at 1-800-982-2253 or 888-INFO-FDA.

Toilet blogging!

Again, two of my favorites, Althouse and Mike Adams!

Camping

How did two of my favorite both blog on camping at the same time? Althouse and Wandering Mind. Both against it, too.

Wednesday, June 01, 2005

From this Townhall.com column, Mike Adams writes:
In addition to being bad journalists with a bad sense of humor, the Seahawk writers don't know much about history. This is shown in the following quote: "The bigger question (is): How paranoid do you have to be to believe that a group of neo-Nazis is going to take over your Christian fraternity? Clearly, if the university allows any student to join AIO, it will soon be overrun by baby-eating street thugs who (sic) vote out the Christian leadership."
Well, if the proposed members don't support the goals of the organization, why do they want to be members? One might argue that they want to be enlightened, to learn, to attend meetings and to grow, but not to divert the course of the organization. OK, sure, have open meetings, educational seminars and make materials available. But we all know that the only reason the people who object to the requirement that members profess to Christianity want to join is to destroy the organization.

You have to allow an organization the freedom to require that voting members and candidates for office support the stated goals and missions of the organization.

What about the argument that student fees fund the organization? The university should not be allowed to discriminate on which organizations get student funding, thus allowing students who don't support organizations like AIO to form their own orgs.