Wednesday, August 31, 2005

Wow, this guy's professionalism is impressive. As a physician employed by an insurance company, I am used to being thought of as an insurance whore, which, of course, I am not, but this is over the top. Read in a letter written by a physician in support of his patient's disability claim:
We have had extensive functional capacity evaluations clearly outlining this patient's physical ability. The Gestapo hired guns at [insurance company] have this information...It is astounding to me that a medical doctor hired as a hit man by the insurance company...

In summary, thse sons of bitches already have their mind made up. The hired guns and closers have made their edict...I suggested that the patient seek legal relief and sue their ass [sic] off.
Beyond the idiocy of this letter, the functional capacity evaluations, which were well done, clearly demonstrated light capacity. All the reviewing doctor at the insurance company did was agree with the findings in the FCE submitted by the claimant!

You have to wonder if he is familiar with Godwin's Law.

Tuesday, August 30, 2005

Yes, indeedy, Grand Rounds. Yeah, Yeah, Yeah!

Monday, August 29, 2005

Rectal Exam Sensitivity Improved Without Gloves
“What we found was striking,” says Casiano. “Basically, a glove appears to really hinder these exams. You wind up missing a LOT of things. Like tiny little hemorrhoids you never even knew were there. Or, little irregularities in the shape of the prostate. While not clinically relevant for the most part, these are things we feel physicians ought to know about their patients.”

Based on the findings, Casiano’s group is recommending that all physicians either forgo the use of gloves entirely during rectal exams, or at least cut the index finger off from the gloves. Also recommended is that physicians who do a great number of rectal exams, e.g. gastroenterologists, should keep their fingernails neatly trimmed, as fecal material “tends to accumulate” under the nails.

“Doing rectal exams without gloves may sound a little repulsive at first,” added Casiano, “but we find that physicians eventually like the bonding experience it gives with their patients. And you’d be surprised – a little antibacterial hand gel goes a long way."
I'm sorry, did you say that physicians like the bonding experience?

Saturday, August 27, 2005

'

You know, I really hate the use of scare quotes. Those are the quotation marks writers put around a phrase when they are questioning the real meaning of the words. In a comment on this post, Greg P did that with the phrase noble cause.

But, Greg, you missed the point. You see, the soldiers in Irag volunteered to be there for the very reasons outlined in this letter. As someone who was in the military, I feel very proud of the noble cause that service represented. You diminish and insult the very real nobility of that service with the scare quotes. You are suggesting that it isn't a noble cause. Maybe not for you, but it certainly is for those who volunteered.

So, Greg, the noble cause is very real and deserves to be honored, not insulted. If you don't believe service in the military is a noble cause, then don't. But don't belittle others' use of the phrase with scare quotes.

Friday, August 26, 2005

Alan Matthews hated being late for work. He was due at the ER at 10pm and had overslept. No wonder, as he hadn't laid down until about 6.

What a day! Started at 10pm last night, his third straight night and then his brother's annual lake bash today. It was stupid and he shouldn't have gone. He really needed the sleep. And getting slightly toasted when he had to be at work tonight was another bad idea. "Well, maybe more than slightly," he thought with a grin.

But, whatever, he was sure he had slept off the alcohol. Besides, this was a Thursday night and these were traditionally slow. Heck, he might even get a couple of hours of sleep, if he got lucky. "Anyway, even at 50% I'm better than most and I'm sure I can get through this, luck or no," he smirked to himself.

But, right now, he didn't feel lucky. His head was aching, despite the 800mg of Motrin he had gulped down on his way out the door.

"God, I hope it's a slow night," he swore softly, pulling onto the four-lane divided highway. "At least there isn't any traffic at this time of night, I can make up time on this stretch of road." He didn't see any lights ahead of him and pushed his little BMW to over 100 mph.

He always got a thrill from this car and enjoyed the feel of speed. "I work hard and I deserve this car."

With a start, he awoke and realized he had nodded off. There were a few other cars on the road now and he slowed to about 80. He slid smoothly into the left lane to move around a small Honda. Right at that moment a big Ford dually turned left from the median directly in front of him!

He slammed his car back into the right lane and slipped past the huge truck, noticing the startled expression of the driver and the squeal of tires behind him.

With that adrenaline rush on board, he made it to the ER just on time, without further incident. Relieved, he thought, "Man, if I hadn't had such a great car and such great reflexes, I might've been dead back there." Ignoring, of course, that if he hadn't been in a BMW sports car, he might not have been going that fast to begin with.

Strutting into the ER, he shouted, "All hail the great ME! Here at last!" He chuckled along with a few of the nursing staff. He didn't hear them whispering behind him as he went to relieve his partner. "What an asshole!" "Oh, man, if I had known he was going to be on tonight, I would have called in." "He really does think he's God's gift to medicine, doesn't he?"

"I don't have anything to sign out. There are a couple checking in and we got a call about a trauma coming in from the highway. Some kind of car wreck. One fatality and two others pretty severe. A rollover of some small car. Probably a drunk. Anyway, EMS was going to fly them to the trauma center, but the helicopter was out. Are you going to be OK, or do you want me to stay until they get here?" his partner offered.

"God, you asshole, I can handle ten before you could get your gloves on," he thought. "No, I can handle it. Thanks," he replied. "Go on home."

Katrina walked over by Martha. "Better get the trauma room ready and call x-ray, we're getting a bad one."

"Sure thing, Katrina. Hey, did you smell alcohol on Dr. Loveshimself over there?"

"Yeah. Wouldn't be the first time. You know, too, his brother's big party was today. Judy said he really made an ass of himself drinking! Not that he needed the alcohol to be an ass. I heard his wife left early after he started hitting on that new respiratory therapist. I just hope he's up to this. I wish Dr. Ray had stayed."

Hearing the sirens approaching, the ER team assembled in the trauma room, with built in x-ray and cabinets full of supplies. The mother was going to T5 but the daughter needed to come in here. She was in the worse shape.

Moving the boarded patient over to the trauma table, Katrina called for a chest xray, c-spine and pelvis. Martha prepped to draw blood.

Registration called out, "The woman's brother is in the waiting room. I'll put him in the family conference room. The chaplain is on his way in. EMS reported the driver, an adult male, was DOA with an almost complete decaptiation."

"Doctor, she's not breathing and her BP is 80 over palp. Can you get her intubated?" prompted Martha.

"I know what I'm doing, nurse. Just do your job and let me do mine," he barked, moving to the head of the bed. "Someone find out what happened. Type and cross for 2 and get in two large bore IV's. And someone hold her still. Jeez, turn off some of those alarms, my head is killing me!"

Their eyes meeting in an unspoken message of concern, Martha and Katrina moved to get "fingers and tubes in every orifice" and tried to restrain the increasingly combative teenage girl.

The secretary came in. "Her mother said someone in a little sports car was driving like a drunken maniac and tried to pass them. He swerved to avoid a truck and forced them off the road. They flipped into the ditch."

Matthews' head whipped up. "Did the truck stop?" he asked, his voice quavering. "Did they catch the driver of the car?"

"No, not yet," came the voice of the sheriff's deputy in the corner. "We do know it was a small convertible, something like a BMW."

"God, I can't see anything with this damn collar in the way. Here, you, respiratory therapy chick, hold her head while I take this collar off. I can't do everything myself. Do I have to do my job and yours?" Anything to distract and change the subject.

"He's loosing it, just like last time," Martha whispered to Katrina. "This isn't going well. Have someone call in the surgeon on call."

Muttering and swearing, the doc probed with the laryngoscope, trying to get a clear view of the larynx. "Damn it, I've got to have better exposure!" he yelled as Katrina tried to pull the young woman's leg back to the table.

Dr. Matthews screamed, "I need more room, you idiot!" at the therapist and elbowed her in the chest. She slipped on a puddle of blood and fell backward, letting go of the patient's head. The head lifted from the table as the doc pulled up on the laryngoscope handle, trying to elevate the jaw.

Suddenly, there was a slap as the girl's leg fell to the table. She was no longer combative. There was an unnerving silence in the room as everyone realized just what had happened. Without proper support, and with the traction from the laryngoscope, the patient's c-spine fracture had separated, paralyzing her.

"You fool, look what you did, you incompetent buffoon!" boomed the ER doc. He blustered at the staff staring at him, "That wasn't my fault, this idiot...Well, anyway, it's up to me to save the day, again." He reached up to wipe away the sweat beaded across his forehead, leaving a crimson streak of blood.

"I'll have to do a surgical airway! Get me a scalpel!" he screeched at Katrina. As she hesitated, concerned, he reached across and grabbed a number 10 blade from the counter. Shaking and uncontrolled, he moved the shining silver to the smooth skin of the beautiful young girl's throat.

Tears streamed down his cheeks as he panicked. He had to get her breathing again!

"Please let me help," Katrina said calmly, reaching for the knife.

"Get away!" he brayed, slashing out. Katrina pulled her hand back just as the sharp surgical steel whispered past.

He reached out and cut. Blood the color of magenta squirted, jetting across his chest. With a look of terror, he dropped the knife and stared across the table at Katrina. She reached across to apply pressure, as the flow became a trickle and then just dripped slowly to the floor, the only sound in the room.

Horrorstruck, the staff watched as the doctor left, followed by the deputy.

In the call room, the doctor sat with his head in his hands, tears flowing freely. Sobbing, he looked up as the door opened and Deputy Johnson walked in.

"Uh, what just happened, doc?"

"I...I...I killed that girl."

"Twice."

Thursday, August 25, 2005

You really should read this. But only when you have time to give yourself a few minutes to come back to earth.
AAEM Position Statement on Screening and Redirection of Emergency Department Patients
The primary duty of an emergency department is to care for the most severely ill patients. With increasing emergency department patient volume the care of bona fide emergencies may be compromised if physician, nursing and other resources are occupied with the care of non-emergencies. Therefore, it is the position of the American Academy of Emergency Medicine that the direction of patients who do not have medical emergencies away from an emergency department is ethical. The determination of a non-emergency requires the performance of an appropriate medical screening examination by a qualified provider. If a hospital enacts such a program, AAEM encourages the hospital to provide referral or access to alternative sources of care for such patients.

However, while redirection of individuals without emergencies is an ethical practice, AAEM does not believe it is in the best interests of the hospital, the emergency physicians, or the community at large to deny patients access to care, and would rather hospitals create systems to accommodate all persons presenting to its ED.

5/25/05
Our hospital is not screening and redirecting. I think the biggest concern may be generating ill-will in the community, not a fear of EMTALA.

Wednesday, August 24, 2005

Nanotechnology used to Kill Cancer Cells
The nanocells are small enough (only 200 nanometers) to pass through the tumor blood vessels. They are not small enough to pass through healthy tissue blood vessels.
Nanoparticles Used To Deliver Gene Therapy
According to a paper published this week in Proceedings of the National Academy of Sciences, scientists say they have superseded previous methods of gene delivery into living organisms, without the usual side-effects. Instead of using potentially toxic and unstable viral vectors, University of Buffalo (UB) scientists developed and customized nanoparticles that they successfully used to deliver genes into the brains of living mice. The new findings build on previous research from the same institution.


The new paper describes how the UB scientists used gene-nanoparticle complexes to activate adult brain stem/progenitor cells in-vivo, demonstrating that it may be possible to "turn on" these otherwise idle cells as effective replacements for those destroyed by neurodegenerative diseases, such as Parkinson's. In addition to repairing damaged brain cells, UB researchers say that the nano-particles provide promising models for studying the genetic mechanisms of brain disease.
Unwanted pregnancy spurs malpractice suit
A Bay Point woman says Planned Parenthood and the Contra Costa Regional Medical Center are responsible for the costs of raising her child because they failed to keep her from getting pregnant.
She is suing, alleging "wrongful life."

The article goes on to say:
She decided to keep the child, now named Elija, after seeing him sucking his thumb in a sonogram, according to the complaint.
Nanomaterials to Mimic Cells
Mimicking a real living cell by combining artificial membranes and nanomaterials in one construction is the aim of a new research grant at UC Davis. The Nanoscale Integrated Research Team grant, funded by the National Science Foundation with $1.6 million over four years, will study membranes mounted on aerogels, solid materials riddled with so many tiny pores that they are mostly empty.
Few utilize help available at TennCare fair
"It's a little frustrating when you sit there looking at each other, and waiting for someone to come in," said Sarah Hall of the TennCare Consumer Advocacy Program. "But I think there are reasons, and the biggest of them is those who need the help are either too sick or overwhelmed. I fear a lot have given up."
No, Sarah, the biggest of them is that these people have been trained that they are entitled and they don't expect to have to do anything for themselves. Don't you know that you and the others with you should drive to their houses, fill out the paperwork for them, and then come back to drive them to their appointments?

Tuesday, August 23, 2005

Grand Rounds. Great medical goodness. You should read it. No, really, you should.

Monday, August 22, 2005

The Wandering Mind and SneezingPO have updated, refreshing looks. Check them out!
Put him in the Comfy Chair!!

Although, I would prefer this one:

Malpractice Fix
President George W. Bush's proposal to cap pain and suffering awards at $250,000, which is currently stalled in Congress, would not solve these underlying problems. But the advocacy group Common Good--in conjunction with the Harvard School of Public Health--is taking a look at a different reform possibility: throwing the system out entirely, and replacing it with a new kind of special malpractice court.

Their model would replace juries composed of average citizens with an administrative panel presided over by judges with some medical expertise, and would replace the dueling expert witnesses paid by each side with ''neutral" experts paid by the court. Instead of rolling the dice in today's system, some injured patients could be automatically reimbursed for lost wages, medical costs, and additional fees without having to prove negligence.

Similar systems have been implemented in several countries, including Sweden and New Zealand. And it has already been discussed here in Massachusetts, where both houses of the state Legislature voted last November to clear the way for a commission to look into the feasibility of a medical malpractice court.
I am strongly in favor of a special malpractice court. The issues are so complex that I don't expect the judges or the juries to be able to understand them unless they have time to develop some expertise. I have never met a doctor who felt he was judged, in a malpractice suit, by "a jury of peers."

In the stroke case I presented earlier, the testimony of the plaintiff's expert was so outside the mainstream that the trial judge should never have allowed it. A more experienced judge would have recognized this. One doctor's opinion, unsupported by any medical evidence, does not establish standard of care, especially when there actually is strong evidence to the contrary.

The Fair and Reliable Medical Justice Act, introduced by Senators Michael Enzi (R-WY) and Max Baucus (D-MT) would create special health courts on a pilot project basis. This article states:
The bill's purpose is:

To restore fairness and reliability to the medical justice system by fostering alternatives to current medical tort litigation, including the creation of a special health care court, that promote early disclosure of health care errors and provide prompt, fair, and reasonable compensation to patients who are injured by health care errors;
To promote patient safety through early disclosure of health care errors; and
To support and assist states in developing such alternatives.
The bill would authorize the U.S. Secretary of Health and Human Services to award up to 10 demonstration grants to states for the development, implementation and evaluation of alternatives to current tort litigation for resolving disputes over medical errors. Within that context, the bill specifically authorizes the creation of a special health care court. The hallmark of such a court would be full-time judges with health care expertise, whose sole focus would be on addressing medical malpractice cases.
At Day on Torts, a blog by a trial attorney who represents "only plaintiffs in personal injury and wrongful death cases," Mr. Day wrote:
I wonder if anyone who drafted, sponsored, or supports this bill ever gave any thought to the Seventh Amendment or its counter-part in the constitutions of the 50 states?

Nah. Decisions concerning the responsibility of health care providers are too important to be left to patients.
Sorry, Mr. Day, but perhaps you should read the bill and the amendment again. Of course, your post only indicated that you read the article and didn't follow the link to the actual bill. The Seventh Amendment to the US Constitution states::
In Suits at common law, where the value in controversy shall exceed twenty dollars, the right of trial by jury shall be preserved, and no fact tried by a jury, shall be otherwise re-examined in any Court of the United States, than according to the rules of the common law.
The bill proposes three types of models:
  1. Early Disclosure and Compensation Model

  2. Administrative Determination of Compensation Model

  3. Special Health Care Court Model
Nowhere in the bill does it state that a plaintiff cannot file a civil suit and specifically describes circumstances under which the plaintiff could file suit.

The intent of the bill is to establish these models and a review panel to report on the efect of the grants awarded on the number, nature and costs of health care liabliity claims; a comparison of the claim and cost information between States receiving grants; and a comparison between States receiving grants and States that did not receive grants to determine the effects of the grants and reforms on the liability envronment, health care quality, patient safety and patient and health care provider and organization satisfaction with the reforms.

Let your Senator know what you think about this bill.
Indications for Singulair® Expand with FDA Approval for Perennial Allergic RhinitisGreat, another drug for allergic rhinitis. A great number of people suffer from AR, especially here in East Tennessee. But what about those of us with non-allergic rhinitis? What do you folks tell your patients to use? The only thing that seems to help me, intermittently, is pseudoephedrine, and this is getting harder to get.

Friday, August 19, 2005

Some thoughts for those considering EM as a career, from GruntDoc.

Check out this site for some rather, er, interesting prom attire.

thanks to Fred's World

Thursday, August 18, 2005



We do thinks just a little bit differently here in the south, don't we?
You know, Two Men and a Truck are pretty popular around here, but if you want a real bargain, you should go for Two Chicks and a Roll of Duct Tape!




Bad Precious, Bad Precious! You know you aren't supposed to be on the couch!

UPDATE: More Precious hijinks here.

Tuesday, August 16, 2005

Grand Rounds #47, the blog carnival of medicine, nursing and healthcare, is now up on Circadiana.

Monday, August 15, 2005

How would you like to get this in a letter from a patient? What does it tell you about the patient?
You can't retire because you're the best and I can talk to you easier than the therapy guy. If you left, I'd be left out in the cold with no-one who cares or that I could talk to. I LOVE YOU, DOC.
Willie Mae is a 74 year-old woman who fell at home. As she stated, "I just tripped over my feet." When evaluating patients with falls, you have to be as concerned with the reason for the fall as you are with the results of the fall, perhaps more so.

Willie Mae had good vital signs and was alert. Her family members indicated that her mental status was as sharp as ever.

However, Willie Mae had lost her battle with her sidewalk. On inspection, she had a superficial 5 cm laceration on the right cheek, following the zygoma. She had crusted blood in her nares and the beginning of a pair of impressive shiners. The bridge of her nose was flattened and wide. She had normal occlusion.

She complained of pain in the left shoulder and was unable to lift that arm.

However, CT of her facial bones was markedly abnormal. Her maxillary sinuses were full of blood, as were her ethmoids. She had fractures through both alveolar ridges and through the pterygoid plates. She had almost powdered her nasal bone.

Willie Mae had a LeFort II fracture:

LeFort complexes. These are complex bilateral fractures associated with a large unstable fragment ("floating face") and invariably involve the pterygoid plates. Legend has it that LeFort dropped skulls off of a French tavern roof and analyzed the resulting fracture patterns. This certainly sounds like the kind of study that we would all like to do, even without NIH funding. In reality, LeFort studied fracture patterns produced in cadavers. He found three main planes of "weakness" in the face, which correspond to where fractures often occur: the transmaxillary plane, the subzygomatic or pyramidal plane (this is really two planes with an apex up at the bridge of the nose), and a craniofacial plane.

The LeFort I, or transmaxillary fracture runs between the maxillary floor and the orbital floor. It may involve the medial and lateral walls of the maxillary sinuses and invariably involves the pterygoid processes of the sphenoid. Clinically, the floating fragment will be the lower maxilla with the maxillary teeth.

The LeFort II occurs along yet another weak zone in the face, and is sometimes called a pyramidal fracture because of its shape. A common mechanism is a downward blow to the nasal area.

The most severe of the classic LeFort fracture complexes is the LeFort III. I suppose that this is pretty obvious, given a three-part grading system. In this case, the large unstable (floating) fragment is virtually the entire face! Thus, this fracture is also referred to as craniofacial disassociation. This is a very severe injury, and is often associated with significant injury to many of the soft tissue structures along the fracture lines. Generally, considerable force is necessary to produce this injury, and it is uncommon as an isolated injury. It may also occur in association with severe skull and brain injuries.

With the exception of the LeFort I injury, "pure" LeFort injuries are not commonly seen. More commonly seen are variants of the LeFort classification. One of the most common of these is the LeFort II - tripod fracture complex. This complex is usually due to the large forces encountered in a motor vehicle accident. LeFort was probably unable to apply this much force to the cadaver faces in his study, and it is therefore not too mysterious why he didn't describe these more complex injuries. When describing these injuries, one should probably give a separate diagnosis to each half of the face. Even more complex patterns may be encountered, such as a mixed LeFort II/LeFort III complex or a LeFort III/LeFort II/tripod complex.
From Facial and Mandibular Fractures

She also had a proximal humerus fracture:


Gravity was her enemy.
Our local EMS has a policy that leads to almost all MVC patients being placed in full spinal package. We try to see them as soon as possible to get them off the boards. Our nurses reflexively order C-spine x-rays, although, with most of these, we can cancel the x-rays after clearing the patient clinically.

I am an advocate of doing something all the way or not doing it. When a patient presents to triage with a complaint of neck pain and an appropriate mechanism, such as a fall or MVC and you suspect a c-spine injury, you should fully protect the patient. I have worked in ER's where the triage nurse would just put on a soft collar. Even just placing a hard collar is dangerous. I believe that you are admitting that you suspected a c-spine injury without adequately protecting the patient from the injury. If you don't do anything, at least you could argue later that you felt the likelihood of a significant injury was so low that no protection was required.

Anyway, John, a 56 year-old man, presented about 1700 on a Saturday afternoon. He was complaining of a sore neck and a headache. He had wrecked his truck about 12 hours earlier and walked home, a distance of approximately 2 miles. His father reported that he had taken a "hydro" when he got home and then slept until just prior to presentation.

Our triage nurse alertly called for a collar and spine board. My colleague evaluated him and found a completely normal appearing man, neurologically intact. John was complaining of a sore neck with a good mechanism of injury, so my colleague ordered c-spine films. Here is what we saw:



Up close:



A classic "Hangman's Fracture." Of course, it isn't classic that this man was up and about for 12 hours with this fracture. I commend an alert triage nurse for recognizing this and not blowing this off because of the 12 hour delay in presentation.

We transferred this guy to our local referral Level 1 trauma center and he has done well. He was incredibly lucky.

Why, you ask, is it called a "Hangman's fracture?" Well, I can tell you.

Hanging has been a method of execution for centuries. Initially, the executioner would simply tie a rope around the victims neck and raise them off the ground, resulting in strangulation. The use of the hangman's noose, with it's characteristic knot



will actually break the neck, resulting in a much quicker execution, to the relief of those required to witness. The resulting fracture is a C2 pedicle fracture, as this patient had.

Friday, August 12, 2005

The three best complaints, as noted on the triage sheets, on my last ER shift:

  1. Bleeding from down there. 12 year-old girl, no history of menstrual bleeding. Mother can't figure out what it is.

  2. We're going on vacation next week. I just want to make sure my kids aren't going to get sick. (Registered 4 children to be seen)

  3. Left lower extremity pain for 20 years. Just wanted to get checked.

Honorable mention, just because of how common it is:

  • 18 month old boy with temp of 100.0. Received immunizations yesterday. Taking po well, normal behavior.

Wednesday, August 10, 2005

I heard a report on the radio news yesterday about this. The description of the two was amazingly detailed, down to the exact poundage of their weights. However, until I saw the picture on the web, I didn't know that he is black and she is white. Did political correctness kept this very important info from the newscast?

Tuesday, August 09, 2005

For your enjoyment, Grand Rounds is up.

Monday, August 08, 2005

Trust me, I'm from a pharmaceutical company and I'm here to help
That such a move would be obviously ineffective has not stopped the Pharmaceutical Research and Manufacturers of America from saying that they'll handle any problems with advertising prescription drugs directly to consumers. The Food and Drug Administration, says PhRMA, needn't worry about a thing.

Nanomedicine vs Cancer

Nanotechnology used to target, kill harmful cancer cells
Dai and his team shine a very thin laser beam of near-infrared light on something called a carbon nanotube.

The electrons in the nanotube - a hollow tube, resembling straw, made of interwoven carbon atoms about one-100,000th the diameter of a human hair - become excited by the light and release energy in the form of heat.

The heat is so extreme that it is deadly to cells.

To test this approach as a therapy, Dai placed the carbon nanotubes inside a collection of cancer cells, then shone the three-centimeter laser beam on them. The cancer cells were destroyed.

``They were literally cooked to death,'' Dai said. ``The tube acts like a tiny heater.''

But cells without the carbon nanotubes showed no ill effects - the light passes harmlessly through them.

One of Dai's big challenges was to find a way to deliver the nanotubes to sick cells.

He knew that cancer cells have specific receptors. So his team coated the nanotubes with a certain kind of molecule, called folate, which latches onto folate receptors.

This strategy succeeded in delivering the folate-coated nanotubes inside cancer cells, bypassing the normal cells - like Trojan horses crossing the enemy line.
MIT engineers an anti-cancer smart bomb
The team loaded the outer membrane of the nanocell with an anti-angiogenic drug and the inner balloon with chemotherapy agents. A "stealth" surface chemistry allows the nanocells to evade the immune system, while their size (200 nanometers) makes them preferentially taken into the tumor. They are small enough to pass through tumor vessels, but too large for the pores of normal vessels.

Once the nanocell is inside the tumor, its outer membrane disintegrates, rapidly deploying the anti-angiogenic drug. The blood vessels feeding the tumor then collapse, trapping the loaded nanoparticle in the tumor, where it slowly releases the chemotherapy.
Breakthrough Nanotechnology Reduces Infection Rates of Medical Devices
Bruce Gibbins, PhD, Founder and Chief Technology Officer of Portland based AcryMed, Inc. presented findings on AcryMed's new silver nanoparticle technology, SilvaGard™. Through the discovery of how to create nanoparticles of silver in a solution that are easy to use and tenaciously adhere to surfaces, SilvaGard allows medical device manufacturers to apply antimicrobial silver to device surfaces in a uniform, non-hazardous and cost effective manner. For the first time, antimicrobial products can be created that are chemically and dimensionally unchanged, thus retaining all of their intended properties.

SilvaGard has already been licensed for its first medical device application and is currently in production.

“This is an important step forward in the fight against a serious public health problem-hospital related infections,” stated Jack McMaken, president and CEO of AcryMed. “There are two million hospital acquired infections annually in this country--90,000 result in death. About half of these infections are associated with catheters and other percutaneous devices that provide a support surface for organisms to track into deeper tissue. A typical infection can cost as much as $47,000 per patient to treat. Our SilvaGard treatment provides a legitimate solution to many of these hospital related, life threatening infections by preventing the formation of biofilms on medical devices.”
How conscious are we about ascending infections up Foley catheters and phlebitis and cellulitis caused by IV catheters? This type of technology may do away with the practice of changing IV sites every 2-3 days. A great boon for the patients.
Volcker Says Iraqi Oil Buyer Paid UN Program Chief
The official who ran the scandal- plagued United Nations aid program for Iraq took $147,184 from an oil trading company for helping the business get contracts to buy Iraqi oil, according to an inquiry led by former U.S. Federal Reserve chairman Paul Volcker.
These are comments from office notes by treating physicians and Independent Medical Exams:
    “It is my best clinical guess at this time that …. has suffered some seizures”

    “the patient was unable to recite the alphabet in order (i.e., stating which letter comes before and after another)”

    “the patient made many erroneous errors”

    “these scores (memory) are remarkably low, and generally are not seen in other individuals who have not awoken from coma”

    “he saw his father periodically until he died in a fire when he was 13”

    “the patient was in a state of over-whelmedness”

    “the patient’s spouse is artistic, and has made most of the items decorating the home”

    “the patient cannot work anytime soon in the future”

    “CC: pain in tail”

    “on speeded verbal tasks, the patient held her breath and rushed through part of the test, giving rapid answers until she could no longer breathe. She then gasped and complained of dizziness”

    “I think that she is temporarily totally disabled, I think this will be on a permanent basis”

    “he related that he has difficulties in the bathroom cabinet” [no further explanation given]

    “has blond hair.. could be fixed more carefully”

    “Something happened in December, 2002.” [no explanation of what!]

    [after complete failure of TOMM], “results… must be taken with a grain of salt”

    “at the time of the stroke, he was “playing” with his wife on their bed” (italics in original)

    “[patient] stated that if he has blisters on his feet, he notes that the next couple of days he will have substantial problems in cognitive functioning”.

    “hemorrhoids over the weekend, causing seizures”

    “tends to be cryful”

    “she was traumatized when she moved from Pennsylvania during middle adolescence to Southeastern Wisconsin…. she finds people in Southeastern Wisconsin slow, hypocritical and often too fat”

    “[the claimant] and her ex-husband were friends who used to be lovers”

    diagnosis “Agorapanic disorder”

    “this report summarizes Ms. X…… scores on a brief, but fairly comprehensive screening of neuropsych functions”…. [okay, which one is it?]

    “there is no evidence of significant compression or anxiety” [thank goodness, that compression is devastating]

    “he was born on a marine based in Barstow”…. [I’d like to see that!]

    “patient was hit by a mild truck”

    “the onions expressed to do {sic} not constitute a recommendation that specific claims or administrative action be made or enforced”
Sometimes truth is really stranger than fiction!

Friday, August 05, 2005

Like the man says, "Buckle up."
Funny, I've been craving popcorn this week, also.

Thursday, August 04, 2005

Tales of a Wandering Mind is having shoulder pain. He had mentioned that he had an MRI and now tells us the MRI is normal. Good news. However, he is still having pain and is wondering about an injection.

Funny your doc discussed referring you to pain management and you posted on this today, as I am at a pain management seminar right now.

He asked a question that I will try to answer. These are general comments and not meant to address any specific patient issues.

It is unfortunate that your primary care doc doesn't do injections. This is certainly something that many primary care docs do. I wouldn't refer a patient to pain managment for this type of issue. Most pain management specialist focus on chronic pain issues and don't work with specific limited pain issues such at rotator cuff tendonitis. If I thought my patient needed an injection and I couldn't do it, I would consider referral to ortho/sports med/physiatry.

Consider the ortho referral (or a sports med doc such as I) as your doc may not be as familiar with the treatment modalities or alternative diagnoses to be considered. If he doesn't do joint injections, and shoulders are very easy, his level of interest in ortho/sports med issues may not be high enough to keep him up on these.

For years I thought I had rotator cuff issues in my left shoulder and did rotator cuff exercises out the wazzoo and had intermittent responses and flares. Primarily, as I look back, I just limited the activities that hurt. I can't work overhead for more than a few minutes at a time.

Finally, I got tired of these limits and went to see my neighborhood orthopedist. I knew I didn't have a rotator cuff tear, as there was no weakness, just pain. After a good exam, he diagnosed me with inflammation in my AC (acromio-clavicular) joint. He injected that joint and I was relatively pain free for several months. The AC joint is just toward the midline from the shoulder, where the end of the clavicle (collar bone) meets a part of the scapula.

The pain is starting to bother me again and I will probably seek another injection soon. Sometimes 2 or 3 injections will resolve the issue permanently. Occasionally, surgery is required.

I don't know any details regarding the problems TWM is having, but I wouldn't send a patient to MRI unless he had failed more conservative therapy or I had a very clear idea that there was a problem that was going to require surgery.

Conservative therapy for rotator cuff tendonitis or mild to moderate rotator cuff tear would involve ice, analgesics (NSAID's or Tylenol) and exercise. Frequently, especially if the doc isn't familiar with sports med, referral to physical therapy can teach specific exercises to rehab the shoulder.

If anyone has questions, feel free to comment or e-mail me. I can discuss general issues of disease/injury, even if I can't provide specific diagnosis and treatment over the internet.

Wednesday, August 03, 2005

I am at a CME conference in Hilton Head, SC, this week. Right now, the lecturer is discussing the regulatory environment surrounding pain management and the prescribing of narcotics.

He keeps referring to their "in-house" attorney. How come no-one ever talks about the "out-house" attorney?

Tuesday, August 02, 2005

I have received e-mails asking how Precious is doing. Well, she is doing very well. She has overcome her initial shyness and has incorporated the rest of the house into her domain.

Recently, she had begun to hang out on top of a large wooden box in our foyer. She just seemed to like it there. There actually is a function for this box. This is where Kitty Kitty lives.

This is Kitty Kitty:


Of course, there is little in the picture for scale. Kitty Kitty is about 55 pounds and 16 feet long. Kitty Kitty eats one 10 pound rabbit per month.

Now, Precious is about 11 pounds and probably doesn't smell much like a rabbit, but certainly seemed to get someone's attention when she jumped on the 1/4 inch plywood top to Kitty Kitty's box, causing it to bow in.

By the way, my wife named the snake. She called it Kitty Kitty because she believes that's what the snake thinks, as in "Heeeere, Kitty Kitty!"

Here's what we saw:

Click on the picture for a larger view.

Fortunately for Precious, that hole is only big enough for Kitty Kitty's snout. Next thing we knew, Precious was batting at the snake's snout! What a brave cat!

More to come.
Grand Rounds is up. Read. Ingest. Learn. Enjoy.

Monday, August 01, 2005

This 75 year old man presented to the Urgent Care one evening after a day of golfing. A very unusual presentation, in that he had no history of any significant medical problems, was on no medications and had no history of any significant injuries.

He presented about 7pm with 3 hours of low back pain. He stated that he felt somewhat embarassed about coming in for something so trivial, but that his wife had made him. How many times have we heard that?

He had spent the early afternoon golfing, as was his usual habit. Again, as usual, he went for a soak in the hot tub. As he was getting out, he twisted to place his foot down and felt a sudden onset of sharp low back pain. He pointed to his left lower back area.

On exam, his vital signs were normal and stable. He appeared comfortable and in no distress. He did use his hands on the arms of the chair when asked to stand and was slow to step up onto the exam table.

He was tender to palpation across the low back, especially on the left and there was moderate muscular spasm.

The young doctor, only about 6 months out of internship, was moonlighting in the Urgent Care. She felt comfortable with this presentation and ordered a lumbar spine series, confident she would see degenerative changes.

And she did. What 75 year-old man doesn't have degenerative changes on an LS spine xray?

She informed the patient and his family of her diagnosis: lumbar strain with muscle spasm. She advised the use of Tylenol #3 and robaxin. The patient seemed comfortable with this diagnosis and advice and prepared to leave.

However, the patient's son asked to speak with the doc outside the room. He told her of his concern for his father. "He never complains of pain. You need to understand that for this man to come to the doctor, especially at night, he would have to be in a great amount of pain. More than he would get from a lumbar sprain. And he didn't tell he threw up on the patio as he got out of the hot tub. Are you sure it's OK to go home?"

Upon further interview, the patient admitted that he had been nauseated since the time the back pain began. He also described vague diffuse abdominal discomfort, but no pain.

The doc looked at the x-rays again. Was there something there that she had missed? Were those whitish irregular arcs significant? They measured about 14cm apart at greatest distance.

She went back for further exam. The patient had good distal pulses and no bruit over the abdomen or femorals. No history of claudication. No pulsatile mass in this moderately obese man.

She called the vascular surgeon on call for her group. He scoffed when she told him of her concern and the distance between the arcs on the x-ray. "No aneurysm could be 14cm, it would have ruptured long before that!" he exclaimed. Nonetheless, he agreed to accept the patient for transfer to the ER.

She advised the patient and his family of her concerns. She advised them to drive straight to the ER and not stop at McDonald's on the way there.

On her way home, the inexperienced doc found herself in the middle of a panic attack. She suddenly realized how foolish it had been to send the patient by private vehicle and not by ambulance. What if they went home instead of to the hospital? What if he died in the car on the way? Am I good enough to be doing this?

One week later she got a call from an unusually polite vascular surgeon. Somewhat abashed, he apologized and explained what had been the result of her transfer.

The ER doc had performed a CT scan of the abdomen and called the vascular surgeon about a 10cm abdominal aortic aneurysm. Remember that plain films magnify about 40%? Well, 14cm is 140% of 10cm, isn't it?

After evaluating the patient in the ER, the surgeon decided to postpone surgery until the morning, given the stable condition. As he was leaving the ER, he reconsidered. He called his partner to come in to assist and went to the OR.

They were standing outside the operating room as the elevator door opened and the nurse and the tech wheeled the stretcher down the hall. As they passed the two surgeons, the patient passed out and became very pale.

They threw the pulseless patient onto the OR table, opened the chest and cross-clamped the aorta. Four days later he walked out of the hospital, already planning his next golf date.

Sometimes it is better to be lucky than to be good.