Monday, January 30, 2006

On my wish list: Myvu
Obesity Contagious?
There is accumulating evidence that certain viruses may cause obesity, in essence making obesity contagious, according to Leah D. Whigham, the lead researcher in a new study, "Adipogenic potential of multiple human adenoviruses in vivo and in vitro in animals," in the January issue of the American Journal of Physiology-Regulatory, Integrative and Comparative Physiology published by the American Physiological Society.
OK, I can accept that a virus may make you hungry, but taking in more calories than you burn is what makes one obese. The article describes "adipogenic potential." Does this mean that the virus might make adipose out of nowhere? Or does it mean that there is a greater potential for imbibed calories to be deposited as adipose as opposed to used for some other reason?

No matter what infection you get, if you eat 1500 calories a day and burn 2000, you will not get fat.
Well, this certainly explains a lot about my social life in high school:
He believes the genes which make someone analytical may also impair their social and communication skills. A weakness in these areas is the key characteristic of autism."

Sunday, January 29, 2006

Hey, TWM! Is this you?

Saturday, January 28, 2006

Single workout can lift mood in depressed patients
A single 30-minute walk on a treadmill can give a temporary emotional lift to patients diagnosed with major depressive disorder, the results of a small study suggest.

Researchers found that among 40 men and women recently diagnosed with major depression, those who spent just a half hour on a treadmill reported a short-term improvement in energy and emotional well-being.

Though a single workout is not the answer to clinical depression, the researchers say, exercise could offer depressed patients a way to give themselves an emotional boost.
Works for me.
Now, this is cool. Helpful and informative, too.
This may be the only thing that could get me to vote for Diane Feinstein.
Hospitals may want to rethink cell phone bans
The prohibition against mobile phones in hospitals may do more harm than good, a new report reveals.

Medical facilities prohibit cell phone use, but some doctors already use them. And it turns out they reduce medical errors because communication is more timely, a new study finds.

Mobile phones rarely cause electronic magnetic interference, Yale School of Medicine researchers reported today.
FDA Approves Inhalable Insulin
The first inhalable version of insulin won federal approval Friday, giving millions of adult diabetics an alternative to some of the injections they now endure.

The Food and Drug Administration said the Pfizer Inc. insulin, to be marketed as "Exubera," is the first new way of delivering insulin since the discovery of the hormone in the 1920s.

Pfizer jointly developed the drug and dispenser with Sanofi-Aventis and Nektar Therapeutics. It should be available to patients by midyear, Pfizer said.
Cool beans.

Friday, January 27, 2006

Prize for DNA Decoding Aims to Fuel Innovation
When inventor Burt Rutan's SpaceShipOne soared 63.6 miles above the Earth in October 2004, he captured the $10 million X Prize and helped inaugurate the era of commercial human space flight.

The X Prize Foundation, a nonprofit-education organization, is looking to spur a new adventure -- into human genes.

The Santa Monica, Calif., foundation plans to offer a $5 million to $20 million prize to the first team that completely decodes the DNA of 100 or more people in a matter of weeks, according to foundation officials and others involved.

Such speedy gene sequencing would represent a technology breakthrough for medical research. It could launch an era of "personal" genomics in which ordinary people can learn their complete DNA code for less than the cost of a wide-screen television.

Details of the award are being worked out, and officials say they don't expect anyone to claim the prize for at least five to 10 years.
Hey, let's get started!
So who gets to define normal, anyway?

Experts Say Biology Makes It Harder for Boys to Behave

The problem is, define behave. So boys act like boys. What's the big deal? Our society has defined that boisterous behavior is "not behaving." Isn't this just as wrong as saying that being willing to sit still for hour after hour is abnormal?

Why should we define "behaving" or "normal" in such a way as to exclude 50% of our kids from that category? What about a girl who likes to be active?

Well, if it's tough to control the classroom, sedate those suckers!! Give 'em drugs because we don't want to have to find a way to educate them that accomodates/utilizes their behavior.

Doug Anglin complains that his high school makes it easier for girls than for boys to succeed academically, and the Massachusetts teenager is now trying to prove it to the federal government.

It may sound like sour grapes, but some experts believe Anglin has a point.

In the complaint that he lodged with the U.S. Department of Education's Office for Civil Rights, Anglin, 17, claimed that girls faced fewer restrictions from teachers at Milton High School in Milton, Mass., and that boys were more likely to be punished.

"The system is designed to the disadvantage of males," Anglin told The Boston Globe. "From the elementary level, they establish a philosophy that if you sit down, follow orders and listen to what they say, you'll do well and get good grades. Men naturally rebel against this."

The complaint comes at a time when boys' struggles in school are getting close examination. According to a 2005 report by the Educational Equity Center of the Academy for Educational Development in Washington D.C., boys around the country are increasingly falling behind girls academically, and are more likely to get suspended. And experts told ABC News that Anglin's assessment has merit and describes what prevails in most American classrooms.

"I think he's got it basically right, although I don't believe the system was set up purposely to hurt boys," said William Pollack, director of the Centers for Men and Young Men at McLean Hospital of Harvard Medical School.

Pollack and others noted that in general young boys in kindergarten and first grade are not able to behave as well as girls due to biological and social differences. He said that up until fifth grade, boys require five to seven recesses a day, though most get just one. "With a boy who squirms, you take away his recess," he said, "so then he either acts out and we say he's a discipline problem, or he's very active and we say he has hyperactivity."

...


"We have the data about learning-style differences and behavior-style differences," he said. "This is not a win-lose circumstance. It's not teachers against parents, parents against schools, boys against girls. It's a win-win. We recognize what we now know and use it."
Pollack also said:
The increased focus on testing in schools has also ratcheted up pressure on young students, he said. "In kindergarten, I had to learn … to socialize," he said. "Today they read and write. Some boys can. Most can't. There's a biological component."
Wow, what a thing to say! Can you imagine the reaction if someone stated that girls can't do something because of a "biological component?" We can't even argue that girls don't make good football players in high school without someone bringing up that girl that went to my second cousin's friends school in Mississippi who was the best football player at her school.

UPDATE: I would like to point out that DrHelen wrote about this as well. Her comments here.

Last night I listened to the podcast from Glenn and Helen with Norah Vincent. Get it here. Norah talked about how men don't have it as easy as many women, and some men, think they do. Specifically, she commented that many men don't know what they are missing. Men don't understand or appreciate the "freedoms" they are missing out on, because they have never had them. As a woman masquerading as a man, Norah felt limited in ways that she had not been as a woman, and missed them.

Boys growing up nowadays don't know that they are normal, just different from girls. Our educators should stop trying to force round pegs into square holes and using Ritalin as grease.
Geez, I mean, come on. When do you stop this crap? How many people are going to die so a few environmental wackos can feel better about the ozone layer?

FDA May Make Breathing Difficult for Asthmatics

The government may tell asthmatics to "take a hit" for the environment. But that "hit" won't be from their inhalers, which might be taken away.

A Food and Drug Administration advisory panel voted this week to recommend removing the "essential use" status that permits inexpensive, nonprescription asthma inhalers, like Primatene Mist, to remain on sale.

Powered by chlorofluorcarbon (CFC) propellants, the inhalers shoot epinephrine into the lungs of asthmatics, allowing them to breathe during potentially life-threatening asthma attacks. But environmentalists labeled CFCs a threat to the ozone layer in the 1980s, leading to an international phase-out of CFCs under the 1987 Montreal Protocol.

...

First, accepting for argument's sake that ozone depletion alarmism is justified, only a trivial amount of CFCs would be released into the atmosphere due to inhaler use. No detectable damage to the ozone layer would likely result.

...

No one disputes the basic chemistry of ozone depletion – chlorine atoms from CFCs released into the environment can find their way into the stratosphere where they can chemically react with and "destroy" ozone.

It should be noted, however, that CFCs aren't the only source of chlorine atoms in the stratosphere – Mother Nature, in fact, may supply most of them. Also, ozone is also continually being created so we won't ever run out of ozone.

In any event, none of the alleged environmental and public health horrors of CFC-induced ozone "destruction" have ever been observed despite extensive study – one of the best kept secrets of environmentalism.

While overexposure to UV is a risk factor for some types of skin cancer and cataracts, no scientific study has ever demonstrated a link between ozone depletion and such overexposure or any health effects.
How many people are suffering every day to save a very few the potential ill effect of Vioxx? Better question, how many have died from GI bleeds resulting from non-selective NSAIDs that they were forced to use when Vioxx was withdrawn?

We need to think about the effect of what we do, not just what makes a few feel better.

Quick review: No scientific evidence to link ozone depletion with disease. No evidence that the very small amount of CFC's in inhalers affects the ozone in any significant way. No research into how many lives are saved every year by inhalers utilizing CFC's.

Go figure.

But a few people will feel better because their pet cause is getting a lot attention. They won't even know about the asthma exacerbations and deaths I will see in the ER because people can't get their meds.

Thursday, January 26, 2006

Like a RSS site feed for good medblog stuff: Sneezing PO
Yeah, but the hiccups are gone, aren't they?
You should go here and read this blog. I found it because she is the host for next week's Grand Rounds. I love the name. Barbados Butterfly
So here's an interesting, at least to me, issue. Many of my colleagues, and most of the nurses, will check a blood alcohol on patients who have been drinking. Why?

If they have an altered mental status, the BA may help explain it, but you are going to have to work the patient up anyway. Why not do your work-up without checking the BA? What does the BA add? I would be concerned that an elevated BA might make you less aggressive about your work-up and you could miss something.

The other problem is the disposition problem. If you discharge a patient with documentation of safe gait, an understanding of his situation and an understanding of his discharge instructions, but without a BA, that should be sufficient. If he gets in a problem later, you don't have a pesky BA to explain.

If you discharge that exact same patient with a BA of 150 and then anything bad happens, you have to explain the BA. So the tendency in the ER is to keep the patient until the BA is less than 100. Why 100? Well, that has traditionally been the "legal BA." I often here referrence to "legally drunk."

Help me, Curious JD, but what exactly does legally drunk mean? It isn't against the law to be drunk, is it?

Of course, it is against the law to drive drunk. But we aren't releasing these patients to go drive. Just to walk to a car, driven by someone else, go home and go to bed.

Besides, the legal definition of DUI changes, doesn't it? Here in TN, it is now 80. But those same people feel OK about discharging a BA of 90.

Besides, we've probably all seen someone with a BA of 150 that could pass a field sobriety test, haven't we?

So my theory is this: Don't check the BA. If you think the patient is not safe to discharge, don't. If you think he is safe, document your findings that support your opinion and discharge.

If you are keeping a patient in the ER, or admit for OBS because of an elevated BA, are you suggesting that this person represents a risk to themselves or others? If not, why are you keeping them? If so, this would mean, potentially, an involuntary commital/admission.

What if the patient wants to leave, but you have a BA of 200 on the chart? Let's say that this is a chronic drinker, a frequent-flyer who is always drunk. Someone who comes to the ER, asks for a dinner tray and then wants to leave after he eats. His speech is fluent, maybe his gait is slightly antalgic. He knows where he is, what day it is and understands your instructions.

Do you let him leave? Do you call the police/security to keep him in the hospital?

Do you have a locked ward?

If you have admitted/kept in the ER a patient with the goal of discharging when the BA is less than 100, are you substituting this lab for your clinical judgement? What happens when you go in the room and the patient has eloped?

Give me your opinions about this situation. Under which circumstance would an ER doc be at greater risk if a patient leaves the ER and causes someone else to be injured:
  • A patient is discharged with careful documentation of the ER doc's findings of an apparently safe condition, but without any BA

  • A patient has a BA of 150, but the ER doc has documented findings of an apparently safe condition

  • A patient has a BA of 90, but the ER doc has not documented specific findings of an apparently safe condition

  • A patient has a BA of 150 and the ER doc has felt it necessary to keep the patient until the BA is less than 100, but the patient left without discharge

In the last situation, is the ER doc/hospital liable for not protecting the patient/community from this "legally drunk" patient?
Working in ER today. Just saw this chief complaint:
Hit elbow on peace of medal (steal)

Wednesday, January 18, 2006

Court permits contingency fee waiver
Passed by voters in November 2004 as Amendment 3, the law limits attorneys' fees to 30 percent of the first $250,000 recovered and 10 percent of all damages in excess of that amount in medical malpractice cases.

Since its passage, some trial attorneys have had medical malpractice claimants waive their rights under the fee cap. The attorneys said such cases are too expensive to bring under the smaller fees.
Too expensive? I thought expenses came off the top.

Anyway, look at this:
"We will work to warn the public about the procedure that greedy lawyers will be using to take an unconstitutional share of the client¹s funds," the FMA said in a statement on its Web site. "And if the procedure does not include judicial oversight, the FMA believes that physicians in Florida will be able to follow the same procedure established by the court to have potential patients waive their right to bring a medical malpractice action against the physicians. The FMA will advocate the use of a similar form and waiver procedure for physicians to use in their practices."
What would motivate a patient to sign away their right to sue? And what court wouldn't ignore the waiver if signed? If you told a patient he needed a procedure and then required he sign a waiver before you would do it, his attorney would just argue that he believed the only way to get this "life-saving" procedure would be to sign the waiver.

Tuesday, January 17, 2006

For extraordinary heroism as Combined Anti-Armor Platoon Commander, Weapons Company, 3rd Battalion, 5th Marines, 1st Marine Division, I Marine Expeditionary Force in support of Operation IRAQI FREEDOM on 25 March 2003. While leading his platoon north on Highway I toward Ad Diwaniyah, First Lieutenant Chontosh's platoon moved into a coordinated ambush of mortars, rocket propelled grenades, and automatic weapons fire.


Many say that the Army is broken. Some of our troops are on their third deployment. Recruitment is down, even as our military has lowered its standards. Murtha


With coalition tanks blocking the road ahead, he realized his platoon was caught in a kill zone. He had his driver move the vehicle through a breach along his flank, where he was immediately taken under fire from an entrenched machine gun.



Iraq can not be won “militarily.” Murtha


Without hesitation, First Lieutenant Chontosh ordered the driver to advance directly at the enemy position enabling his .50 caliber machine gunner to silence the enemy. He then directed his driver into the enemy trench, where he exited his vehicle and began to clear the trench with an M16A2 service rifle and 9 millimeter pistol.



the U.S. can not accomplish anything further in Iraq militarily.
Murtha


His ammunition depleted, First Lieutenant Chontosh, with complete disregard for his safety, twice picked up discarded enemy rifles and continued his ferocious attack. When a Marine following him found an enemy rocket propelled grenade launcher, First Lieutenant Chontosh used it to destroy yet another group of enemy soldiers.



…the United States now has a mercenary army. Professor David Kennedy


When his audacious attack ended, he had cleared over 200 meters of the enemy trench, killing more than 20 enemy soldiers and wounding several others.



And there is no reason, Bob, that young American soldiers need to be going into the homes of Iraqis in the dead of night, terrorizing kids and children, you know,… Senator John Kerry

"And I think you're saying the average guy out there who's considering recruitment is justified in saying 'I don't want to serve,"' the interviewer said. "Exactly right," Murtha replied


By his outstanding display of decisive leadership, unlimited courage in the face of heavy enemy fire, and utmost devotion to duty, First Lieutenant Chontosh reflected great credit upon himself and upheld the highest traditions of the Marine Corps and the United States Naval Service.



Who's the patriot? Citation here.

Saturday, January 14, 2006

With a cool new header, the blogger formerly known as the Medical Madhouse now is Doctor. Go check him out!

Friday, January 13, 2006

Wednesday, January 11, 2006

Thinking about buying one of these. What do you think?

If you want to get rid of something, sic the trial lawyers on it. Say goodbye to affirmative action.

Monday, January 09, 2006

After years of ER shift work, Dr. John Moone had no problem sleeping anywhere, anytime. Having just fallen asleep after a string of night shifts, he was surprised when he woke up after only 1 hour of sleep. Then he heard it again. A noise in the living room. There was definitely someone in his apartment!

Wrapping his robe tightly around him, he crept to the door and carefully looked out. There, sitting on the couch, were two people, looking directly at him.

"John, come on out. There is no danger here," said the short, bald man.

"My associate is Peter. I am Sheila." The equally sort, somewhat pretty woman gestured to him to sit in the chair.

Tentatively, John came forward and settled lightly on the edge of the chair, like a cat ready to run at the first sign of trouble. "Who were these people and how did they get in?" he asked himself. Normally very security conscious, he had multiple locks on his door, which appeared undisturbed. No broken windows, either.

"We mean you no harm. We need your help. If you will give us a few moments, we will explain why we chose you and what we need." What was her name? Oh, right, Sheila.

"I want you two to leave. I'll call the police." His stern tone belied his fear and anxiety.

"Please, just a minute of your time." Laughing, Peter added, "Yes, Yes, just a minute."

Confused, but settling down, Peter inquired, "How did you get in?"

"All in due time," was Sheila's answer. Peter snickered, "Due time, how good. Due time."

"Peter, please. Let me explain to Dr. Moone." Turning slightly to face away from Peter, Sheila directed her comments to John. "We are going to tell you some things that will seem very fantastic. You may have trouble believing us. However, you were chosen as someone who would be more likely to accept the ideas we will share."

"Chosen? What do you mean chosen?"

"We have access to full information regarding everyone who has ever lived, anywhere on Earth. This information was screened and our, um, computer might be the best word, indicated that you had the best combination of qualities," answered Sheila, calmly.

"What information? What qualities?" The rising pitch of his voice betrayed his level of anxiety.

"Let me show you something and then answer your first question. Then you might be ready for more information. Come here with me." Sheila indicated the window across the room.

John walked with her to the window. Surprised that he could attend to such things, John noticed the pleasant smell of her perfume.

As he looked out the window, John suddenly felt lightheaded and reached for the window frame to steady himself. There was nothing recognizable out there! Where was the courtyard, the barbeque area or the lap pool that had convinced him to live here? All he could see was more apartments. He seemed much higher than his second story apartment should have been. He looked out on what must have been hundreds of apartment buildings. All the same, it had the appearance of the "projects" in which he had been raised. "What's going on here?" he cried, slipping to the floor.

"Some things have changed. Someone important has died who shouldn't have. Many years ago, actually," Peter added to the conversation.

"And this happened? How could today be so different from yesterday because someone died some time in the past?"

"You asked how we go into your apartment. Nobody has locks on their doors. It might interfere with 'official entry requirements' according to the current regime." Sheila rolled her eyes.

"Careful!" came Peter's voice from across the room. "We can't be 100% sure that the monitors are off."

"Sorry. You're right. I better get to the point. John, one of the reasons you bubbled to the top of the list is because of some books you bought on Amazon. You demonstrated an interest in 'alternative history' type stories." Sheila's voice was gentle, trying to lead him along.

"You mean those books by Turtledove? And how do you know what books I bought?"

"We told you," Peter sounded irritated, "We know everything about you."

"Yes, those books," replied Sheila, with a disapproving glance towards Peter. "You seemed likely to accept the concepts we are going to share with you."

"Oh, jeez. Just tell me what is going on."

"We are from the future. Or, rather, a future." Sheila's head rocked with the force of John's interruption.

"Oh, come on!" He screamed. "You guys are nuts. What drugs did you give me? What the hell is going on here? Who are you?"

"John, please..." Sheila began.

"I told you this wouldn't work," Peter interrupted. "We should have drugged him and taken him, like I said."

"Peter, let me explain. I think he will understand," Sheila answered.

"Somebody explain, or get the hell out!" shouted John.

"John, sit down. Promise me you will listen for 5 minutes without interruption. I'm sure you will understand." Sheila's soft tones had the desired effect, calming John.

"As I said, we are from the future. Actually, just like in the books you have read, the future is malleable. Something happened to alter the timeline with which you are familiar. Someone broke the rules and altered the past. We are here to ask you help fixing that."

"Help fix what? Why me?" questioned John.

"As I said, I will explain. Just follow along. You were chosen for several reasons. You have read a great deal of science fiction, fantasy, especially alternate history type books. Well, this is like one of those stories. We thought you might be more accepting, given your interest.

"Additionally, you are an experienced medical doctor. You have skills we need. You see, as the world became more peaceful, less time and energy was spent on war and crime, so our healers don't have any skills in trauma care. Advances in infectious disease management has wiped out what you would consider infections and resulted in additional lost skills. Imagine someone in your time asking you to perform a procedure that hasn't been taught for centuries. You wouldn't be able to do it.

"We are here to ask you to travel with us and help repair time, so to speak. The world you see outside your window is the result of a change in an event hundreds of years ago that has been amplified through the years.

"As you know, in the latter part of the 18th century, your country fought for independence from Great Britain. The leader of that fight was George Washington, who went on to become your first president. What do you think would have happened if he hadn't been in that role? Some things may have been drastically different, and some may have been very similar. Look at your money."

John walked to his hall table and picked up his wallet. In it he found a red and white piece of paper with a very unfamiliar picture on it.

"What is this? Who is this? What happened to my money?"

"Someone has changed what you thought was history. George Washington died during the winter at Valley Forge. He never became your president. As a matter of fact, the colonies lost the war and remained under the rule of Great Britain."

"But if, as you suggest, those things changed, how can I remember the previous history?"

"I better let Peter address that," answered Sheila.

"John, that is a great question, and very perceptive. We don't understand everything that happens with time shifts," explained Peter. "That's one of the reasons we have tried so hard to prevent these things from happening.

"The best we can come up with is that some people are unaffected. For some reason, people like you awaken in what seems like a new world, but with memories of the previous history. Some people are able to adjust and fit in, others have been locked up in mental hospitals. As we have recognized what we call 'alternative history syndrome,' we have created 'neighborhoods' for these people. Sometimes hundreds of people remember the same history.

"Interestingly, at times, some people will simply live on in their new life as if nothing had changed. They appear to live in total denial of what they had done or said previously and proceed as if their new life was what had always existed. For example, in your day, there was blogger who supported your President Bush and the Iraq war. Suddenly, his writing shifted 180 degrees, without any explanation, and he was adamantly against those same issues.

"OK, OK, so what do you want?" asked John.

"We need you to go with us to Valley Forge, January 1778. We don't know why General Washington died or how to fix it," Sheila replied.

"Why change it?" John queried. "What's wrong with the alternate history? Do you try to go back and fix other shifts?"

"Peter..." said Sheila.

"Right. Another good question. This change was not accidental, nor was it the result of a natural temporal shift. Sheila and I work for a company that runs, well, what you would call a time tourism business. Someone broke the rules and caused this shift." He glanced nervously at Sheila. "Instead of, at most, a few hundred people not following the shift, this has pretty much split down the middle. Half the world is living in one history, half in the other. You can imagine the problems that are resulting. The results are mixed. Someone like you remembers one history but is living in a community caused by another history. That is why the view out your window is so odd."

"But what can I do?" asked John.

"We need your medical skills. We need you to travel to Valley Forge and examine General Washington, diagnose him and treat him."

"But how do I travel? What if I can't figure out what is going on? What equipment/supplies can I take with me?" So many questions filled his brain that only a few could slip out.

Peter answered, "We cannot venture outside this apartment. You can bring anything you have here that you think will help. We may be able to get a few things, but the world out there is very different from what you remember, and, frankly, very dangerous."

Jane added, "Get what you can and come back here. Time is short."

"Ha, ha." Peter snorted, "Time is short."

Dr. Moone grabbed his lab coat that contained his stethescope and penlight. He had a suture kit in the other room, along with the Augmentin he had picked up to take to his mother later that day.

As he walked back into the living room, he saw Peter fiddling with a small handheld device. "Ready?" Peter asked.

"Ye...."

Looking around, John saw Peter and Sheila standing in front of him. They were wearing different clothes, things he recognized from history books. Glancing at a nearby window, he realized that he, too, was wearing period clothing. In his pockets, he felt his stethescope and the bottle of antibiotics. He saw Peter holding an attache with his suture kit in it.

The building next to him had a sign in the window that said, "Long Live the King of Prussia." He realized that he was only about 2 miles away from Valley Forge, in what he new as King of Prussia, Pennsylvania. This must be the King of Prussia Inn, where George Washington wintered Valley Forge.

He followed Sheila and Peter into the small inn. A man was waiting for them and brought them to a small first floor room where a man was lieing on the bed. The aide gestured for John to come forward.

The man on the bed was slightly diaphoretic and tachypneic. Reaching down, John could feel a strong pulse at General Washington's wrist, with a heart rate about 120. Good color and the fingernails pinked up quickly after being compressed.

"Has he been eating?" John asked the aide.

"Yes, Doctor. But poorly. He says he has no appetite and thinks he should try to eat light, anyway, to spare food for the troops."

Listening with his stethescope, he heard clear breath sounds and a regular heart beat. "Has he been injured?"

"Four days ago he stepped on a sharp bone in the field. It pierced his boot and his right foot."

Pulling the blanket aside, John recognized the smell of pus. As he examined the right foot, he saw that it was diffusely swollen and red. The foot was swollen and the patient winced when John moved it.

"Sir, can you help me? I need to get back to my men?" General Washington had awakened.

"I believe I can," John answered. He thought to himself, "Wow, this is really him. Should I ask for an autograph?"

"Will you have to amputate?" the aide asked.

"No. Sir, you have an infection of your foot. I need to examine the wound more closely to see if there is any foreign body in there. This will be unpleasant." He opened the suture set and began to probe the wound. He removed two small slivers of bone and washed the wound carefully, as he said, "Dilution is the solution to pollution.

"Here, take these pills. One pill twice a day. That is the best I can do."

After years of ER shift work, Dr. John Moone had no problem sleeping anywhere, anytime. Having slept after a string of night shifts, he awoke as the alarm sounded. He hopped quickly out of bed and ran to the window. There was his familiar view of the lap pool.

"I guess it was just a dream," he thought as he searched for the Augmentin he had picked up for his mother.

Sunday, January 01, 2006

In an earlier post, I mentioned the AAEM's beginning a Remarkable Testimony project. The first case listed was with regard to the testimony of Dr. Tarlow who made some real woppers. On another blog, I called his testimony "crap" and was asked what I meant by that. Here are further comments:

  • Page 7: "And, in fact, half the people practicing ER medicine are not board-certified." He doesn't support this statement and I certainly doubt it. Almost every doctor I've ever been associated with in an ER has been board certified. Maybe not in emergency medicine, but board certified.

  • Page 7: "The American Medical Association really mandates people take examinations every few years." We all know that the AMA has nothing to do with board examinations and some boards do not require recertification.

  • Page 12: "...people with seizures don't develop seizures at age 50, okay, unless there's a tumor or aneurysm or something bad. People who have seizures at 40 or 50 typically have had them for many, many years, generally as an adolescent." It is certainly less common for older patients to develop seizures, but not so uncommon as to say it doesn't happen.

  • Page 14: Fast heart rate and fast respiratory rate are very non-specific and would not be useful to rule-in or rule-out a seizure. Most of the patients I see who are post-ictal are not tachycardic or tachypneic.

  • Page 15: Indicated that if a patient doesn't have incontinence of urine or stool, tachycardia, tachypnea, no history of seizure disorder and negative blood tests, she didn't have a seizure. What blood tests rule out a seizure? None that I know of. It is certainly possible that a patient could have none of the above and still have a seizure.

  • Page 16: "Facial droop. That's a seventh nerve palsy." Facial droop can certainly be a sign of a stroke, but not if it is a seventh nerve palsy, but rather an upper motor neuron lesion. If he felt it was a seventh nerve palsy, how did he rule out Bell's Palsy?

  • Page 16: "...in fact, she has all these symptoms" One of the symptoms he had just referenced was "sudden loss of bowels" but had indicated earlier that she had not had bowel incontinence which would have been a sign of a seizure.

  • Page 17: "If a person really thinks a patient has a seizure, they really, really, really think they have a seizure, the medication is clear. It's Valium IV push, Dilantin, and phenobarbital. No question about it. That's the therapy, period. Okay?" Well, no, Dr. Tarlow, not OK. ER docs see patients every day who they feel really, really, really have had a seizure and may not use any of those drugs. Personally, if a patient is seizing in front of me, I might use Ativan, not Valium. I might not use Dilantin if it had failed for that patient in the past, or if she was allergic to it. I use phenobarbital, but rarely.

  • Page 18: "We'll give them Valium until they become unconscious, intubate them, and load into that--load in the Dilantin and the phenobarb, if you really think they had a seizure." WHAT THE HELL???? Dr. Tarlow, are you suggesting that every patient you see in the ER who you believe had a seizure gets intubated? And you induce with Valium alone? The incredible vast majority of seizure patients get treated without intubation.

  • Page 18: "The patient didn't get any of these medications, so I don't believe the doctor thought at this time it was a seizure at all." Many patients who present to the ER with c/o seizure, who aren't actively seizing, may not receive any treatment in the ER at all. Especially if it is a first seizure.

  • Page 18: "If a person has a stroke or a TIA, then depending on what's involved, you're going to get tPA--which is that special magic bullet drug called tissue plasminogen activator--within three hours, or heparin or coumadin..." Just not true. If a patient presents to the ER with symptoms of a TIA, either resolved or rapidly resolving, you may do nothing. Certainly, the diagnosis of TIA is an absolute contraindication to use of tPA.

  • Page 22: Stated that you don't give tPA in a patient with a seizure because the seizure may have been secondary to a bleed or a tumor and these would be contraindications to use of tPA. Stated "If the head is normal, despite the fact the patient really had a seizure, it doesn't matter." Yes it does, Dr. Tarlow. If you suspect the presentation is secondary to a seizure, even with a normal CAT scan, you don't use tPA. Not because of the possibility of another condition, but because you don't treat seizures with tPA. Pretty basic.

  • Page 22: "...even with a seizure...you'll still give them tPA." A seizure at the onset of a stroke is one of the exclusion criteria for the use of tPA in stroke. See this.

  • Page 23: "It's a very classic--if you've ever seen a seizure, there's no way you would not--miss that diagnosis." Other than Dr. Tarlow, I've never heard of a doctor claiming that he could never miss any diagnosis, especially one as complicated as seizure.

  • Page 24: Indicated that the NINDS study and the NIH have established the standard of care for stroke treatment. "That's why we have the National Institutes of Health..." This is an unfounded claim. Neither the NINDS nor the NIH establish SOC. Specifically, the American Academy of Emergency Medicine has written:
    It is the position of the American Academy of Emergency Medicine that objective evidence regarding the efficacy, safety, and applicability of tPA for acute ischemic stroke is insufficient to warrant its classification as standard of care. Until additional evidence clarifies such controversies, physicians are advised to use their discretion when considering its use. Given the cited absence of definitive evidence, AAEM believes it is inappropriate to claim that either use or non-use of intravenous thrombolytic therapy constitutes a standard of care issue in the treatment of stroke.

  • On Page 25, he indicated that frequent checks should be recorded and that "It doesn't have to be the doctor..." Then, on page 26, he criticized the doctor because his next notation was 2 hours later.

  • Page 26: "...one needs to check that every 15 minutes, maybe 30 minutes..." This is an unreasonable standard, especially for a busy ER. Has anyone out there seen this as a SOC?

  • Page 33: In response to a question about whether the administration of tPA would have saved her life, he answered, "There's no question it would have." This is unfounded. There have been no studies demonstrating that use of tPA in stroke decreases mortality.

  • Page 34: "The Food and Drug Administration in very conservative. They will not approve a drug unless it is both safe and effective." Right, safe in the proper context and when the benefits outweigh the risk. However, tPA is not safe or effective in every patient. We all know that there have been drugs approved for use by the FDA that were later recalled. Vioxx, anyone?

  • Page 35: "...it [tPA] saves people's lives." Again, there is no evidence that tPA used to treat strokes decreases mortality from strokes.
This is commentary on Dr. Tarlow's testimony. I haven't read a transcript of the whole trial or the defendant's testimony. I can't comment on the merits of the trial or whether the defendant did or did not commit malpractice. So, Elliot, don't get on that train again. The testimony of Dr. Tarlow was full of errors and should not have gone to the jury.
Is it realistic to think that the local health departments can absorb the load of the uninsured?
Gov. Phil Bredesen recently announced a Safety Net program that will give the state's health departments a total of $140 million to allow the facilities to expand medical services. Those 191,000 people cut from TennCare will have another option, with many of them being absorbed by the local state clinics.
Why does Gov Bredesen think the health departments can now handle the load when they couldn't before?
"Good management has led us to a place where we can extend medical assistance programs for the benefit of our neighbors in need," Bredesen said in a news release.
If good management can do it now, can I get a refund on all the money wasted by the previous "bad management"?

How are they going to handle this? Nurse practitioners, for one, in Montgomery County.
The extra staff coming as part of the Safety Net program includes two nurse practitioners, two registered nurses, two nursing assistants and two office assistants.
And in Anderson County:
By Jan. 3, the new primary care services will be available at 39 county health departments across the state, with eight more counties scheduled to be added later in the year, according to a press release from the Tennessee Department of Health.

Fees will be based on income, with a $5 minimum.

The new and expanded adult primary health care services are for acute and chronic illnesses, said Sandy Halford, assistant regional director at the East Tennessee Regional Health Office in Knoxville. Acute illnesses include sicknesses like sore throats, earaches and pneumonia, while chronic illnesses include high blood pressure, diabetes, arthritis and certain heart conditions.
Note this comment:
No narcotics will be offered.
New staffing in Anderson and Roane counties as well:
When fully staffed for the new services, the health departments in Anderson and Roane counties will have new staff members, including a doctor, nurse practitioner, registered nurse, certified nursing assistant and two office support workers, Halford said. New physicians have already been hired for the Anderson and Roane county health departments, she said.
It will be interesting to see how this works. I anticipate a much higher need for funding than what the Governor is now describing. These health departments are going to be overwhelmed.

I like the comment about the narcotics. These health departments are going to be inundated, at least initially, with drug seekers.

Good luck.