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Army Searches For Rabid Animal That Infected And Killed A Soldier

Wow, that is awful beyond belief.

Army seeking troops bitten by stray animals following rabies death – Army – Stripes.

SEOUL – The Army is redoubling its search for anyone who might have been bitten by a wild animal in Iraq or Afghanistan following the Aug. 31 death of a soldier from rabies, the service’s public health command stated Wednesday.

“The death of this soldier is very tragic, and we are taking actions to Read more »

*This blog post was originally published at GruntDoc*

It’s Not A Tumor: Dr. Val Lacks Veterinary Savvy

onaoncomputerAs some of my Twitter friends already know, I had a bit of a scare a few days ago with my cat. I know that I more-or-less promised not to let this blog degenerate into cat talk (and for the record I love dogs too), but please indulge me because I think there’s a larger lesson to be learned.

A few days ago I was emailing away on my computer when I heard an odd thud behind me. I turned around to find my cat lying on her back with one leg fully extended, her pupils dilated, and a fine tremor in all four legs. This lasted for about 10 seconds and then she jumped back onto her feet and walked away as if nothing had happened.

My husband denied giving her any catnip, and since I hadn’t seen this odd behavior in her before I decided to keep a close eye on her. About an hour later she was walking across the floor when she suddenly raised her back rear leg, hopped a few steps, flopped onto her back and did the same weird leg extension, trembling, and let out a bizarre yowl.

That buys her a trip to the vet – and I started running my differential diagnosis through my head. It seemed to me that she was having some kind of focal seizures – and I wondered if she could be in renal failure (she had had a UTI earlier in the year) with metabolic encephalopathy, or perhaps a small tumor that had started to trigger some seizure activity. The episodes seemed to resolve completely in between episodes so I didn’t think she was having a stroke, she also wasn’t continuing to limp and when I pressed on her bones she didn’t flinch so I didn’t think she had broken anything. I called the vet and when asked for the “chief complaint” I was just as helpful as many ER patients:

Dr. Val: My cat’s ‘acting weird.

Receptionist: Could you be more specific?

Dr. Val: Well, she’s acting like she’s had catnip, but she hasn’t.

Receptionist: Uh huh… And what do you mean by that?

Dr. Val: She keeps falling on the floor and stiffening her rear leg. Then she gets up as if everything’s fine. This seems to be happening every hour or so.

Receptionist: I see. And is it possible that she could have eaten something toxic? Do you have poison lying around the house?

Dr. Val: Not that I’m aware of.

Receptionist: Well it sounds like you should bring her in. Can you be here in 15 minutes?

Dr. Val: Wow, that’s not much time. But I can try! I think she might be having seizures…

And so with the vet’s office being 15 minutes away, you can imagine the frenzied efforts that ensued – I managed (single handedly) to put together a cat carrier and stuff the “seizing” feline into it and hoist her onto a cart and push her down the city sidewalks, much to the amusement of onlookers, who probably fully believed that I was a cat-abuser, hearing the pitiful cries coming from inside the cage.

To make a long story short, I explained to the vet-on-call what I’d witnessed, and suggested that my cat might have a brain tumor. Luckily for me, the vet did not blindly take my diagnosis for granted, but performed her own physical exam.

The conclusion?

Vet: Dr. Jones I don’t believe your cat is having seizures. She has a subluxing patella.

Dr. Val: Um, so you’re saying that her knee cap popped out of place?

Vet: Pretty much, yes. That’s why she flops on the floor and stiffens her leg. She’s trying to get the knee cap to slide back into place. It’s a grade 3 subluxation, which means it pops out easily, but still goes back into place on its own.

Dr. Val: How do we fix it?

Vet: She’s a surgical candidate. We can create a divot in her femur to help keep the knee cap in the right groove.

Dr. Val: Wow, we don’t do that for humans. Are you sure that will work?

Vet: Well, you can try glucosamine. It will reduce the inflammation.

Dr. Val: Glucosamine doesn’t reduce inflammation in humans – and there’s no conclusive evidence that it improves joint health either. Isn’t this more of a mechanical problem that needs a mechanical solution?

Vet: [Becoming irritated] Yes, well you can see our orthopedic specialist. She’s not board certified though – but she has a lot of experience with these kinds of things.

Dr. Val: Well, is there a board-certified orthopedic veterinary surgeon that we could consult with? How much do you think that would cost?

Vet: There’s an animal hospital in Friendship Heights. I’m sure their surgeons are all equally well qualified. I guess the procedure would cost around $2000.

Dr. Val: Wow, $2000 to put a divot in a cat’s femur? Gee… I don’t know…

Vet: You should also know that your cat needs her rabies shot.

Dr. Val: She needs another one?

Vet: Yes, they need one every year.

Dr. Val: How likely is a house cat to get rabies? Are there rabid mice that could get into our condo?

Vet: [Scowling] It’s the law. All cats must get a rabies shot every year. There is one rabies shot that can be given every three years, but it’s been associated with osteosarcomas in cats. Would you like to give her that vaccine?

Dr. Val: Uh, no. But seriously, where is my cat going to catch rabies?

Vet: Maybe she’ll catch it from the other pets at the animal hospital when she goes for surgery?

Dr. Val: [Visions of Cujo dancing in her head] Well, that doesn’t sound like a very safe place to take her.

Vet: Would you like to buy some glucosamine?

Dr. Val: No thanks, I think I’ll go now.

***

I learned a few things from this amusing interaction:

1. People should try not to make diagnoses beyond their level of expertise. (Brain tumor versus subluxing patella? Yikes.)

2. Vets do not necessarily practice evidence-based medicine. (Glucosamine for a subluxing patella?)

3. There’s a lot of money in cat vaccines.

4. Cash-only practices are quite lucrative. My little visit cost $300.

What do you think I should do with/for my poor cat?

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Latest Cartoon

Richmond, VA – In an effort to simplify inpatient medical billing, one area hospitalist group has determined that “altered mental status” (ICD-9 780.97) is the most efficient code for use in any patient work up.

“When you enter a hospital, you’re bound to have some kind of mental status change,” said Dr. Fishbinder, co-partner of Area Hospitalists, PLLC. “Whether it’s confusion about where your room is located in relationship to the visitor’s parking structure, frustration with being woken up every hour or two to check your vital signs, or just plain old fatigue from being sick, you are not thinking as clearly as before you were admitted. And that’s all the justification we need to order anything from drug and toxin screens, to blood cultures, brain MRIs, tagged red blood cell nuclear scans, or cardiac Holter monitoring. There really is no limit to what we can pursue with our tests.”

Common causes of mental status changes in the elderly include medicine-induced cognitive side effects, disorientation due to disruption in daily routines, age-related memory impairment, and urinary tract infections.

“The urinalysis is not a very exciting medical test,” stated Dr. Fishbinder. “It doesn’t matter that it’s cheap, fast, and most likely to provide an explanation for strange behavior in hospitalized patients. It’s really not as elegant as the testing involved in a chronic anemia or metabolic encephalopathy work up. I keep it in my back pocket in case all other tests are negative, including brain MRIs and PET scans.”

Nursing staff at Richmond Medical Hospital report that efforts to inform hospitalists about foul smelling urine have generally fallen on deaf ears. “I have tried to tell the hospitalists about cloudy or bloody urine that I see in patients who are undergoing extensive work ups for mental status changes,” reports nurse Sandy Anderson. “But they insist that ‘all urine smells bad’ and it’s really more of a red herring.”

Another nurse reports that delay in diagnosing urinary tract infections (while patients are scheduled for brain MRIs, nuclear scans, and biopsies) can lead to worsening symptoms which accelerate and expand testing. “Some of my patients are transferred to the ICU during the altered mental status work up,” states nurse Anita Misra. “The doctors seem to be very excited about the additional technology available to them in the intensive care setting. Between the central line placement, arterial blood gasses, and vast array of IV fluid and medication options, urosepsis is really an excellent entré into a whole new level of care.”

“As far as medicine-induced mental status changes are concerned,” added Dr. Fishbinder, “We’ve never seen a single case in the past 10 years. Today’s patients are incredibly resilient and can tolerate mixes of opioids, anti-depressants, anti-histamines, and benzodiazepines without any difficulty. We know this because most patients have been prescribed these cocktails and have been taking them for years.”

Patient family members have expressed gratitude for Dr. Fishbinder’s diagnostic process, and report that they are very pleased that he is doing everything in his power to “get to the bottom” of why their loved one isn’t as sharp as they used to be.

“I thought my mom was acting strange ever since she started taking stronger pain medicine for her arthritis,” says Nelly Hurtong, the daughter of one of Dr. Fishbinder’s inpatients. “But now I see that there are deeper reasons for her ‘altered mental status’ thanks to the brain MRI that showed some mild generalized atrophy.”

Hospital administrators praise Dr. Fishbinder as one of their top physicians. “He will do whatever it takes to figure out the true cause of patients’ cognitive impairments.” Says CEO, Daniel Griffiths. “And not only is that good medicine, it is great for our Press Ganey scores and our bottom line.”

As for the nursing staff, Griffiths offered a less glowing review. “It’s unfortunate that our nurses seem preoccupied with urine testing and medication reconciliation. I think it might be time for us to mandate further training to help them appreciate more of the medical nuances inherent in quality patient care.”

Dr. Fishbinder is in the process of creating a half-day seminar on ‘altered mental status in the inpatient setting,’ offering CME credits to physicians who enroll. Richmond Medical Hospital intends to sponsor Dr. Fishbinder’s course, and franchise it to other hospitals in the state, and ultimately nationally.

***

Click here for a musical take on over-testing.

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Eat To Save Your Life: Another Half-True Diet Book

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Unaccountable: A Book About The Underbelly Of Hospital Care

I met Dr. Marty Makary over lunch at Founding Farmers restaurant in DC about three years ago. We had an animated conversation about hospital safety the potential contribution of checklists to reducing medical errors and his upcoming book about the need for more transparency in the healthcare system. Marty was…

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