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The iPhone TickDoctor

August 9th, 2009 by Paul Auerbach, M.D. in Better Health Network, Health Tips

Tags: Identification, Infectious Disease, iPhone, Lyme Disease, Tick, TickDoctor, Ticks

Dr. Jeremy Joslin is a wilderness medicine aficionado and has without question posted the greatest number of intelligent and useful comments to posts at this blog. So, I’m pleased to learn that he has created a very useful iPhone application named TickDoctor.

TickDoctor provides a stunning visual atlas of the most common ticks encountered in North America. Although not yet comprehensive, most common ticks are represented. For each tick species, the user is able to identify males, females, and nymphs. In many instances, there are included images of the engorged female, which often looks very different from its non-fed state.

More than just a beautiful atlas, TickDoctor provides instructions for prevention of tick bites and how to remove them if bites should occur. If a bite has occurred, or if you’re just plain curious, Dr. Joslin has included medically relevant data on each species, describing which diseases have been associated with it.

While this application should never substitute for the advice of a physician, it will help guide you to the identification of the tick in question and provide a framework of reference for dealing with “what to do next.”

I’ve been informed by Jeremy that, “if you have a great photo of a tick and want it considered for the next application update, let me know. You can do this by posting a comment and I’ll follow up with you. We’re always interested in making the atlas better.”

This post, The iPhone TickDoctor, was originally published on Healthine.com by Paul Auerbach, M.D..

Diabetes And Getting Pregnant

August 9th, 2009 by KerriSparling in Better Health Network, True Stories

Tags: Endocrinology, High Risk Pregnancy, Obstetrics And Gynecology, Pregnancy, Type 1 Diabetes

I stood there with my best friend as she rubbed her pregnant belly.  The whole waiting room was filled with these lovely women and their round beachball bellies of varying sizes.

And I felt oddly self-conscious with my lack of roundness.

Last Friday was my first official appointment at the Joslin pregnancy clinic.  It’s located at Beth Israel in Boston and is a beautiful hospital, different from the Joslin Clinic across the street that feels like home at this point.  I’m not pregnant, and we aren’t trying to become pregnant YET, but this appointment puts things into full swing to bring me to a safe level of pre-pregnancy health.

Sigh.  This all sounds redundant, even to me.  I’ve talked the Big Talk before.  “Oooh, look at me!  I’m going to really wrangle in my numbers and have an A1C you can bounce a quarter off!”  And I’m all gung-ho for a week or two, armed with my little log book and my good intentions, but within a few days, Other Things start to creep in.  Like work.  And stress.  And getting to the gym.  And social stuff, like hanging out with my friends and going to RI on weekends.  Eventually my good intentions end up in the spin cycle, and my log book starts to gather dust.  My workload piles up.  And my stress levels skyrocket.

I’m so frustrated because I want to have a career.  And I want to have a baby.  (I’d also love some tight control of my diabetes, too.)  These things would be excellent, but it feels like tightly managing type 1 diabetes is a full time job unto itself.  Slacking off is easy, and frustrating, and not healthy for me or any baby I’d like to have.

But I also realize this is one of my biggest hurdles when it comes to pregnancy planning – the whole “sticking with the pre-program.”  This becomes more and more obvious to me when I go back and re-read old blog posts where I’m so excited to get back into better control, only to be derailed by those Other Things.  So during the course of my appointments on Friday with the endocrinologist, the registered dietician, and the certified diabetes educator, I admitted my faults freely.

“I need help being held accountable.”

They didn’t quite hear me at first.  “We can do some tweaking, and in a month or two, we can revisit your A1C and see if it’s lower and then we can give you the green light for pregnancy.”

I knew I needed more than that.  I had to be completely honest.

“Guys, I really need to be held accountable.  I know this sounds crazy and I seem very compliant, but I have trouble following through.  I’m great out of the gate, but I lose steam after a few weeks and I’m at the point where it isn’t good enough anymore.  I’m out of excuses.  And I’d really like to join the ranks of those pretty pregnant ladies out there.  Please help me?”

And they listened.  We spent the rest of the day working out a plan for me.  One that will actually make a difference.  One that will get me there.

I’ll be in Boston every three weeks until I’m pregnant.  This is a huge commitment but I need to make diabetes a priority without fail.  I want this.  I want to succeed at this more than anything else.  I’ll have my blood sugars logged for those three weeks and we (my husband and my diabetes team and I) will all review them together.  Chris is in charge of my meals, in that he’ll be helping me plan my day, food-wise, and he’ll be counting carbs and measuring things for me. I’ll be eating relatively similar items every day so I can manage the trends and control them.  I’ll continue to test all the live long day and wear the pump and the CGM, but I’ll actually use these devices to their fullest potential, instead of just going through the motions.

With these appointments spaced just a few weeks from one another, I hope I can stay tuned in to intense diabetes management for three week stints.  Being sent out for three or four months is too much for me.  Obviously, because I burn out well before my follow-up appointments.  I just plain can’t pay rapt attention for that long.  But three weeks?  Can I do that?

I have to do that.

I will do that.

*This blog post was originally published at Six Until Me.*

Playing Tennis In Prison

August 9th, 2009 by Toni Brayer, M.D. in Better Health Network, True Stories

Tags: Prison, San Quintin, Tennis

I spent this morning on the “yard” at San Quintin Prison, playing tennis with the inmates. The prison has a tennis court, built right in the middle of the yard with hundreds of inmates shuffling about, shooting hoops, playing dominoes, working out or just milling about.

The guys who play tennis are a remarkable bunch. They are serious about their game, play whenever they can during the week and are really happy on Saturday morning when authorized “outsiders” come to play with them.

We play round robin; first team to 4 wins and a new foursome takes the court. They seem to have an understanding among themselves about who plays when. It is competitive but, believe it or not, very gentlemanly. Everyone is encouraging, with lots of high-fives and there is no cheating or bad line calls. The best part is when I am not playing, I am sitting on the bench with the guys, just chatting.

The tennis players in San Quintin are without attitude or posturing. Some do yoga or go to school. Some work in various prison jobs like making furniture, or stocking or cleaning cell blocks. Keep in mind some of these guys are there for life and they look pretty young to me.

In case you are thinking they have a soft life there, playing tennis and hanging out with civilians, think again. One guy showed me his lunch. It was 2 slices of white bread, a piece of bologna and mustard with a handful of corn chips. They can not receive gifts from the outside. If they have the money, they can order things from a catalog (tennis shoes, clothes, food items, personal supplies) every three months up to 30 lbs. There is no internet, no ipods, no electronics, no cable TV.

People ask if I feel “safe” there and I must say I do. Certainly the tennis players are respectful and warm. The other prisoners in the yard watch us but keep a respectful distance and no-one has ever made a comment or shown any aggression. Of course there are 4 guard towers with guns pointed down at all times.

One of the tennis inmates told me this cell block is less troublesome and there is less gang activity or fighting. Most of them are long timers or even lifers. I was told that “Bert”, one of the guys I played with before was finally released after 23 years. I hope he is playing tennis on the outside.

For a look at how it is playing tennis in San Quintin, watch this.

*This blog post was originally published at EverythingHealth*

A South African Surgeon Treats An American Tourist

August 9th, 2009 by Bongi in Better Health Network, True Stories

Tags: Bowel Ischemia, General Surgery, Ischemic Bowel, South Africa

Recently I spoke a bit about interaction with foreigners. The impression I left would have been strained to say the least. But as with all things there must be balance.

They were tourists (aren’t they all?) when in the Kruger she developed severe abdominal pain. Her son brought her to hospital.

When they called me, besides the usual clinical history the casualties officer made a point of mentioning to me that they were American and that her son, the one who brought her in, was a physician. Let me take a moment here just to mention a language difference between English and Americaneese. In South African English, a physician is a specialist in internal medicine. In American, it seems, a physician is simply a doctor. At that time I did not know this. None of us did. So when the patient told us her son was a physician we all naturally assumed he was a physician and not just a common or garden variety MD.

I mentally prepared myself for a confrontational family. Usually with non medical first worlders they question you at every turn. A physician (South African definition) traditionally is sceptical of the knife-happy surgeon. I couldn’t help thinking of the internist in scrubs trying to protect his patient from the destructive steel of the blood crazed surgeons. All I could hope for was a benign abdominal cramp which would soon pass.

The patient was in pain. She associated her discomfort with some or other something she had eaten the previous day in the Kruger. But it just seemed too severe. Besides, could anything bad actually come out of the Kruger? She had none of the signs which indicated that she needed immediate surgery. But the pain really bothered me. It nibbled away at the back of my mind. Then came the x-rays. They were worrying. I was looking at a partial obstruction, but the bowel was just too distended. One more thing to quietly eat away at my mind.

Then suddenly the son appeared as if out of nowhere. He greeted me in a friendly manner. I introduced myself as the surgeon. Even after hearing who or rather what I was, he remained friendly. I remained guarded. Afterall I was under the impression I had to do with a physician (when in actual fact I later found out he was only a doctor).

I showed him the x-rays. He could see they were not good. I then went on to tell him I was worried and I felt an operation was in order. At this stage let me mention that a partial bowel obstruction does not need to be operated immediately. It can be left for the next day. But in this case there were just a few too many things eating away quietly at my mind. I had a pretty good idea what this meant. He surprised me. He said that I should do whatever I thought was needed. I did.

The operation went as I expected. I expected necrotic bowel. I resected what was needed and did all the other things that us surgeons do in these circumstances. But when you have necrotic bowel, especially in people with a few years behind their names, the patients tend to be much sicker than they initially looked. This was no exception. We were worried about here generally and her hemodynamics and kidney function specifically. We were worried enough to send her to ICU. The gas monkey even felt the need to leave her intubated. I concurred.

After I had tucked her into bed in ICU I wondered where her son was. It was way after midnight so it was reasonable to expect him also to be neatly tucked into his own bed in one of the many guest houses in nelspruit. But I just felt I’d better check in the ward where his mother would have gone to if she hadn’t ended up in ICU. He was a colleague and besides, he might expect the worst if he found his mother in ICU intubated unexpectedly. I took a stroll to the relevant ward.

I found him and his wife sitting in the scantily lit room where his mother should have ended up patiently waiting for her return. I smiled. I was starting to like them.

I greeted them warmly. I didn’t want them to expect the worst. I then went on to explain that there had been necrotic bowel due to a twist of the bowel and therefore we felt it prudent rather to send her to ICU. I reassured them that she was well and we expected no further unforeseen problems. I warned him that she would be intubated and reassured him we would probably wean the ventilator and extubate her the next day. He was pretty ok with everything but I could see in his eyes the normal amount of stress associated with hearing that your mother needed to be admitted to ICU.

He put a strong face on it. He asked me a few questions and I did my best to reassure him on each point. Then he asked a question I was afraid I would not be able to reassure him on.

“And when we go down to ICU, will we be able to speak to the intensivist?”

“Umm…errr….that would be me.” After all, this was a peripheral town in South Africa. In fact there is no real intensivist in our entire province. Suddenly I felt sorry for these Americans. They were far from home, their mother was very sick and the best they had to look after her in ICU was a mere surgeon. There must have been at least some inkling of a misgiving in their minds. But he didn’t show it. He smiled at me and simply said;

“Ok. Well we’ll see you tomorrow morning then?” I was impressed.

The next morning I did not see them. They must have still been asleep after such a late night, I assumed. However the following few days their involvement really did leave an impression on me. It was also about this time that I realised he was not in fact a physician as I understood the word, but a doctor who was busy specialising in tropical diseases (or some such thing).

Anyway the patient did well. She had the setback of a bit of wound sepsis which, considering everything, I could live with (although I have heard that some people in America want to put it onto a never event list?????). That was soon sorted out and after not too much time she was sent on her merry way.

This case also caused me to be contacted from the States. The patient herself sent a thank-you letter as soon as she got home, as did her son. She then sent a further thank you letter a year later and the year after that.

So, if I left the impression that I have my reservations about treating foreigners, please think of this delightful old lady and her equally wonderful family.

*This blog post was originally published at other things amanzi*

Medicine & Information Overload

August 8th, 2009 by Joshua Schwimmer, M.D. in Better Health Network, Opinion

Tags: Index Medicus, Information, Information Overload, Medicine, PubMed

Image by Nuevo Anden via Flickr

The growth of medical knowledge is difficult to visualize. One classic representation is the Index Medicus — a comprehensive index of medical journal articles — whose bound copies filled the shelves of medical libraries for 125 years. In 2004, however, the National Library of Medicine decided to stop publishing the Index. The first reason was practical: the Index Medicus had grown from 82 pounds in 1985 to an estimated 152 pounds in 2004. The second and more important reason was the widespread availability of the search engine PubMed — an electronic database of medical literature available for free via the Internet — which made the printed index obsolete. Compared to the Index Medicus, PubMed was more convenient, could be searched more easily, could be updated more quickly, and certainly weighed less. Copies of the Index Medicus are now a historical curiosity; many physicians now search the medical literature exclusively through PubMed.

The story of the Index Medicus and its successor, PubMed, illustrates three ideas.

First, the quantity of new medical information is more than any single physician can absorb, and keeping up to date with this expanding body of knowledge is challenging. As of April 2009, for example, PubMed contained information on 18,782,970 citations in the medical literature and was adding over 670,000 new entries per year. Doctors must not only absorb this flood of new ideas about treating, diagnosing, preventing, and understanding disease — deciding which information is relevant and which is not — but also learn how to apply and explain this knowledge to the patient sitting with them in the exam room or laying ill in a hospital bed.

Second, in parallel with this unprecedented expansion in medical knowledge, new media and technologies have emerged — of which PubMed is one example — which has made the task of searching, organizing, and retrieving relevant information easier. Potential sources of information for physicians include not only printed journal articles like those indexed in PubMed, but lectures, case conferences, and newer Internet resources such as reference tools (e.g., UpToDate), discussion groups, online expert systems, clinical resource tools, and podcasts.

Third, the expansion of medical information and proliferation of new technologies has required physicians to develop new skills and strategies to keep their knowledge current. Often, the availability of new knowledge overwhelms physicians’ ability to process it, a condition known as information overload. In physician’s offices, one symptom of information overload is the common spectacle of unread piles of medical journals stacked up on every available horizontal space.

While many medical schools now require classes on searching the medical literature and evidence-based medicine, few resources have been available designed to teach physicians how to learn and practice medicine more efficiently. (That’s why, over two years ago, I started writing The Efficient MD blog.)

Since then, I’m glad to report that online resources for physicians have proliferated. Ways of improving efficiency and reducing information overload are now common topics on medical blogs. For example, see recents posts in Life in the Fast Lane, Clinical Cases and Images, and Musings of a Distractible Mind.

Thanks for reading!

—

(Much appreciation to Jacque-Lynne Schulman, Stephen Greenberg, Margaret Vugrin, and Dean Giustini for helping me with an updated estimate of the weight of the Index Medicus. Any inaccuracies in this post are, of course, my own.)

(This post is also published on The Efficient MD blog.)

This post, Medicine & Information Overload, was originally published on Healthine.com by Joshua Schwimmer, M.D..