July 24th, 2009 by Shadowfax in Better Health Network, True Stories
No Comments »
Long, long ago, when I was a medical student, we joked that you could tell how senior a physician was by how much junk was in their lab coat pockets. As students, we tended to carry around big bags full of every medical gadget we could think of, plus a few reference texts. The attendings were slim and graceful in their long white coats with empty pockets.
When I became an intern and moved into the hospital full-time, all that crap became just too much to lug around. I ditched the bag, and my short white coat (with interior pockets, thank god) became loaded down with tons of stuff: reflex hammers, pocket reference guides, photocopied research papers for reading, patient lists, a procedure log, a PDA with epocrates, a bit of a snack maybe, and more. The coat weighed at least ten pounds fully loaded. As a junior resident, I pared it down to the few references and gadgets I actually used frequently, and the coat got a lot lighter. With each succeeding year I have lightened the load somewhat, down to the absolute essentials. I shed the white coat years and years ago. Now the only things I bring with me to the hospital are:
Three items. It’s very liberating. Of course, I have epocrates and more on every computer workstation, so the references are there in the ER for me, but still, it’s something of a victory over inanimate junk and my own packrat tendencies that I can go to work with only three things in my pockets.
The downside is that if I happen to forget any one of these three sacred totems, it totally ruins my whole day.
*This blog post was originally published at Movin' Meat*
July 21st, 2009 by GruntDoc in True Stories
No Comments »
The patient with a loving family, a job, good insurance and an abnormal test. Terrible.
When they come in, with their abnormal test (a sono in this case) from an outside place, from a doctor who sends them to your ED with ‘you need more tests’, it’s hard to keep the stiff upper lip. The family, well dressed and pleasant, just make it worse. I know what’s coming. I’d encourage them to run for the door, if I thought it’d help.
The sono usually says “…blah blah blah mass in the blah blah…further imaging is recommended…blah“.
While this usually isn’t a true emergency, let’s face it: the patient deserves an answer and their doctor has given up (or in) and has sent them to me. (And it’s not like I don’t know how to order CT’s, I do).
While waiting for the CT you imagine it’s all going to be nothing, unlike the ones before. Very very occasionally it’s good news, and relief all around.
The vast majority of the time that CT has been utterly horrible news for everyone involved. There are tears, and referrals, and ‘…I don’t know for certain, you need a biopsy, because diagnosis leads to prognosis…’ and I feel rotten for about a week. Unlike the family, for whom I’ve just unmasked Death, who get to have him as a constant companion.
I don’t know if it’s because they seem so normal, or I see myself in everyone in the room, or guilt. Dunno. But it’s horrible.
*This blog post was originally published at GruntDoc*
July 19th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network
No Comments »
There’s a satisfying post on WhiteCoat where he rants against patient-reported allergies. A sample:
When I ask patients about their medical allergies, more often than not patients suffer from at least one. During a recent shift, I had 17 people who told me that they had medication allergies. When someone has an allergy, I always ask what the allergic reaction is. The responses I received included the following:
* Seven people had allergies to various medications (most often penicillin) because their parents told them they had a reaction as a child. They didn’t know what the reaction was, but they have never taken the medication since.
* Four people had nausea and vomiting with medications that typically cause nausea and vomiting as one of their side effects…
He’s right — a lot of people have unwarranted concerns about mild or entirely predictable reactions, and sometimes this can be frustrating on a busy shift. But I also like the commenter who wrote:
I’m not sure how you think the patient is supposed to know which things actually require medical attention, especially when doctors and nurses refuse to give any guidelines over the phone. ‘Come on in, and if you’re aren’t seriously ill, then we can make fun of you on the blog tomorrow.’
Patient perceptions of allergies is a subset of a larger issue facing all of emergency medicine — patient perception of disease. We don’t expect patients to triage themselves, or figure out which symptoms are worrisome and which are benign. That’s our job. I try to look at proper allergy reporting as another opportunity for patient education (my favorite is explaining why someone can’t be allergic to the iodine atom).
More importantly, from the informatics perspective, allergy reporting is a big frustration as well (and one we can actually do something about, ourselves). Patient-reported allergies find their way into every EMR, and trigger the most inane alerts and stops, forever. If a patient reported vomiting once after codeine, every subsequent doctor who sees this patient will have to jump through electronic alert hoops just to order IV morphine. It doesn’t matter if the patient is taking oxycontin and wears three fentanyl patches. The same goes for antibiotics — I think most lay folks would be surprised that we have to wrestle, years later, with the inherited family warning of about penicillin reactions, even when ordering a 4th-generation cephalosporin with essentially no cross-reactivity…
There’s no intelligence built into the system, yet, I think because everyone’s afraid that if a patient has a bad outcome because that 14th medication alert was eliminated, they’d be liable. This line of thinking ignores the notion that bad outcomes are probably happening because there are so many useless alerts, they all tend to be ignored.
Someone told me recently (perhaps it was Dr. Reider?) that non-clinical folks involved in setting up electronic health information exchanges thought that communicated allergies to new providers would be the top priority, and were surprised when physicians considered allergies to be less important than, say, recent EKG’s, imaging, current med lists, and the like.
I wonder if this attitude toward allergy records is because we don’t think most allergies are that serious, because we can most often treat whatever arises… or because we’re overcome with alert fatigue.
Whatever the reason, there’s no doubt in my mind that if we had an intelligent, efficient system to process patient-generated allergy reports, we’d be less frustrated with this information, and more sympathetic to the patient’s concerns.
*This blog post was originally published at Blogborygmi*
July 17th, 2009 by Paul Auerbach, M.D. in Health Tips
2 Comments »
In the May 14, 2009 issue of the New England Journal of Medicine, in an article entitled “Antivenom for Critically Ill Children with Neurotoxicity from Scorpion Stings,” Dr. Leslie Boyer and colleagues report the results of a study in which the efficacy of scorpion-specific F(ab)’2 antivenom was compared to placebo in the treatment of 15 children ages 6 months to 18 years who were admitted to a pediatric intensive care unit with clinically significant signs of scorpion envenomation (N Engl J Med 2009;360:2090-8). The primary clinical end point was the resolution of the clinical syndrome within 4 hours after administration of the study drug. Secondary end points included the total dose of concomitant midazolam (Versed) – a sedative – and quantitative plasma (bloodstream) venom levels, before and after treatment.
The results showed that the clinical syndrome resolved more rapidly among recipients of the antivenom than among recipients of placebo, with a resolution of symptoms in all 8 antivenom recipients versus one of 7 placebo recipients within 4 hours after treatment. More midazolam was given to the placebo recipients (by necessity to treat symptoms) than in the antivenom recipients. Plasma venom concentrations were undetectable in all 8 antivenom recipients, but in only one placebo recipient one hour after treatment, which indicates that the antivenom neutralized circulating antivenom.
The conclusions are very helpful for clinicians treating scorpion envenomation syndromes with neurotoxic manifestations in critically ill children. They are that intravenous administration of scorpion-specific F(ab)’2 antivenom resolved the clinical syndrome within 4 hours, reduced the need for concomitant sedation with midazolam, and reduced the levels of circulating unbound venom.
This is very important new information. It is estimated that in North America, predominately in Mexico, more than 250,000 people per year are stung by scorpions. The major culprits are of the genus Centruroides. The antivenom used in this study was scorpion-specific F(ab)’2 antivenom (Anascorp, Centruroides [scorpion] immune F(ab)2 intravenous [equine], Instituto Bioclon).
The authors note that there has never been an approved, marketed antivenom therapy for scorpion envenomation in the United States. The only previously available scorpion antivenom in the U.S. was a goat-derived whole IgG (immunoglobulin G) preparation that has not been produced since 1999. Based on the current study, it now appears that there is a relatively safe product for treatment of critically ill children. Its use for critically ill adults and for children and adults with non-critical scorpion envenomation syndromes remains to be studied with the degree of rigor necessary to suggest its regulatory approval for use in the U.S.
image courtesy of about.com: Phoenix
This post, At Last: An Antidote For Scorpion Stings, was originally published on
Healthine.com by Paul Auerbach, M.D..
July 13th, 2009 by Nicholas Genes, M.D., Ph.D. in Better Health Network
No Comments »
I enjoyed NYC Dr. Kent Sepkowitz’s column in Slate the other day — Paging Dr. Feelgood — where he recaps the careers of some celebrity docs and tries to imagine the pathway to enabling addicts. Key part:
In a strange way, I actually stand in awe of these guys. I have taken care of a few celebs in my career, and for me it was an awful experience. If you f*ck it up, you’re toast. Once I took care of a very important person, a person you have heard of and are very interested in, someone you would be shocked to know had the problem—asthma—that I treated him for. Well, almost treated him for. His complaints and his recollection of near death last time he had the identical symptoms so unnerved me that I asked a colleague to assume his care.
But the Dr. Feelgood experiences no such hesitancy… Perhaps it all starts innocently—a rich, famous guy with a tiny problem walks into the office. He can’t sleep at night. He’s so friendly, sincere, not stuck up like some celebs. Then he comes back a week later because of a sore ankle, wanting a little codeine and bearing an autographed photo or a CD. Other patients notice and figure you must be a pretty good doctor if Mr. Showbiz is coming in….
I once wrote about that concern over VIP complaints, in a medscape column. And, like the author, the only thing that impresses me about these celebrity docs is their creativity — Sepkowitz describes how the first Dr. Feelgood used solubilized placenta. And, while the risks of propofol dosing are drummed into our heads in training, it never occurred to me a doctor-to-the-stars might use propofol outside the hospital on an unmonitored patient.
While it didn’t surprise me that propofol has been considered in
palliative care and even implicated in a murder, it turns out propofol (diprivan) abuse and dependency is not unheard of and, as this review by Roussin shows, some IRB actually permitted trials:
Normal healthy volunteers (n = 12) were exposed in a blind fashion to acute bolus injections of 0.6 mg/kg of propofol and to a similar volume of soy-based lipid emulsion (similar to the vehicule of propofol) twice. After these sampling sessions, they were asked to choose which drug they preferred to be injected with. Propofol was chosen by 50% of the subjects, and seemed to have been based on the pleasant subjective effects. In contrast, the choice of placebo (Intralipid®) seemed to have been based on either non-intense subjective effects during the propofol sampling session (increased dizziness, confusion) or residual effects (fatigue) after the sessions. These results suggest that, in some healthy volunteers, propofol functioned as a reward.
…From a psychopharmacologists’ standpoint, propofol shares properties in common with many drugs that are abused. In particular, the onset of the effects of propofol are rapid and this drug makes people ‘feel good’ and feel relaxed [45]. The mood-altering effects of subanaesthetic doses of propofol delivered via an infusion or by an acute bolus injection have been assessed in human healthy volunteers [44,52]. Subjects reported feeling high, lightheaded, spaced out and sedated….
I read up on propofol use a lot a year ago, in preparation for a talk on procedural sedation. At that point I think its only foray into pop culture’s collective consciousness was a poem by Karl Kirchwey called “Propofol” that ran a year ago in the New Yorker. It began:
Moly, mandragora, milk of oblivion:
I said to Doctor Day, “You bring on night.”
“But then,” he said, “I bring day back again,”
and smiled; except his smile was thin and slight.
Now everyone’s talking about propofol. The ASA is using this opportunity to reintroduce talk of restricting propofol to their specialty alone (despite abundant and mounting evidence that it’s used safely in ED procedural sedation). Reporters are wondering why propofol administration is not as closely logged as, say, opiates.
All this activity suggests it soon will be. And while keeping this drug out of the hands of abusers and enablers is a worthy goal of regulation, I hope those who’ve demonstrated a safe track record are not prohibited from using this unique medication.
*This blog post was originally published at Blogborygmi*
