March 1st, 2008 by Dr. Val Jones in True Stories
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I was reading Keagirl’s latest post about a urology consult that she did in the psychiatric lock-down unit. Her patient was hearing voices – specifically that his left testicle was speaking to him. The good doctor was able to maintain a straight face through the exam and interview. There have been times when I suspect that my expression has given away my underlying feelings. A few of my awkward moments:
***
Dr. Val: Hello, Mr. R. I understand that you’ve had thrush in the recent past, and that your CD4 count has been as low as 25. Have you had any problems with thrush lately?
Mr. R: Oh, not at all. I found a way to cure it.
Dr. Val: Oh, very good. Tell me what works for you [expecting to hear ‘nystatin swish and swallow’ or ‘diflucan,’ I smile hopefully at the patient].
Mr. R: Well, basically since I started drinking my own urine the thrush has gone away.
Dr. Val: Oh… [pregnant pause] I see [scribbles note on clipboard as she takes one step back from the bedside.]
***
Dr. Val: [interviewing new patient in the inpatient drug detox program] So tell me a little bit about what brings you here today, Mr. S.
Mr. S: Well, you know, I have a real problem with crack cocaine, heroine, and alcohol.
Dr. Val: Yes, I see. Well, it’s good that you’re here now. [I smile genuinely].
Mr. S: But doc, I have to tell you why this all started.
Dr. Val: [Leaning forward, expecting a potentially important insight] Yes, what do you think is behind the drug addiction, Mr. S?
Mr. S: Well, I was born with a deformed penis and I think a lot of this has to do with my low self-esteem.
Dr. Val: Hmm. Well, I can see how that might be very challenging to overcome [eyebrows furrowing in a concerned expression mixed with mild awkwardness and some surprise].
Mr. S: I’d really like to show you what I’m talking about.
Dr. Val: Um… well, I uh… don’t think that will be necessary at this time. I trust you…
***
Nurse: [calling from psychiatric lock-down unit]: Is this the rehab consultant?
Dr. Val: Yes, I’m on call for rehab today.
Nurse: We have a man here with difficulty swallowing and we were wondering if you could take a look.
Dr. Val: Ok, what brought him to the psychiatric lock down unit?
Nurse: Well, he tried to kill a nurse at the transferring hospital – she got too close and he got a hold of her neck. But he’s not too hard to pry off because he has no eyes.
Dr. Val: No eyes?!
Nurse: Yeah, he cut them out several years ago during a psychotic episode. He used a piece of broken glass to gouge out his eyes and cut off his nose and ears too.
Dr. Val: Oh my gosh… that’s really terrifying. [Pauses with images of Silence of the Lambs floating through her mind] May I ask why he can’t swallow?
Nurse: I don’t know why he can’t swallow. That’s why I’m calling you.
Dr. Val: Well, I mean, how do you know he’s not swallowing? Did you see him choke?
Nurse: No he’s not drinking at all.
Dr. Val: Well, is there a cup next to him? Does he know it’s there?
Nurse: [silence]
Dr. Val: Ok, I’ll put him on my consult list…
***
You can’t make this stuff up.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
January 3rd, 2008 by Dr. Val Jones in Opinion
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How has the Physician Quality Reporting Initiative (PQRI) been going? Some insights are offered from an internist in the trenches, (the only 1 of 20 physicians in his practice who was able to figure out how to comply with the PQRI rules), The Happy Hospitalist:
I found out today many docs may not have qualified because of the way the government PQRI computers crunched the data (imagine that). You see, if my quality indicator was for antiplatelet use in stroke, and I submitted to CMS stroke as the 4th ICD code, along with three comorbid conditions ( like DM, COPD, CAD), unless I submitted stroke as diagnosis #1, PQRI would reject my submission. So CMS accepts your E&M code with stroke listed as the 4th diagnosis to get paid, but when that claim makes it to the PQRI folks, because stroke was diagnosis #4 and not diagnosis#1, PQRI would reject the submission and doctors all over this country were dinged for not reporting on 80% of qualified patients…
I also found out that PQRI indicator #36 calls for rehab ordered for all “intracranial” hemorrhage. During my meeting today I found out that the only ICD codes linked to this quality indicator are “intracerebral” hemorrhage. Sub dural bleeds, which are intracranial, are excluded. So are subarachnoids. They have problems even defining what they are trying to measure.
October 14th, 2007 by Dr. Val Jones in True Stories
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I had dinner with a physician friend of mine who works in New York City. She told me an interesting story about her last couple of days at work…
A patient of hers was in the hospital on a fairly high dose of steroids to treat an autoimmune disorder. He was generally a very even tempered and friendly person, but was a little bit grumpy when she visited him on rounds that evening. He was complaining of slight shortness of breath and some mild stomach pain – and that the hospital food was bad. His labs from that morning were all normal, and he had no fever or abnormalities in blood pressure or heart rate.
On sheer gut instinct, my friend ordered a CT scan of his abdomen right away. Lucky she did, because this gentleman had a perforated colon (from ruptured diverticulae) with air under his diaphragm, causing shortness of breath. Because he was on steroids, the body’s usual response to early sepsis was blunted. He was rushed to the OR where surgeons corrected the problem. In this situation, if it weren’t for a gut instinct, this patient may have died.
I think this case illustrates how important it is to know your patients, to take their concerns seriously (especially when they’re on medicines that could minimize serious symptoms), and if something doesn’t seem right (even if lab tests and vital signs argue otherwise) you should listen to your gut. Sometimes instinct is smarter than science.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
October 9th, 2007 by Dr. Val Jones in News
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I was intrigued by a news story all over the wires today and yesterday – that blood transfusions may do more harm than good. Over 4.5 million Americans receive blood transfusions for one reason or another each year in the US. Two new studies have been published in the Proceedings of the National Academy of Sciences, suggesting that blood can get “stale” much sooner than we think. Although we’ve known for a while that blood transfusions should be given only when critically needed, this news is interesting in that it may explain why blood transfusions are not a panacea.
Blood contains nitric oxide – a gas that is used as a signaling molecule in humans. It can trigger the relaxation of blood vessel walls, which is important in getting blood flow and oxygen to areas of the body that need it. Nitric oxide exists in small amounts in the bloodstream, but it can evaporate rapidly once outside the body (such as in a transfusion bag). So the question is: how critical is it to have nitric oxide dissolved in the blood given via transfusion?
The Red Cross keeps blood for up to 42 days after it is donated (though nitric oxide depletion may occur within hours) and will continue to do so until it is clearly shown that the expiration dates should be shortened. Further research is underway to test whether or not infusing nitric oxide back into blood is a viable option to improve its ability to oxygenate the recipient. It’s not easy to do this, since nitric oxide is a very tricky gas that can become a free radical or an acid in the presence of certain oxygen species. So the exact proportion of nitric oxide is critical – a little does just the right thing, but too much can be harmful or even fatal – which is probably why we haven’t tested this in humans yet, only dogs.
Still, many have high hopes for adding nitric oxide to the blood supply – Dr. Jonathan Stamler of Duke University appears to have applied for more than 50 nitric oxide associated patents and, not surprisingly, is taking the lead on various research studies, including the two new ones mentioned in my first paragraph.
My personal take on this? Blood transfusions are a serious treatment that can save lives, but should not be given willy nilly to “boost” people’s hematocrits. I’ve witnessed physicians giving their patients an extra unit of blood “just to perk them up a bit” prior to discharge from the hospital. That behavior is not safe or appropriate. So before you undergo a blood transfusion, make sure you really need one. Until we figure out how to replace nitric oxide safely in the blood supply, the life-saving potential benefits of a transfusion must outweigh the risks of stroke and heart attack from nitric oxide-depleted blood.This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
September 7th, 2007 by Dr. Val Jones in Health Tips
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Is it safe to eat microwave popcorn? In case you missed it, a surprising new case of diacetyl lung damage
(so-called popcorn lung) was discovered in a patient who is a popcorn fanatic.
He reported eating 2 bags of artificial butter flavored popcorn per day
for years on end and began to notice shortness of breath.
My bottom line: avoid diacetyl, don’t avoid popcorn. Popcorn itself is
not harmful or dangerous (unless you’re under age 5 and are at risk of
choking or inhaling it) – just make sure it’s not laced with chemicals.
Five years ago the New England Journal of Medicine published a study linking a popcorn chemical (diacetyl) to a serious lung condition in 8 popcorn factory workers.
The lung condition, also known as bronchiolitis obliterans, is an
inflammatory reaction to diacetyl that can reduce lung capacity by as
much as 80%. Certain people who inhale too much of the chemical form
scar tissue as a reaction, making the lungs stiff and causing cough and
shortness of breath.
In this week’s case, the astute pulmonologist examining the popcorn addict remembered the 2002 NEJM article, and thought to ask him about popcorn exposure as part of her work up for his breathing complaints. As it turns out, his exposure to popcorn chemicals is the likely cause of his lung damage. Sadly, though, once the scarring occurs there is no way to return the lungs to their original state of heath. The only known treatment for popcorn lung is a lung transplant.
There has been incredible interest in this story because microwave popcorn is a part of most of our lives. The United States is the single largest consumer of popcorn worldwide, and we purchase over 1 billion pounds of unpopped corn per year. We naturally wonder: could this happen to me? Am I (or my kids) at risk?
First of all, I think that diacetyl should be avoided by all consumers of popcorn. ConAgra, the parent company for Orville Redenbacher and Act II, has agreed to immediately remove this chemical from its artificial butter flavored popcorn. Nonetheless, we should scrutinize the labels of any popcorn that we intend to purchase to make sure that it doesn’t contain diacetyl.
Second, the good news is that not everyone’s body forms scar tissue in reaction to this chemical. In the same way that we’re not all allergic to the same environmental agents, our bodies are not all going to respond to diacetyl by developing lung scarring. That said, why tempt fate by inhaling fumes that have harmed a small number of people?
Third, it does seem that it requires prolonged and high exposure to diacetyl to be at risk for popcorn lung. So if you’re not a buttered popcorn maniac (consuming several bags per day for years on end) your risk is extremely small, even if in the past you’ve eaten the occasional microwave popcorn containing the chemical.
If you are looking for alternative healthy snack options check out this link.
Hope this post allows some of you to breathe easier!This post originally appeared on Dr. Val’s blog at RevolutionHealth.com.
