neverending cough
It's making my head hurt. Allergen city, here we come. Bronchioles don't fail me now. I fucking love this time of year. Please pass the Zyrtec. And the albuterol.
17:13 · permalink · 6 comments
Wed, 29 Sep 2004 topthe suburbs are killing us
Interesting. An article in the L.A. Times notes that some scientists have noticed a correlation between poor health and suburban living (There is a Pubmed citation for the original article.) They compared regions of sprawl like Atlanta or San Bernardino and Riverside or Bridgeport-Danbury-Stamford, CT to compact urban cores like New York, Chicago, and San Francisco, and they found that people in the compact urban cores live, on average, about 4 years longer.
Air pollution tends to be pretty much the same whereever you are. The wind carries all that shit whereever it blows, and it doesn't matter if you're out in the boonies. So apparently the exercise that city-dwellers get from walking all over the place outweighs whatever putative mental health benefits there are from living in less dense spaces (although it is surprising that the long commute times doesn't have an effect.)
Me, I'm a city-dweller by choice anyway, although I suppose that doesn't mean much in car crazy Southern California. Give me a decent public transportation system with easy access to work and supermarkets, and I'll ditch my car in an instant.
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Wed, 22 Sep 2004 topfree software
There's a spurt of free medical software (for MacOSX) on freshmeat today, by David Davies-Payne: CF Score which helps with staging CXRs of CF patients, Bone Age which helps calculate, well, bone age, and Renal Growth, which helps with keeping track of how a (pediatric) patient's kidney is growing on serial renal US.
05:19 · permalink · add a comment
Tue, 21 Sep 2004 topbloated americans
This article in the Observer points out the link between obesity and socioeconomic status, and also at the link of poor overall health and the patchwork government and private health care coverage system that we have here in the U.S. This has translated into a slowing down in the rate of increase of life-expectancy, and some postulate that if current trends continue, the average lifespan of an American will actually start going down.
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Mon, 20 Sep 2004 topMDR TB
Wired reports that we might soon be looking at a worldwide epidemic of multi-drug resistant TB (link from Slashdot.)
As an aside, I think that this is one of the biggest arguments for instituting universal health care.
16:39 · permalink · add a comment
Sat, 18 Sep 2004 topovercrowding in the e.d.
This month's issue of Pediatrics has an interesting policy statement regarding what the AAP deems a crisis evolving in the EDs of the U.S., entitled, simply enough, "Overcrowding Crisis in Our Nation's Emergency Departments: Is Our Safety Net Unraveling?" It clarifies some of my own assumptions with regards to this topic, setting some facts straight.
Some interesting snippets:
In the past decade, physicians and administrators responsible for the management of municipal emergency medical services (EMS) systems and hospital EDs have been voicing their concern regarding the capacity of their services. Their concern has been driven by an increasingly familiar phenomenon, overcrowding of EDs, which has worsened to the point of crisis in certain communities. Surprisingly, this saturation of emergency services is not primarily a result of excessive, inappropriate use of the ED by those with nonemergent problems. [My emphasis] (878)
So, contrary to conventional conservative wisdom, the majority of people utilizing the ED are not illegal immigrants exploiting the system for free primary care.
Hospital EDs hold a very strategic position in the continuum of care in our society. Accessible and always open, the ED remains one of the few institutions available to aid all persons. Services are provided regardless of economic or social status and without an impointment. As previously noted, this societal responsibility has been both affirmed and mandated through federal legislation. [My emphasis] (879)
There is no escaping EMTALA, and, at least in the U.S., you can't just throw somebody out on the street and let them die.
The importance of the ED's role has increased over the past decade as other public health and social care programs have eroded. Many people in need do not qualify for public support or are unable to take advantage of services to which they are entitled, including several million uninsured and underinsured children who could qualify for Medicaid or State Children's Health Insurance Program (SCHIP) benefits. [My emphasis] (879)
When the GOP slices and dices the budget for health care (and education and social welfare and all those things that libruls love wasting money on), something has to give. Those tax breaks don't come for free, and if the price is some MDR TB in border communities, then so be it, I guess.
The thing that really strikes me is the fact that a lot of people in dire straits are underinsured. Sure their job might provide them with minimal coverage, or maybe their job doesn't, but they're able to scratch together $75 or so a month to get some coverage, but they sure ain't going to be going to their PCP every month to get their blood pressure or fasting glucose checked, even though they were diagnosed with hypertension or diabetes when they signed on to the plan and had to get examined. Hell no, not with a $1,000 deductible. (And until the hospital my mom works for got bought by a corporation, this is exactly the sort of coverage my parents had. And they're health care professionals. What's it like for the average joe?) Basically, thousands of working Americans have coverage that will only handle massive catastrophes, like getting run over by a car, or having multisystem organ failure. Their version of preventive care is a little too much like the rhythm method as a form of contraception. The odds are kind of stacked against you.
The number of uninsured Americans have grown steadily every year, even during the economic boom of the 1990s. In our nation of amazing wealth, there is also great poverty. There were approximately 43.6 million uninsured Americans in 2002…. In fact, the proportion of the nonelderly American population (younger than 65 years) with health insurance coverage decreased in 2002 to a post-1987 low of 82.7% (880)
Things are getting better, my ass.
An analysis of data from the 1988 National Health Interview Survey provides additional insight into the problem. Indigent children with Medicaid insurance were more likely to have a regular source of health care than those without Medicaid coverage. (880)
Again, since the unemployed poor can usually qualify for Medicaid, the people who get really screwed (i.e., who are uninsured) are the working poor who can't afford health insurance.
Viewed as a proportion of total ambulatory care utilization, data from the 2001 National Ambulatory Medical Care Survey indicate that ED visits represented 25% of all outpatient use by the uninsured versus 17.5% by Medicaid recipients and nearly 8% by those with private insurance. Although it would seem that Medicaid and uninsured patients are more likely to use the ED for acute episodic care, when one controls for confounding variables, this does not hold true. Several studies have found that the lack of an established primary care relationship or the lack of accessible primary care services (not the lack of health insurance) are the primary risk factors for nonurgent ED visits. In fact, it was the steady growth in the utilization of emergency services by privately insured patients that represented the largest segment of increased ED visits between 1996 and 2001. [my emphasis] (880-1)
Again, it ain't the illegal immigrants that are costing us. It's the people who can actually afford health insurance (or have jobs that offer it) who, for some reason or other, don't have a doctor they like. I'm not pointing fingers. Just as there are shitty doctors, there are shitty patients, and, at least in my limited experience, I've found the affluent to be more annoying than the indigent. But, obviously, that's my own bias.
One third of the directors reported that patients had experienced poor outcomes as a result of overcrowding.…
Although no single factor stood out as the primary reason for ED overcrowding, the factor most commonly associated with crowding was the inability to transfer existing ED patients to hospital inpatient beds. Ninenty percent of the surveyed hospitals reported "boarding" of admitted patients in their ED, with nearly 50% indicating an average boarding time of 2 hours or longer. Inpatient beds in greatest demand were intensive care unit and other monitored beds. (882)
As much as internists and pediatricians like to blame the ED doc for shoddy diagnosis and management, the problem is seems to be systemic. While, at certain teaching institutions, attempts to avoid or at least stall admissions may be a factor (no, no internist or pediatrician ever does that—hah), in most cases, it's just that there aren't enough beds, or more accurately, there aren't enough nurses to staff all those beds.
Numerous other factors have contributed to the overcrowding crisis. Although some problems are internal to the ED, most are not. Insufficient access to primary and subspecialty care services and bariers to follow-up care each contribute significantly to the problem. The ED has been characterized by some as the proverbial "canary in the coal mine," with ED overcrowding representing a warning sign of growing distress within hospital and primary care delivery systems and a fraying health care safety net. [My emphasis] (883)
While probably requiring another paper to examine, I have no doubt that health insurance coverage factors into this problem. If you couldn't pay for primary care in the first place, I doubt you'll be able to pay for it to follow-up.
Also interesting is the phrase "canary in the coal mine," the exact same phrase the internist on NPR used when describing the ED crisis. There is a sense that something has got to give, and I have a feeling that medicine will be radically different by the time I finish residency. Probably depending on which political party controls the country, we'll either resemble a third-world country where only the well-to-do can afford medical care and the poor are dying on the street (which some Republicans might consider as killing two birds with one stone), or we'll be forced to adopt some sort of socialized system, most likely single-payer. The half-assed way we're doing things just won't cut it.
The ED overcrowding crisis did not mysteriously appear and, in reality, has been lurking in the shadows for some time. It is attributable, in part, to the absence of a coherent national health policy to create a comprehensive health care and social services delivery system for all Americans. (884)
Anyway, as I've mentioned before, my politics are pretty transparent. I'm a shameless advocate for a single-payer system. After all, if you accept Medicare and Medicaid, you're pretty practically already there. The effects on your practice would be pretty minimal.
Now, obviously, none of this applies to anyone who has been practicing since the bad old days when we were a third world country with regards to health care access. You guys are no doubt used to much higher reimbursements and a much better lifestyle. What can I say. Times change. I hope you saved some of your money for retirement and didn't go buck-wild buying yachts.
But anyone training now has no excuse. If you go into med school with your eyes blindfolded with regard to how fucked up everything is getting, you have no one else to blame but yourself. This is not going to be some cush profession where everyone is going to be kissing your ass. As they say, you are either part of the solution, or you are part of the problem. And if you'd rather have your Benzo and your bling-bling than adhere to the Hippocratic Oath, well, things are going to get a little rough, at least in the foreseeable future. Maybe you can still opt out. Defaulting on your loans kind of sucks, but lots of people—even Donald Trump—have rebounded from bankruptcy. Do something that makes you happy, that earns you the dough you've always wanted.
OK. I'm getting off my soapbox. At least for now.
19:56 · permalink · add a comment
Thu, 16 Sep 2004 toptag, you're it (the games between the ED and the floor)
There is an unspoken rule in pediatrics about who has to change the diaper. It is somewhat similar to the unspoken rule about the trash can. The last one to fill up the trash can has to empty it. The last one to open the diaper and find it soiled or wet has to change it. And anyway, it's not that hard to change a diaper on a baby who can't even hold up her head, much less roll over.
Now if only such rules applied to admissions and the various interventions that need to be done before they come up to the floor.
As an aside, I was pretty happy with my experience of managing a DKAer through the night for the first time. I've dealt with DKAers before, earlier in the month, and as a medical student, but I was never the one staying up all night to follow the pH and the HCO3-. Sure, I didn't get very much sleep at all, but it was worth it to see a half-dead, shriveled-up little girl wake up the next morning with good skin turgor and a good appetite marveling at the IVs in her arms, telling her mom, "This is weird" in the semi-comprehensible way that almost-2 year olds talk.
Sure, any monkey could've done what I did, but it still felt good nonetheless.
Of course, it didn't help too much that for some reason the ED thought it wise not to have insulin on-board before sending the kiddo to us. Sure, a pH of 7.2 is not the worst ketoacidosis I've ever seen even in my thus-far brief career, but the HCO3- of 8 and the fact that they both started going in the wrong direction until we finally got the drip running was not exactly reassuring. Now, don't get me wrong. I do realize I am just an intern with little-to-no clinical experience, but I do think I know enough to realize that maybe it's a little weird not to give a DKAer some insulin at all.
Now, in their defense, I have met good ED docs. I've had them call me up on the floor, asking me what happened to the patient they sent up the night before, wondering if they were right about their diagnosis, and, being good docs, more often than not, they were. (Similarly, in defense of radiologists, I've run into good ones in the reading room, asking me about patients they did studies on, and what diagnosis they ended up having since the studies proved negative.) So in my opinion, it's not the field, but the person. It isn't so much that he's an ED doc, or she's a dermatologist. There are in fact some really good lifestyle-field physicians out there who are sincerely interested in what they are doing and wouldn't trade it for the world. It's just that anyone who went into medicine for the lifestyle alone tends to simply not be a good physician.
Don't get me wrong. We all have our duties to fulfill. The ED doc is not responsible for generating a differential diagnosis with 60-odd different possibilities, replete with zebras and wombats. The internist is not going to reasonably manage a 2 year old. The radiologist is not going to be doing appy's. Medicine is specialized because the field is way too big. There is simply too much data, more than any one person can be expected to even know about, much less actually understand. So the best docs are not the ones who necessarily know the most, because computers can know a lot, and they are still just big hulking, thoughtless machines. The best docs are the ones who know their responsibilities, and, perhaps just as importantly, who know their limitations. You gotta know when to ask for help. You gotta know when the scope of your care ends. Because, honestly, when it comes to medicine, sometimes no intervention is better for the patient than shitty intervention. The resus room is no time to be doing mad scientist experiments.
Anyway, since I've been a med student far longer than I've been an intern, it is no skin off my back to simply be told what to do, instead of managing patients the way I want to manage them. Hell. I don't even have a license yet. So if you say admit, then the patient will get admitted, even if it's for no good reason.
Of course, this is not going to stop me from cursing your name to the high heavens when you send me a kid who gets worked up for some sort of anatomical obstruction because he's been vomiting and the KUB, UGI, BE, and CT abdomen all end up negative, but for some reason you didn't decide to get the CBC until he was already on his way up to the floor, and he comes up with a bandemia that would make the knees of grown men weak, and now we have to do an LP even though it would've been a magnitude of order easier to have done it down in the ED, and, yep, surprise, surprise, the kid is septic.
But I'm not bitter. Incoherent, yes, but not bitter.
Work avoidance is not pretty. I'm not accusing anyone of work avoidance, but, sometimes, you've got to wonder what the hell is going on in the brains of some people.
But on to another tack. Seriously, lifestyle costs lives. If you aren't going to be hardcore about what you're doing, do us all a big favor (and I speak as a consumer of healthcare and not as a practitioner) and find something else to do, for God sake.
12:57 · permalink · add a comment
topignorance (why I tend to equate conservatism with stupidity) part 2
overheard:
Will you stop taking my son's temperature rectally? You're going to make him gay.
Shee-it.
So when the lawyer gets me up on the stand asking me why we didn't give the kid Tylenol when his temperature was 107°F and now has permanent brain damage, can I tell him that I didn't want to make him gay by taking his temp?
topignorance (why I tend to equate conservatism with stupidity)
now it's no secret that I'm a bleeding heart liberal, the likes of which probably requires 8 units of PRBCs a day to keep beating, metaphorically speaking. in the '50's I'd probably be called a communist, and in the early 20th century, I'd probably be called an anarchist, even though I'm really not either of those, and I actually like to think of myself as a centrist.
be that as it may, my politics run considerably to the left of mainstream America, so if I offend you, I suggest you find something better to read. Maybe you can have a look at some goatse.cx pictures. (do you think this guy might need a sweat chloride test? anyway.)
so I'm listening to, of all things, NPR, where they start talking about how the California emergency medicine system is in a major crisis, and I automatically think about all those clueless, heartless bastards who assume that this is because of undocumented immigrants (in neocon-speak, "illegal" immigrants). in the neoconservative mindset, the answer would be to close our borders, force docs to be agents of the INS, and maybe eventually just abolish medicaid.
in other words, we should return to the Dark Ages and emulate the health care systems of most third world countries, where the only people who get medical care are those who can pay for it.
of course, you do realize that Mycobacterium tuberculosis doesn't really understand class boundaries, right?
the sad fact of the matter is that in our "advanced" nation, the people who don't have insurance are mostly the working poor and lower middle class.the truly poor (in neocon-speak, "the lazy") are eligible for Medicaid, so they don't have anything to worry about. it's those people who work jobs that earn them just above the poverty line, but don't provide health coverage who really get screwed. so it's these folks who don't know that they're hypertensive or diabetic until they have a CVA or an MI, and their first presentation is in the ED, transported by ambulance, requiring some pretty intensive and expensive interventions that probably will not get reimbursed by anyone.
now you tell me, from a societal standpoint, do you think it would be cheaper to fund some primary care physicians to do some blood pressure checks and fingersticks, get these guys on some cheap, once a day beta-blocker and/or cheap, once a day sulfonylurea, and remind these guys once in a while that if they don't take their meds, they might end up hemiplegic or dead? or should we just wait until they need to be cath'ed and/or given tPA, where we have to pay EMS $500 minimum for the transport, and where we continue to put weight on the all ready overburdened shoulders of the ED docs?
seriously, some people might claim that we can't change anything because these people will be non-compliant anyway, but, I dunno, I like to think the drive for self-preservation is a lot stronger in most people than that. most likely these guys have an uncle or a dad who keeled over dead from a stroke or a heart attack, and it isn't like they aren't familiar with the consequences of being unhealthy, it's just that they don't have the money to pay for an office visit every month.
let's constrast this to people on welfare, who are typically eligible for medicaid (MediCal in the state of California.) studies show that since these folk don't have to worry about paying for health care coverage, they tend to use it. a lot. much to the consternation of many docs and HMO executives. I can't cite any studies off the top of my head, but it is well known that people who have health coverage tend to use it.
so to claim it is futile to change the system without any contrary data strikes me as a little phony.
the fact of the matter is that because of a little known thing called the Oath of Hippocrates and a better known thing called EMTALA, it is both unethical and illegal to deny someone medical care at an emergency facility. I really do not think it is in the scope of our duties to find out whether or not a patient who is in respiratory distress and is cyanotic has their proper documentation or not before initiating treatment. honestly, anyone who thinks otherwise is, in my book, a hazard to public health and should get their license revoked.
because, how are you going to tell if someone is an "illegal" immigrant when they're in extremis? by the color of their skin? by their accent?
what happens if you're wrong and the patient dies?
and the cynical side of me knows that the lawyers and malpractice insurance carriers will be all over this one. the state passed the law that requires docs to check for documentation status prior to treatment? well, that increases our risk. we'll have to raise your malpractice insurance premiums.
now, I'm not going to debate the morality of sneaking into the U.S. without going through the proper channels. I really haven't decided how I feel about that. I do know from various anecdotes that your immigration status doesn't tend to get checked as often if you happen to be white. (I was talking to a German physician and an English physicist about how they noticed how easy it is for them to get through various hoops, which they also noticed that brown and black skinned Americans find pretty hard to go through.) I also find it somewhat dubious that historically-speaking, the U.S. grabbed an enormous chunk of Mexican land in the early 19th century (which some politicians at the time recognized as pure, cynical exploitation), and to tell certain brown-skinned people to go back where they came from is somewhat cruelly ironic. and to tell them that it's their fault that their home country is all messed up is a little too much like bashing a little kid on the head with a shovel and then blaming him for being retarded.
and since we're on the subject of medicaid, something which the neocons would no doubt love to abolish, consider that even the most cush hospitals in California are somewhat reliant on state funding. if Sacramento shut down MediCal tomorrow, probably 75% of all community hospitals would have to shut down as well, and even facilities like Cedars-Sinai (where all the stars go for their medical treatment) would probably be hurting. Many places that you wouldn't think took care of indigent patients receive probably around 40% of their revenue from the state.
anyway. enough of my political ranting. fact of the matter is that our job description entails taking care of people regardless of ability to pay, and anyone who gainsays that might want to read that Hippocratic Oath a little more closely. And they may want to hire a lawyer who can figure out the loopholes in EMTALA. but if you can find a private practice that doesn't accept Medicaid in the state of California (hah!), good for you, whatever I say doesn't apply, and you can tell me to shut the fuck up, but for everyone else, to say otherwise is simply to ignore reality.
10:44 · permalink · 3 comments
Thu, 09 Sep 2004 topthe 5 S method (6 S if you're lucky)
Medicine is always great for ridiculous little mnemonics. The more useless a piece of information is, the more likely it is to have a mnemonic.
In any case, one of the things I learned on my 3rd year medical student Medicine rotation was the 5 S method, which was a list of high-priority things to do when post-call.
- Stool (or, more vernacularly, Shit)
- Shower
- Shave
- Sustenance
- Sleep
Essentially, it boiled down to sleep. The other things were considered sleep "equivalents" (convertible in the way you can convert dosages amongst different opiods to obtain identical results) So, from my senior-at-the-time's perspective, a 15 minute shower was almost as good as 1 hour of sleep. Now, 1 hour of sleep would still be superior if you could get it, but if you couldn't, you could make do with a 15 minute shower. I didn't figure out accurate conversion factors for the other S's but I will leave that as an exercise to the reader.
Oh, and the 6th S? (And, sadly, I was never so lucky) Sex.
I also thought that tooth brushing was one of those critical post-call activities as well, but unfortunately, it doesn't start with an S. I suppose you could use Spanish sipilio or the less transparent, but somewhat accurate (and medically derived) phrase "swish and spit-out" (in contrast to "swish and swallow")
Changing socks was also huge.
So was changing underwear, but, again, not an S.
Any other suggestions to lengthen this treatise on crucial post-call activities?
Sun, 05 Sep 2004 topthey can always kill you more
An interesting turn of phrase I noticed in a patient's history the other day: "sudden cardiac death x 3."
Which is technically possible. Code, reload, repeat. 360 joules times 3, baby!
On an unrelated topic, I've noticed that we physicians tend to overuse the exaggerated phrase: "You're killing me!" When I'm post-call and delirious, it sometimes makes me want to grab people by the neck and start squeezing on their trachea, telling them, "No, now I'm killing you."
By the way, I'm just being facetious.
topcurse of eden
JT makes an interesting point about knowledge and dangers inherent therein. But, through my few years of medical training, and of endless pimping sessions, I've come up with a couple of coping mechanisms.
The more you know, the more you ought to realize how much you don't know.
This is extraordinarily apparent in molecular biology. We have all these neat theories about neurodevelopment and the pathophysiology of various genetic mutations, but even a cursory search on Pubmed will reveal that there is a lot more conjecture out there than there is cold, hard data.
Then there is the fact that patients rarely read the textbooks. You would think that as we amass more and more knowledge, the need for specialists would decrease. But atypical presentations abound. You consult the endocrinologist not because you need help managing a run-of-the-mill type II diabetic, but because you come across a patient who bizarrely alternates between hyperglycemia and hypoglycemia, isn't on insulin or sulfonylureas, and has a normal fasting glucose and HbA1c. You've already gone down the abdominal mass and pancreatic islet cell tumor pathway, with a negative CT abdomen, and even a negative octreotide scan, but you've come up with nothing, and the patient just got recently admitted to the ICU for a seizure because of a blood sugar of 10, and is now running in the 600s.
Many specialists comment on how generalists have access to the exact same books that specialists have access to. It's not like there's some secret hematology textbook or secret nephrology journal.
Ultimately, the knowledge most important in clinical management lies not in textbooks and original journal articles but is based on experience. This is why medicine will always have an artistic component to it, and why it will never be purely scientific.
Will it really change your management right now or can it wait?
This is the caveat regarding ordering tests. To paraphrase a line from Chris Rock: Why you wanna know? Why you wanna know? It's not like you're discovering anything, like you're planting a flag. Samuel Shem encapsulates this idea in the rule: "If you don't check a temperature, you can't find a fever." Contrary to what many anal-retentive residents and attendings with obsessive-compulsive personality disorder would believe, this doesn't mean you should check your patient's every orifice on the off-chance you missed something. This means that if you don't want to know, don't ask. It will save you hours and days of grief.
An ER resident I worked with as a medical student learned this the hard way. He had a patient who had some kind of infection that wasn't going away despite being in and out of doctor's offices and ERs with antibiotics, both oral and intramuscular. Interestingly, despite the infection, the patient's white count was in the normal range. The resident convinced the guy to sign a consent to do an HIV test. Of course, it came out positive, and the guy was all like "I knew it. My wife's a dirty skank. When I get home, I'm going to kill the bitch!"
Now, maybe the guy was just fucking around with them, and he really wasn't going to kill his wife. And since he was probably going to be admitted, they didn't think much of it, until he tried to sign out AMA. That's when the cops got involved. The whole Tarasoff case got invoked.
I remember watching this guy get surrounded by about 6 cops, who were trying to herd him into the isolation room, threatening: "You can either go there voluntarily, or we can do this the hard way." The guy demurred.
The lesson the resident and I learned was that you shouldn't order an HIV test in the ER, because it's not like starting anti-retrovirals is an emergency.
As Cypher from "The Matrix" declaims, "Ignorance is bliss."
Or, as illustrated by the reparte between a 3rd year medical student and my senior resident:
MS3: So this girl is in for a severe HA and a fever of 103. She also has a complex and troubling social history. Would you like to hear about it?
PL3: (As she gets the LP kit ready) No
