Recently I evaluated a 50 year-old Somalian immigrant in the ED for chest pain and shortness of breath. She had a soft, but emaciated expression that was a uneasy mixture of worry and fatigue. The woman was fairly well known to the ED - she had been in multiple times with this complaint. Every time she was given an EKG, a chest xray, and her blood was tested for cardiac enzymes that show if a heart attack had occurred. These had always been negative. She had a cardiac stress test done as an outpatient some months back that also showed no cardiac disease. Yet, still it is hard to ignore chest pain that seems to cripple a patient.
Three of her children were present when I saw her, two grown ups and an adolescent. Her eldest son, around 30 years-old was professionally dressed in a collared shirt and spoke English very well. It was clear he was educated and was her main health care decision maker, as she spoke no English. Everyone asked me over and over, almost out of desperation, what had been causing her pain. It was clear from this questioning that in their many unfortunate encounters with the American health care system, no doctor had provided a very good - or very understandable - explanation. The son told me that his mother was upset at him because he was not able to find an explanation - or find a doctor who could give an explanation. He was at his wit's end, exhausted and frustrated.
It was clear to me that there was more to the story than heart or lung disease. On my psychiatry rotation last month I spent a day each week at a volunteer psychiatric clinic for immigrants - especially those from war-torn areas such as Africa, Vietnam, the Balkans - and learned a great deal there about how psychosocial context for people in this unique situation can exacerbate medical illnesses.
It turned that this woman's chest pain episodes started six years ago when she came to the US. Her son said that she had always been somewhat of an anxious person, but that it never led to inexorable chest pain that required emergency care in Somalia. She was also living in a broken family that caused her considerable grief: her youngest son, only 10 years-old, was still in Somalia with her husband.
A lot of symptoms that doctors cannot explain get chalked up to anxiety, depression, and stress. And many patients resent this. They feel their doctors are telling them that their symptoms are all somaticized, "between their ears," made-up fake symptoms that are not worth testing, treating, or even empathy. And many doctors dislike patients with somaticized symptoms because they have a strong suspicion that tests will not reveal a diagnosis. And so they are reluctant to treat pain that they feel has no "organic," that is anatomical or physiological, basis. To an extent this is understandable: treating chronic back pain, for instance, that is largely aggravated by anxiety and poor living habits with a narcotic runs a significant risk of dependence. Long term use of narcotics will address chronic pain (and anxiety) very well but at the expense of reducing that person's overall functionality - their ability to work, parent, etc. So in the end the doctor has addressed one problem by creating a larger one. This happens all the time because chronic pain is so damn elusive.
OK, back to my Somalian woman in the ED. She has chronic pain. She has no identifiable (at least by our diagnostic tools) biological cause for that pain. She is that difficult patient many MDs loathe to treat because the direction and outcome of a treatment are not clear. This is because the cause of her pain is anxiety and depression from being uprooted from her traditional community and living in a fragmented family. On top of that, she has very limited resources to turn to here in Portland, Maine. There are no traditional Somalian healers. There are no Somali (and possibly no Arabic) speaking MDs. There is no free psychiatric clinic for refugees. There is no pill or surgery or test or procedure that will fix any of this. The English-speaking American MD has very little to offer this woman because her needs are not medical in nature. And yet, her suffering manifests itself as a medical condition.
I spoke at length with the family in the ED (a privilege I have as a medical student unbound by the obligations of high patient turn-over) and explained to them what I thought was the cause of her recurring chest pain. In a nutshell I told them it was in fact "between her ears," which I believe is true, but in such a way as to not dismiss the fact that she really did have chest pain, that her symptoms were not just illusory manifestations of her broken psychosocial context. I urged the family to understand the relationship of this pain to her social circumstances, that it was not unlike having a headache caused by poor sleep due to stress. I also apologized to the family for the fact that there was nothing I could offer them except a pill - a benzodiazapine which is essentially a martini in pill form, a very effective medication for anxiety. I recommended that she follow up with a family doctor and consider getting a prescription so she could have this medicine around when the pain gets really bad. Most likely it would keep from coming back to the ED, getting all those senseless tests done over again by a doctor who probably will not have the time to talk to her like I had.
In the end it seemed the family was satisfied with this explanation, although the son was reluctant to have his mom start popping pills. He preferred she do yoga or meditate, both of which I readily encouraged, although, I explained, these methods are better thought of as prophylactics and would unlikely help in a severe, acute situation.
As I enter my last year of medical school I am more and more convinced that nearly every medical condition has an underlying psychiatric one. This story is an obvious example, but in many cases the relationship is subtle and indirect. It is convenient and simple to think of so-called "adult-onset" diabetes (type 2, associated with obesity) as just a medical problem, which is, the condition in which the body's tissues lose their ability to respond to insulin, resulting in an elevation of blood sugar. Yet, nearly every patient with type 2 diabetes is overweight, eats poorly, and does not exercise. Obesity is itself is an interesting phenomenon in this country - indeed all post-industrial societies - and my gut instinct is that there are a handful of anomalous psychiatric states underlying these lifestyles that are so self-destructive, such as depression and addiction.
25 June 2008
24 June 2008
Tachyarrhythmias
Paroxysmal Tachycardias 150-250 bpm
- Paroxysmal Atrial Tachycardia
- An irritable atrial focus produces a normal wave sequence, if P' waves are visible.
- P.A.T. with block
- Same as P.A.T. but only every second (or more) P' wave produces a QRS.
- Paroxysmal Junctional Tachycardia
- AV Junctional focus produces a rapid sequence of QRS-T cycles.
- QRS may be slightly widened.
- Paroxysmal Ventricular Tachycardia
- Ventricular focus produces a rapid sequence of (PVC-like)
- Wide ventricular complexes.
- Atrial Flutter
- Continuous (“saw tooth”) rapid sequence of atrial complexes from a single rapid-firing atrial focus. Many flutter waves needed to produce a ventricular response.
- Ventricular Flutter / Torsades
- A rapid series of smooth sine waves from a single rapid-firing ventricular focus; usually in a short burst leading to Ventricular Fibrillation.
- Torsades de Pointes if amplitude of wave varies like a ribbon.
- Erratic (multifocal) rapid discharges
- Atrial Fibrillation
- Multiple atrial foci rapidly discharging produce a jagged baseline of tiny spikes.
- Ventricular (QRS) response is irregular.
- Ventricular Fibrillation
- Multiple ventricular foci rapidly discharging produce a totally erratic ventricular rhythm
- without identifiable waves.
- Needs immediate treatment.
Conduction Blocks
Sinus (SA) Block
- An unhealthy Sinus (SA) Node misses one or more cycles.
- The SA Node usually resumes pacing, but the pause may evoke an “escape” response from an automaticity focus.
- 1° AV Block: PR interval greater than .2 s.
- 2° AV Block: some P waves without QRS response
- Wenckebach - PR gradually lengthens with each series does not produce a QRS.
- Mobitz - some P waves don’t produce a QRS response. More advanced Mobitz block may produce a 3:1 (AV) pattern or even higher AV ratio.
- 3° AV Block: no P wave produces a QRS response
- P waves—SA Node origin.
- Rate of QRS determined by AV node (40-60 bpm) or ventricles (20-40 bpm)
- QRS greater than 0.12 sec.
- Right BBB: R and R' in V1 or V2
- Left BBB: R and R' in V5 or V6
- With Bundle Branch Block the criteria for ventricular hypertrophy are unreliable
- With Left BBB infarction is difficult to determine on EKG.
Arrythmias
Sinus Arrhythmia
- Irregular rhythm that varies with respiration.
- All P waves are identical.
- Considered normal.
- Irregular rhythm. P waves change shape as pacemaker location varies.
- Rate less than 100/min.
- Same as wandering pacemaker but rate is great than 100/min.
- Irregular ventricular rhythm.
- Erratic atrial spikes (no P waves) from multiple atrial automaticity foci.
- Automaticity focus escapes overdrive suppression to pace at it inherent rate (rhythm) or to emit transient beat.
- Due to loss of upstream pacing (e.g. sinus arrest) or conduction block
- Atrial foci paces at 60-80 bpm (non-SA node source)
- AV nodal foci paces at 40-60 bpm (may cause retrograde atrial depolarization)
- Ventricular foci paces at 20-40 bpm (Stokes-Adams Syndrome)
- Irritable focus that spontaneously fires a beat.
- Atrial & AV node foci
- Epinephrine
- Increased sympathetic stimulation
- Stimulants: caffeine, amphetamines, cocaine, beta1-receptor agonists
- Digitalis
- Hyperthyroidism
- Stretch
- Ventricular foci
- Hypoxia
- Hypokalemia
- Mitral valve prolapse, myocardis
EKG Interpretation
RATE
- 300, 150, 100, 75, 60, 50
- For bradycardia & irregular rhythms: rate = cycles/6 sec. strip ✕ 10
- P before each QRS.
- QRS after each P.
- PR intervals (for AV Blocks).
- QRS interval (for BBB).
- If Axis Deviation, rule out Hemiblock.
- QRS above or below baseline for Axis Quadrant (for Normal vs. R. or L. Axis Deviation).
- For Axis in degrees, find isoelectric QRS in a limb lead of Axis Quadrant using the “Axis in Degrees” chart.
- Axis rotation in the horizontal plane: (chest leads) find “transitional” (isoelectric) QRS.
- In V1
- P wave for atrial hypertrophy.
- R wave for Right Ventricular Hypertrophy.
- S wave depth in V1…
- + R wave height in V5 for Left Ventricular Hypertrophy.
- Scan all leads for:
- Q waves
- Inverted T waves
- ST segment elevation or depression
- Find the location of the pathology, and then identify the occluded coronary artery.
23 June 2008
A Comment about Transparency in Medicine
Original story about crap left in people after surgery: http://www.msnbc.msn.com/id/25120613/
My comment: http://cmolstrom.newsvine.com/
And yet more thoughts! This is not a defence of surgeons as much as an explanation for how things are from their perspective I guess.
In the OR staff joke, "how often is a final count off when the patient leaves the OR?" The answer of course is never, because a patient should never leave the room with an off count and unexplained missing item would be found. The point is that something gets left behind and the count is still correct! Human error, but there are better and better systems with built in redundancy that improve catching errors if they happen, because they will.
One example is putting a small metallic strip in every gauze pad or towel so that it will show up on xray. A normal gauze or even towel will not show up on CT or xray, which could be why some patients need to be re-opened to find the damn thing. Some people do not recover well from abdominal surgery - especially if they have other illnesses - and so a left behind towel is not the first thing to come to mind since that sort of thing is rare. In that case the corrective surgery should not be the responsibility of the patient - probably the surgeon since he or she is ultimately responsible (although the scrubs, etc., are hospital employees).
Not all cases are clear cut though. Certain specialized staple guns that use a ribbon of stables and work by zippering together two pieces of tissue usually shed some extra staples in the process. Going after all those staples would take extra time (more anesthesia risk) and expose risk to organs due to the "fishing around" - the risks are not worth the benefit. The risks theoretically are, I suppose, a perforation of something, but that never happens so I'm told. Just sitting there they will not cause infection because they are sterile just like the other staples that will remain in permanently. It is debatable whether a surgeon should tell every patient about these things that never cause a problem even if they theoretically could. Of course patients want to know everything but in reality doctors filter out information since there is little use in telling a patient about extremely rare 1 in a 100 million risks and complications that do nothing but cause anxiety. Believe it or not many people do not understand statistics. This is a frustrating aspect of the profession.
Example - Last night in the ED I saw a woman with abdominal pain and tingling in her arms and legs that got better after vomiting once. She was totally healthy, 34 years old, no history of any diseases, mother of 2 infants. She was also a very anxious woman, prone to anxiety attacks, corroborated by her husband, and had given a history very suspicious of anxiety-induced abdominal pain: her cousin's son had just been diagnosed with a brain tumor and she had visited the family earlier that day. She has two kids and has been festering on that...what about my children? To an extent this is natural maternal feeling, but the chances of her kids getting are brain tumor are really, really, rare. The chances of her having a heart attack or stroke (what she thought she had) are extremely unlikely. Can't say impossible - you never say never in medicine - but very unlikely. What do I tell her? I say it is very unlikely for reasons x, y, and z that you have a heart problem, and the tests we ran here show that. But should I also say, "but an EKG (heart tracing) is not 100% on the money for heart problems, and so there is still a chance this could be your heart" and send her home an anxious again? Reassurance involves minimizing some information and maximizing other, and some people take that as not being up front with the patient.
Leaving extra staples in is one of those things that surgeons never talk about - not because of denial but because patients are not likely to understand the very low risk of complication and will just make them worry. Hell, every veteran doctor has seen a zillion patients who start to have symptoms only after they are made aware of a disease (which they don't have, but think they might). "I'm having belly pain after my surgery (everyone does) and the doc told me about those staple...I wonder if it could be..." and so that the belly pain gets worse for no physiological reason. This is called somatization.
Another example, just last night! 20 month old girl comes in with 4 very worried family members because she is wheezing. She improves some on medicated oxygen (for asthma) but not back to 100%. Parents are very anxious because they've never seen many infants with asthma. From a physician's view in fact the girl is doing really well overall, her blood oxygen is totally normal, she does not look infected. Half of the treatment involves reassuring the parents. We get a chest x-ray to rule out a foreign body aspiration. Her lungs look great, but she has an unusually shaped aortic arch. X rays are not at all the test of choice to diagnose an aortic problem, plus she was poorly aligned in the machine, so the film is a little cock-eyed. But the shape is unusual nonetheless. We talk to radiology and they did not even feel it was necessary to comment on the aorta in their report. So, of course I am not going to tell the parents, "the xray looks normal, except we thought the aorta was a bit strange - oh, don't worry, it is probably nothing just the way the film was" Worried parents don't hear anything after "don't worry...." It would have been nuts to say anything. There was no explanation for the unusual shape, she clearly had no cardiac problems. Normal anatomic variant? Weird artifact from the film? At any rate should I worry the parents about these details?
Every doctor has their own way of talking to patients about adverse effects, risks, complications, abnormal test results -in my woman above many would just say "it's not a heart problem, don't worry" and leave it at that. I think it is important that patients know our tests and diagnostic skills are not perfect, that there's other possibilities even with someone like this woman. But at the same time I can't dwell on the other possibilities without making her totally freak out. Its a fine line, and every patient is different. The bottom line for me is: when in doubt, talk it out!
My comment: http://cmolstrom.newsvine.com/
And yet more thoughts! This is not a defence of surgeons as much as an explanation for how things are from their perspective I guess.
In the OR staff joke, "how often is a final count off when the patient leaves the OR?" The answer of course is never, because a patient should never leave the room with an off count and unexplained missing item would be found. The point is that something gets left behind and the count is still correct! Human error, but there are better and better systems with built in redundancy that improve catching errors if they happen, because they will.
One example is putting a small metallic strip in every gauze pad or towel so that it will show up on xray. A normal gauze or even towel will not show up on CT or xray, which could be why some patients need to be re-opened to find the damn thing. Some people do not recover well from abdominal surgery - especially if they have other illnesses - and so a left behind towel is not the first thing to come to mind since that sort of thing is rare. In that case the corrective surgery should not be the responsibility of the patient - probably the surgeon since he or she is ultimately responsible (although the scrubs, etc., are hospital employees).
Not all cases are clear cut though. Certain specialized staple guns that use a ribbon of stables and work by zippering together two pieces of tissue usually shed some extra staples in the process. Going after all those staples would take extra time (more anesthesia risk) and expose risk to organs due to the "fishing around" - the risks are not worth the benefit. The risks theoretically are, I suppose, a perforation of something, but that never happens so I'm told. Just sitting there they will not cause infection because they are sterile just like the other staples that will remain in permanently. It is debatable whether a surgeon should tell every patient about these things that never cause a problem even if they theoretically could. Of course patients want to know everything but in reality doctors filter out information since there is little use in telling a patient about extremely rare 1 in a 100 million risks and complications that do nothing but cause anxiety. Believe it or not many people do not understand statistics. This is a frustrating aspect of the profession.
Example - Last night in the ED I saw a woman with abdominal pain and tingling in her arms and legs that got better after vomiting once. She was totally healthy, 34 years old, no history of any diseases, mother of 2 infants. She was also a very anxious woman, prone to anxiety attacks, corroborated by her husband, and had given a history very suspicious of anxiety-induced abdominal pain: her cousin's son had just been diagnosed with a brain tumor and she had visited the family earlier that day. She has two kids and has been festering on that...what about my children? To an extent this is natural maternal feeling, but the chances of her kids getting are brain tumor are really, really, rare. The chances of her having a heart attack or stroke (what she thought she had) are extremely unlikely. Can't say impossible - you never say never in medicine - but very unlikely. What do I tell her? I say it is very unlikely for reasons x, y, and z that you have a heart problem, and the tests we ran here show that. But should I also say, "but an EKG (heart tracing) is not 100% on the money for heart problems, and so there is still a chance this could be your heart" and send her home an anxious again? Reassurance involves minimizing some information and maximizing other, and some people take that as not being up front with the patient.
Leaving extra staples in is one of those things that surgeons never talk about - not because of denial but because patients are not likely to understand the very low risk of complication and will just make them worry. Hell, every veteran doctor has seen a zillion patients who start to have symptoms only after they are made aware of a disease (which they don't have, but think they might). "I'm having belly pain after my surgery (everyone does) and the doc told me about those staple...I wonder if it could be..." and so that the belly pain gets worse for no physiological reason. This is called somatization.
Another example, just last night! 20 month old girl comes in with 4 very worried family members because she is wheezing. She improves some on medicated oxygen (for asthma) but not back to 100%. Parents are very anxious because they've never seen many infants with asthma. From a physician's view in fact the girl is doing really well overall, her blood oxygen is totally normal, she does not look infected. Half of the treatment involves reassuring the parents. We get a chest x-ray to rule out a foreign body aspiration. Her lungs look great, but she has an unusually shaped aortic arch. X rays are not at all the test of choice to diagnose an aortic problem, plus she was poorly aligned in the machine, so the film is a little cock-eyed. But the shape is unusual nonetheless. We talk to radiology and they did not even feel it was necessary to comment on the aorta in their report. So, of course I am not going to tell the parents, "the xray looks normal, except we thought the aorta was a bit strange - oh, don't worry, it is probably nothing just the way the film was" Worried parents don't hear anything after "don't worry...." It would have been nuts to say anything. There was no explanation for the unusual shape, she clearly had no cardiac problems. Normal anatomic variant? Weird artifact from the film? At any rate should I worry the parents about these details?
Every doctor has their own way of talking to patients about adverse effects, risks, complications, abnormal test results -in my woman above many would just say "it's not a heart problem, don't worry" and leave it at that. I think it is important that patients know our tests and diagnostic skills are not perfect, that there's other possibilities even with someone like this woman. But at the same time I can't dwell on the other possibilities without making her totally freak out. Its a fine line, and every patient is different. The bottom line for me is: when in doubt, talk it out!
Alcohol Withdrawal
Minor withdrawal 6 to 36 hours
Tremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, GI upset
Seizures 6 to 48 hours
Generalized, tonic-clonic seizures, status epilepticus (rare)
Alcoholic hallucinosis 12 to 48 hours
Visual, auditory, and/or tactile hallucinations
Delirium tremens 48 to 96 hours
Delirium, tachycardia, hypertension, agitation, fever, diaphoresis
Tremulousness, mild anxiety, headache, diaphoresis, palpitations, anorexia, GI upset
Seizures 6 to 48 hours
Generalized, tonic-clonic seizures, status epilepticus (rare)
Alcoholic hallucinosis 12 to 48 hours
Visual, auditory, and/or tactile hallucinations
Delirium tremens 48 to 96 hours
Delirium, tachycardia, hypertension, agitation, fever, diaphoresis
18 June 2008
The Omnivore's Dilemma
This is a great book on a timely, important topic. Here are some key points I've gleaned from it.
Food should be protected from capitalist ventures because there is little, if any, room for innovating things that evolution has already mastered.
Eating "organic" food is not as important as eating whole, unprocessed food. A good maxim is: if your grandmother doesn't recognize an ingredient then don't eat it.
- Processed food is a supply-driven business but it has to deal with the problem of the "fixed stomach" - that is, food consumption, unlike computers or clothes, is biologically limited by the size of our guts. So, in order to make profits, the industry must either (a) get people to spend more on the same number of calories (the Whole Foods approach) or getting people to eat more (the General Mills and McDonald's approach).
- Super-sizing has been a way to get people to spend more money. However, studies has shown that mammals over-eat when presented with the opportunity because they (we) are evolutionarily designed to feast when food is available to tide through the next famine. We are programmed to respond most readily to high-energy substances like fat and sugar, because fatty, sweet things provided our ancestors with the biggest caloric bang for the hunting or gathering.
- High fructose corn syrup (HFCS) was invented in 1980. It is not found naturally in any food, but its constituents, fructose and glucose are naturally occurring sugars. It is very sweet and a source of highly-dense calories. As such we respond very strongly to it, but our sensory apparatus is not well designed to appreciate the calorie load in HFCS because it is not found in whole food. It teases our taste buds and tricks our guts.
- HFCS has found its way into nearly every processed food item. At the same time the average caloric intake in the US has increased 10% (about 200 calories) per day, while calorie expenditure (work and exercise) has remained level or even decreased. Those 200 calories a day end up in fat cells around our waists and hips. We now have an obesity and diabetes epidemic due to consumption of energy-dense processed foods.
- A family meal at McDonald's of 4510 calories requires 10 times as many calories to produce (raising the corn, raising the beef, processing the foods, reconstituting them, transportation). That's 1.3 gallons of oil!
- Food processing is an irrational use of energy: it involves taking natural whole foods and braking them down into constituent chemicals which are then reassembled into a new products.
- There is a 90% loss of energy each move up the food chain, say from grass, to cow, to carnivore. That's why there's a lot more plants than predators in a given ecosystem. In other words only 10% of the calories of grass (or corn) a cow eats go into making tissue (meat) that we eat, while rest goes to keeping the animal alive or is excreted as waste. This inefficiency is why eating meat - especially cows - is environmentally costly. A more sustainable diet is eating (more often) lower on the food chain where we are able to reap the energy from the sun in the most efficient manner - directly from plants.
- Cows have been taken from their natural habitat - a grassland - and placed in cow-cities, feedlots, where they are fed corn (not their natural diet) and wallow in their own excrement. This is the cheapest way to make meat. But overcrowding and an unnatural diet make the cows sick (just like occurs in human slums), so they are routinely treated with large quantities of medicine and hormones which, when excreted, leach into the soil and contaminate nearby water supplies.
- Farmers have always this problem: they make good money during famines because of high prices, and loose money in boom years because of low prices. Unlike consumer products which are driven by demand, agriculture is usually driven by supply: the price of wheat is determined by the bounty rather than the demand for it. To ease the burden of unpredictability in this market, the government provides subsidies so that farmers are guaranteed an income when prices fall below costs. But this just encourages farmers to produce more crop (for greater profits), which results in surplus and even lower market price. The end result is that taxpayers are subsidizing overproduction. The market as found ways of using this surplus: feeding us more and exporting the rest. It is economically irrational.
Food should be protected from capitalist ventures because there is little, if any, room for innovating things that evolution has already mastered.
Eating "organic" food is not as important as eating whole, unprocessed food. A good maxim is: if your grandmother doesn't recognize an ingredient then don't eat it.
Benzodiazepine Half-life
Short Half Life (less 12 hr)
Lormetazepam
Temazepam
(Zopiclone)
Triazolam
Loprazolam
Intermediate Half Life (12-20 hrs)
Lorazepam
Oxazepam
Long Half Life (>20 hrs)
Nitrazepam
Diazepam
Flurazepam
Chlordiazepoxide
Lormetazepam
Temazepam
(Zopiclone)
Triazolam
Loprazolam
Intermediate Half Life (12-20 hrs)
Lorazepam
Oxazepam
Long Half Life (>20 hrs)
Nitrazepam
Diazepam
Flurazepam
Chlordiazepoxide
Opioid Dosing Equivalents
| Drug | Dose | T1/2 | |
| Morphine | 10 mg I.V. | 30 mg p.o. | 2-4 |
| Codiene | 100 mg I.V | 200 mg p.o. | |
| Hydromorphone | 1.5 mg I.V. | 7.5 mg p.o. | 2-3 |
| Hydrocodone | | 30 mg p.o. | |
| Methadone | 10 mg I.V. | 20 mg p.o. | 15-20 |
| Fentanyl | 100 ug = 4 mg I.V. morphine | | 1-2 |
| Meperidine | 75 mg I.V. | 300 mg p.o. | 2-3 |
| Levorphanol tartrate | 2 mg I.V. | 4 mg p.o. | 12-16 |
| Oxycodone | | 30 mg p.o. | 3-4 |
| Oxymorphone | 1 mg I.V. | 6 mg p.r. | 2-3 |
DVT - Imaging and Labortory Findings
1. Contrast venography—Although contrast venography remains the gold standard for diagnosing DVT, it has been largely replaced by ultrasonography in most institutions. The advantages of contrast venography include a sensitivity and specificity of nearly 100% and the ability to detect DVTs of the calf, iliac vessels, and inferior vena cava that can be missed by ultrasound. Its primary disadvantages include its invasive nature, use of contrast material, and availability. Additionally, 5-15% of studies performed are technically inadequate.
2. Ultrasonography—Ultrasonography is the most accurate noninvasive study for diagnosing lower-extremity DVT, with a sensitivity of 93-100% and a specificity of 97-100% in detecting proximal DVTs. The limitations of ultrasonography are its ability to detect pelvic and calf DVTs (20% of which will extend into the popliteal vein and thigh).
3. D-Dimer assay—D-dimer is formed when fibrin is degraded by plasmin. The testing for the presence of D-dimer is by latex agglutination (least sensitive), whole blood agglutination (bedside, qualitative), and enzyme-linked immunoassay (ELISA) (most accurate). When combined with ultrasound, the whole blood agglutination and ELISA have an almost 100% negative predictive value.
From Current Diagnosis & Treatment Emergency Medicine - 6th Ed. (2008)
From Current Diagnosis & Treatment Emergency Medicine - 6th Ed. (2008)
Rochester Criteria for Identifying Febrile Infants at Low Risk for Serious Bacterial Infection
1. Infant appears generally well
2. Infant has been previously healthy:
3. Born at term (>/=37 weeks of gestation)
5. Infant has these laboratory values:
2. Infant has been previously healthy:
3. Born at term (>/=37 weeks of gestation)
- No perinatal antimicrobial therapy
- No treatment for unexplained hyperbilirubinemia
- No previous antimicrobial therapy
- No previous hospitalization
- No chronic or underlying illness
- Not hospitalized longer than mother
5. Infant has these laboratory values:
- White blood cell count of 5,000 to 15,000 per mm3
- Absolute band cell count of <=1,500 per mm3
- Ten or fewer white blood cells per high-power field on microscopic examination of urine
- Five or fewer white blood cells per high-power field on microscopic examination of stool in infant with diarrhea
Canadian C-Spine Rule
For patients with trauma who are alert (as indicated by a score of 15 on the Glasgow Coma Scale) and in stable condition and in whom cervical-spine injury is a concern, the determination of risk factors guides the use of cervical-spine radiography. A dangerous mechanism is considered to be a fall from an elevation 3 ft or 5 stairs; an axial load to the head (e.g., diving); a motor vehicle collision at high speed (>100 km/hr) or with rollover or ejection; a collision involving a motorized recreational vehicle; or a bicycle collision. A simple rear-end motor vehicle collision excludes being pushed into oncoming traffic, being hit by a bus or a large truck, a rollover, and being hit by a high-speed vehicle.http://content.nejm.org/cgi/content/full/349/26/2510
Canadian CT Head Rule
CT Head Rule is only required for application in patients with minor head injuries who have any one of the following:
High risk (for neurologic intervention)
CT = computed tomography; GCS = Glasgow Coma Scale.
From Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1394.
High risk (for neurologic intervention)
- GCS score <15>
- Suspected open or depressed skull fracture
- Any sign of basal skull fracture (hemotympanum, "raccoon" eyes, cerebrospinal fluid otorrhoea/rhinorrhea, Battle's sign)
- Vomiting >=two episodes
- Age >=65 years
- Amnesia before impact >30 minutes
- Dangerous mechanism (pedestrian struck by motor vehicle, occupant ejected from motor vehicle, fall from height >3 feet or five stairs)
CT = computed tomography; GCS = Glasgow Coma Scale.
From Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, et al. The Canadian CT head rule for patients with minor head injury. Lancet 2001;357:1394.
17 June 2008
Medice is a Crappy Gig
Doctors know that doctors are increasingly dissatisfied with their profession. The reasons are many, but mostly stem from an ever-increasing amount of non-clinical work that is not reimbursed (dealing with insurance companies, for instance, for payments or pre-authorizations). Combine that with Medicare payments that have not kept up with inflation (and in fact have decreased) and you have a recipe for disaster for both doctor and patient. The end result is that doctors spend less time seeing each individual patient - the 15 minute visit is becoming standard in primary care - because doctors must cram in more patients during the day to keep the clinic afloat. And then there's all the extra work they don't get paid for, which makes for long work days, sleepless nights, and a fast-track to burnout. Furthermore, a litigation-obsessed culture and the rise of the "professional patient"* that make the years of intense, hard-fought training seem trivial.
What do do?
Most of this is a result of doctors' own apathy to take action, to stand up to crappy work conditions. This passivity is also our virtue, since the majority of doctors are willing to put up with exploitation for the sake of patient care. The equivalent to a physician strike has been threatened by many doctors - refusing to take more Medicare patients if the reimbursement system is not repaired - but ultimately doctors feel that this would violate their professional ethics. Plus it would make the profession look bad in the eyes of the public; rarely does our community hold lawyers, politicians, business executives, or even professors, to the same strict standard.
* The patient who demands certain medical care or self-righteously questions physician expertise after a little bit of internet reading that gives an inflated sense of medical understanding.
What do do?
Most of this is a result of doctors' own apathy to take action, to stand up to crappy work conditions. This passivity is also our virtue, since the majority of doctors are willing to put up with exploitation for the sake of patient care. The equivalent to a physician strike has been threatened by many doctors - refusing to take more Medicare patients if the reimbursement system is not repaired - but ultimately doctors feel that this would violate their professional ethics. Plus it would make the profession look bad in the eyes of the public; rarely does our community hold lawyers, politicians, business executives, or even professors, to the same strict standard.
* The patient who demands certain medical care or self-righteously questions physician expertise after a little bit of internet reading that gives an inflated sense of medical understanding.
13 June 2008
Motocycle Helmet Laws
I am doing a visiting clerkship at Maine Medical Center in Portland this month. I was shocked to see motocyclists not wearing helmets. This is a law in Oregon since...for a long time I suppose. I also just learned that Pennsylvania repealed their helmet law a few years ago. It is no suprise that the number of motocycle fatalities and hospitalizations increased since that law was repealed in 2003. It is odd indeed that there are several states that still do not have universal helmet laws (requiring helmets for all riders) while many states such as Oregon, New York, and Massachusetts have had such laws for over 30 years. I was told that, at least in Maine, the motocyle lobby is more powerful than the public health lobby.
Decision-making by special interests rather than public interest has become a familiar story of what we accept as democracy in our own government, which is a large reason I think we tolerate rather liberal use of alcohol, tobacco and firearms, all of which are massive threats to public health. Sure, there are cultural reasons too, which was immediately obvious in the absurd public reaction to Obama's comment about guns and poverty while campaigning in Pennsylvania. I cannot pretend to separate out "authentic cultural principles" from a special-interest positions, but I think that lobbying, marketing and public relations more often than not hijack public debate on these very important topics by normalizing one side of the issue in the interest of private gain.
Decision-making by special interests rather than public interest has become a familiar story of what we accept as democracy in our own government, which is a large reason I think we tolerate rather liberal use of alcohol, tobacco and firearms, all of which are massive threats to public health. Sure, there are cultural reasons too, which was immediately obvious in the absurd public reaction to Obama's comment about guns and poverty while campaigning in Pennsylvania. I cannot pretend to separate out "authentic cultural principles" from a special-interest positions, but I think that lobbying, marketing and public relations more often than not hijack public debate on these very important topics by normalizing one side of the issue in the interest of private gain.
06 June 2008
So you want to live longer?
Here is a story on possibly the newest anti-aging fad: resveratrol. It's found in red grapes and other foods. In lab animals it has been shown to switch on a set of enzymes called sirtuins that are associated with anti-inflammatory and anti-neoplastic processes. Sirtuins apparently extend life in worms, flies and rats. The mechanism is thought to be that similar to the calorie-restriction theory of life-prolongation. This theory says that low-grade starvation stimulates the body to switch from reproduction (in which a body's resources are ultimately directed to offspring) to preservation (in which the body's resources are directed at the self). Hence, a longer life, as counterintuitive as it sounds. I should say, however, that there is no evidence in humans that this is the case. The calorie-restriction diet fad and resveratrol supplements have not been around long enough to know if they have any significant effects and a clinical trial measuring longevity would probably take several decades. If you consider the risks minimal compared to the potential benefit, you might just hedge your bet and do it anyway, which is the only rational explanation for why someone would willingly starve themselves. Furthermore, I am not sure if CR would really make a significant difference compared to simply following your doctor's advice, which is, eat lots of fruits and vegetables and get exercise. Only recently with all the media attention around obesity and diabetes has the American mainstream really started to take these doctor's orders to heart. (Incidentally, high gas prices may be the biggest boon to healthy aging as it will discourage dependence on the car).
Calorie-restriction diets are pretty controversial in the medical community. The obvious concern is the risk of malnutrition - but that could be lessened with supplements, if you think that is a good way to get nutrition (I don't). Another concern is that CR is really just anorexia - or possibly some other disorder - in masquerade. CR people, like anorexics, are obsessive about calorie counting; in fact their entire daily routines can revolve around it. Anorexia is a very complex disease that involves psychosocial factors and possibly organic brain disease. Many anorexics are very functional, educated, smart individuals. They can be very good at rationalizing their self-destructive behavior. CR, if a flavor of anorexia, would not simply be a rationalization of chronic self-starvation, it would be a pseudo-medical and pseudo-scientific theory defending anorexia as a healthy lifestyle choice.
Another element I find amusing about the anti-aging community is that it is almost entirely composed of young and youngish people who probably have very little contact with elderly folks. I have quite a bit of contact with older people. One thing that is fairly consistent is that old people don't talk about wanting to live longer. You just don't see 85 year-olds talking to you about the latest and greatest fad to keep them young and healthy. My theory about that is simple: old people get tired of living. And this is hard to foresee when you are fit, healthy, functional, and have life changes to look forward to when you are in your 20s, 30s and 40s.
One thing I enjoy most about my older patients is talking to them about how they view the quality of their lives. If they are happy, then what are their secrets? If they are not, then what when wrong? I hear a lot of the same answers.
The secret to aging well is pretty simple: keeping a good sense of humor; being passionate about something; and having meaningful personal relationships. If an 80 year-old has got those three or just two of three, then chances are, they are pretty happy with their life, regardless of their medical problems. This brings to mind an 81 year-old gentleman I met while in Burns, Oregon that had a smile and energy of someone more than half his age. We like to think that it just genes; but this guy also had the magical trifecta: he was always telling jokes and laughing, he played bluegrass guitar and fiddle very well several times a week, he had a large family close by in town and many friends with whom he played music.
How about those who don't do so well as they age? Invariably these are people who don't have any interests or hobbies (dispassionate); people who are unable to deal with stress well (lack humor); people who have a weak social support system (few nearby friends/family). People think that you are prone to get depressed as you age simply because your body and mind break down. We know quite well, however, that how one perceives pain and disability plays a very large role in the meaning of the pain or disability. In other words, a depressed individual is more likely to attribute more significance to their knee pain than is someone who is not depressed. A person who throws out their back at work as opposed to working in the yard is much more likely to see the doctor for a disability claim, and there is very good data that shows people who claim disability for an injury recover much more slowly than those who do not, regardless of the severity of the disability. So my point is, that we deteriorate as we age, but what that means to us - will it become a disability that impairs our sense of well-being or not - is very much a matter of how many of those protective factors (passion, humor, relations) we have in our lives.
Nevertheless, even the happy 81 year-old I mentioned conceded that life is getting long. He is happy, but life has a very different meaning for him now than it did 50 years ago. Back then he had a series of life-changes to look forward to: graduating from school, perhaps college, getting married, having children, buying a first home, developing a career. But at 81 all the big life-changing events have happened.
The tragic thing about aging is that our mental and physical functioning will decline, at varying rates, as we approach death. Ideally that decline should be short and fast; the worse case perhaps is Alzheimer's dementia, where the decline is insidiously slow and protracted, and involves not simply ending up in wheelchair but in loosing your mind and identity. The goal of simply extending life I think misses the point, and that is not about how long to live, but about how quickly to die. One could be the most devout CR dieter for many decades and eke out another five years of life. But eventually that person will die and it will be the same process as any one else: cancer, infection, heart attack, dementia, and maybe trauma. It maybe swift or interminable, but the death is the same.
Calorie-restriction diets are pretty controversial in the medical community. The obvious concern is the risk of malnutrition - but that could be lessened with supplements, if you think that is a good way to get nutrition (I don't). Another concern is that CR is really just anorexia - or possibly some other disorder - in masquerade. CR people, like anorexics, are obsessive about calorie counting; in fact their entire daily routines can revolve around it. Anorexia is a very complex disease that involves psychosocial factors and possibly organic brain disease. Many anorexics are very functional, educated, smart individuals. They can be very good at rationalizing their self-destructive behavior. CR, if a flavor of anorexia, would not simply be a rationalization of chronic self-starvation, it would be a pseudo-medical and pseudo-scientific theory defending anorexia as a healthy lifestyle choice.
Another element I find amusing about the anti-aging community is that it is almost entirely composed of young and youngish people who probably have very little contact with elderly folks. I have quite a bit of contact with older people. One thing that is fairly consistent is that old people don't talk about wanting to live longer. You just don't see 85 year-olds talking to you about the latest and greatest fad to keep them young and healthy. My theory about that is simple: old people get tired of living. And this is hard to foresee when you are fit, healthy, functional, and have life changes to look forward to when you are in your 20s, 30s and 40s.
One thing I enjoy most about my older patients is talking to them about how they view the quality of their lives. If they are happy, then what are their secrets? If they are not, then what when wrong? I hear a lot of the same answers.
The secret to aging well is pretty simple: keeping a good sense of humor; being passionate about something; and having meaningful personal relationships. If an 80 year-old has got those three or just two of three, then chances are, they are pretty happy with their life, regardless of their medical problems. This brings to mind an 81 year-old gentleman I met while in Burns, Oregon that had a smile and energy of someone more than half his age. We like to think that it just genes; but this guy also had the magical trifecta: he was always telling jokes and laughing, he played bluegrass guitar and fiddle very well several times a week, he had a large family close by in town and many friends with whom he played music.
How about those who don't do so well as they age? Invariably these are people who don't have any interests or hobbies (dispassionate); people who are unable to deal with stress well (lack humor); people who have a weak social support system (few nearby friends/family). People think that you are prone to get depressed as you age simply because your body and mind break down. We know quite well, however, that how one perceives pain and disability plays a very large role in the meaning of the pain or disability. In other words, a depressed individual is more likely to attribute more significance to their knee pain than is someone who is not depressed. A person who throws out their back at work as opposed to working in the yard is much more likely to see the doctor for a disability claim, and there is very good data that shows people who claim disability for an injury recover much more slowly than those who do not, regardless of the severity of the disability. So my point is, that we deteriorate as we age, but what that means to us - will it become a disability that impairs our sense of well-being or not - is very much a matter of how many of those protective factors (passion, humor, relations) we have in our lives.
Nevertheless, even the happy 81 year-old I mentioned conceded that life is getting long. He is happy, but life has a very different meaning for him now than it did 50 years ago. Back then he had a series of life-changes to look forward to: graduating from school, perhaps college, getting married, having children, buying a first home, developing a career. But at 81 all the big life-changing events have happened.
The tragic thing about aging is that our mental and physical functioning will decline, at varying rates, as we approach death. Ideally that decline should be short and fast; the worse case perhaps is Alzheimer's dementia, where the decline is insidiously slow and protracted, and involves not simply ending up in wheelchair but in loosing your mind and identity. The goal of simply extending life I think misses the point, and that is not about how long to live, but about how quickly to die. One could be the most devout CR dieter for many decades and eke out another five years of life. But eventually that person will die and it will be the same process as any one else: cancer, infection, heart attack, dementia, and maybe trauma. It maybe swift or interminable, but the death is the same.
02 June 2008
Young evangelical Christians are starting to act, well, Christian after all
Well finally some of the guys are actually reading the Bible and thinking about it, literally, like a good Evangelical should. If you were to rewrite the Bible today based on the content of right-wing Christian power brokers all you would find would be anti-abortion this and anti-gay that. Nothing about helping the poor. Nothing about stamping out disease. Nothing about the environment. Nothing about that Godforsaken war. And yet. And yet, the real Bible is exactly the opposite, isn't it?
01 June 2008
Done with psychiatry and onto 4th year
I just finished my clerkship in psychiatry. It was pretty fun. It was very interesting. But I'm not sure if I want to be a psychiatrist. Psychiatrists seem to be a pretty happy, low-strung group of people. Psychiatry is really different from the other medical specialities. Only in psychiatry can you treat any illness with the same medication, and the same illness with any medication.
The field is somewhat maligned by the rest of the medical profession. Doctors view psychiatry as a medical field like physicists view sociology as a scientific field. It is soft in terms of method and subjective in terms of evidence. The large majority of doctors dislike mental illnesses, exemplified by diseases like schizophrenia and bipolar disorder. They dislike the diseases because they are poorly explained by modern biomedical paradigms (e.g. molecular and cell biology). They remain resistant to the kinds of physical explanations given to other diseases. We know a whole lot about how the heart works and why heart attacks happen. With our knowledge of that organ we've been able to develop a very accurate mechanical model of physiology and disease. We are far from that stage when it comes to diseases of the mind, although there is no doubt that these diseases are ultimately based on dysfunctional biology too. Psychiatry is a good 200 years behind cardiology. This is not a failing of the field but proof of how extraordinarily complex the brain is.
My attending likes to poke fun of neurologists, the other kind of doctors who study the brain. Actually, neurologists diagnose and treat nerve abnormalities, and to the extent that this involves the brain, that organ too. Neurologists have the same prejudice towards mental illness that is widely found in medicine: they hate it. This must sound odd to someone who does not make a clear distinction between the mind and the brain. Indeed this duality - formalized by Rene Descartes - is largely rejected by neuroscientists, who view the mind has a manifestation of a whole bunch of ultra complicated neuronal connections (synapses). The above-mentioned attending likes to say that neurologists and indeed most of the medical community think of the brain as the motor and sensory strips, the visual cortex, Broca's area (language control) and the basal ganglia, thus excluding most of the brain that constitutes the essence of being human: executive cognition.
Perhaps more than mental illness, most doctors dislike the mentally ill patient. The reasons for this is varied. Many doctors went into medicine because they like the application of biology to making people's bodies work better. To be honest, many doctors (and especially surgeons) are not much different than car mechanics, except the car is very sophisticated and the stakes for success and failure are very different. Sure, a lot of doctors (and especially internists) do like the fact that their patients have personalities, quirks, desires, flaws, and so forth. This guarantees variety and unpredictability to the profession. Personality, however, often becomes an impediment to the doc doing her job. For example, the patient with chronic low back pain who wants an easy fix with a pain killer instead of loosing weight. Or the individual who fails to control his diabetes with proper diet and exercise because he suffers from depression. People find all kinds of excuses to not do what their doctors tell them. To some extent this is normal, we all do it, but for those who are mentally ill, it is more than a matter of making excuses. The reasoning machinery we take for granted is skewed or even grossly flawed in these people. You can't just tell a schizophrenic that he has to take his medicines or he'll go crazy, just like you can't tell a depressed person to cheer up and get on with their life.
The field is somewhat maligned by the rest of the medical profession. Doctors view psychiatry as a medical field like physicists view sociology as a scientific field. It is soft in terms of method and subjective in terms of evidence. The large majority of doctors dislike mental illnesses, exemplified by diseases like schizophrenia and bipolar disorder. They dislike the diseases because they are poorly explained by modern biomedical paradigms (e.g. molecular and cell biology). They remain resistant to the kinds of physical explanations given to other diseases. We know a whole lot about how the heart works and why heart attacks happen. With our knowledge of that organ we've been able to develop a very accurate mechanical model of physiology and disease. We are far from that stage when it comes to diseases of the mind, although there is no doubt that these diseases are ultimately based on dysfunctional biology too. Psychiatry is a good 200 years behind cardiology. This is not a failing of the field but proof of how extraordinarily complex the brain is.
My attending likes to poke fun of neurologists, the other kind of doctors who study the brain. Actually, neurologists diagnose and treat nerve abnormalities, and to the extent that this involves the brain, that organ too. Neurologists have the same prejudice towards mental illness that is widely found in medicine: they hate it. This must sound odd to someone who does not make a clear distinction between the mind and the brain. Indeed this duality - formalized by Rene Descartes - is largely rejected by neuroscientists, who view the mind has a manifestation of a whole bunch of ultra complicated neuronal connections (synapses). The above-mentioned attending likes to say that neurologists and indeed most of the medical community think of the brain as the motor and sensory strips, the visual cortex, Broca's area (language control) and the basal ganglia, thus excluding most of the brain that constitutes the essence of being human: executive cognition.
Perhaps more than mental illness, most doctors dislike the mentally ill patient. The reasons for this is varied. Many doctors went into medicine because they like the application of biology to making people's bodies work better. To be honest, many doctors (and especially surgeons) are not much different than car mechanics, except the car is very sophisticated and the stakes for success and failure are very different. Sure, a lot of doctors (and especially internists) do like the fact that their patients have personalities, quirks, desires, flaws, and so forth. This guarantees variety and unpredictability to the profession. Personality, however, often becomes an impediment to the doc doing her job. For example, the patient with chronic low back pain who wants an easy fix with a pain killer instead of loosing weight. Or the individual who fails to control his diabetes with proper diet and exercise because he suffers from depression. People find all kinds of excuses to not do what their doctors tell them. To some extent this is normal, we all do it, but for those who are mentally ill, it is more than a matter of making excuses. The reasoning machinery we take for granted is skewed or even grossly flawed in these people. You can't just tell a schizophrenic that he has to take his medicines or he'll go crazy, just like you can't tell a depressed person to cheer up and get on with their life.
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