Tuesday, January 31, 2006

Bob Woodruff: A Look at the Injuries

Bob Woodruff, co-anchor of ABC World New Tonight broadcast was seriously injured Sunday with his cameraman Doug Vogt from a roadside Improvised Explosive Device (IED). According to reports, Woodruff suffered wounds to his extremities as well as his head. He is currently recovering in Germany and is scheduled to be transferred tonight to a medical center in Bethesda, MD.

The most common cause of personnel wounded in action recently are due to roadside bombs. These are land mines or booby traps made out of locally available materials or another piece of ordnance, such as a cannon shell. These were used as far back as the Vietnam War. The IED today are larger as they are intended to damage the armored vehicle as well as the personnel inside of it.

I thought it would be interesting to review some of the injuries caused by these types of devices and some of the challenges facing Bob Woodruff in the coming months.

Most of the injuries caused by IED are traumatic in nature and are caused by foreign bodies. While woodruff suffered trauma to his extremities he was said to also have suffered head injuries. In the Iraq and Afghanistan conflicts, traumatic brain injury (TBI) accounts for 22 percent or higher of the injuries - a larger proportion of casualties than it has in other recent U.S. wars. This is because the personnel in Iraq and Afghanistan are wearing body armor which does a great job of protecting the core, however, their head and extremities are still exposed.

From an article published in the NEJM in May (Available here for free):

According to the Joint Theater Trauma Registry, compiled by the U.S. Army Institute of Surgical Research, 22 percent of the wounded soldiers from these conflicts who have passed through the military's Landstuhl Regional Medical Center in Germany had injuries to the head, face, or neck. This percentage can serve as a rough estimate of the fraction who have TBI, according to Deborah L. Warden, a neurologist and psychiatrist at Walter Reed Army Medical Center who is the national director of the Defense and Veterans Brain Injury Center (DVBIC). Warden said the true proportion is probably higher, since some cases of closed brain injury are not diagnosed promptly.
But those serving and touring do wear protective helmets and eye shields so how do they still have such a large proportion of Traumatic Brain Injury? There are also closed brain injuries:

Kevlar body armor and helmets are one reason for the high proportion of TBIs among soldiers wounded in the current conflicts. By effectively shielding the wearer from bullets and shrapnel, the protective gear has improved overall survival rates, and Kevlar helmets have reduced the frequency of penetrating head injuries. However, the helmets cannot completely protect the face, head, and neck, nor do they prevent the kind of closed brain injuries often produced by blasts. As insurgents continue to attack U.S. troops in Iraq, most brain injuries are being caused by IEDs, and closed brain injuries outnumber penetrating ones among patients seen at Walter Reed, where more than 450 patients with TBI were treated between January 2003 and February 2005.

A blast creates a sudden increase in air pressure by heating and accelerating air molecules and, immediately thereafter, a sudden decrease in pressure that produces intense wind. These rapid pressure shifts can injure the brain directly, producing concussion or contusion. Air emboli can also form in blood vessels and travel to the brain, causing cerebral infarcts. In addition, blast waves and wind can propel fragments, bodies, or even vehicles with considerable force, causing head injuries by any of these mechanisms. Approximately 8 to 25 percent of persons with blast-related injuries die.
Twenty five percent of those with blast related injuries die. Not such great odds for Woodward but so far all the indication are that he is improving.

Thus far, not much has been said to specifically address the injuries suffered by Woodruff. It is not known if they were serious enough to cause other complications.

The brain's size frequently increases after a severe head injury. This is called brain swelling and occurs when there is an increase in the amount of blood to the brain. Later in the illness water may collect in the brain which is called Brain Edema. Both Brain swelling and Brain Edema result in excessive pressure in the brain called Intracranial Pressure ("ICP"). Around-the-clock monitoring during this time is essential in order that Intracranial Pressure can be immediately treated. Treatment of brain swelling can be difficult. Very strong medications are administered and in some cases, removal of small amounts of fluids from the brain may be beneficial. If all these measures fail, a craniotomy may be performed.

But let’s say all ends well. What will Woodward have to face after his stay in the Intensive Care Unit?

Soldiers with TBI often have symptoms and findings affecting several areas of brain function. Headaches, sleep disturbances, and sensitivity to light and noise are common symptoms. Cognitive changes, diagnosed on mental-status examination or through neuropsychological testing, may include disturbances in attention, memory, or language, as well as delayed reaction time during problem solving. Often, the most troubling symptoms are behavioral ones: mood changes, depression, anxiety, impulsiveness, emotional outbursts, or inappropriate laughter.
Long term the prognosis is good. Most adults with a mild TBI recover completely within a year, but moderate and severe traumatic brain injuries are more likely to cause long term effects.

I am constantly amazed at the courage and perseverance of our young men and women who are in Iraq. Their life is threatened every single day. They are targets, just as those traveling with them are targets. Reporters who enter battlefields and war zones do it for the sake of their career and because it’s their job.

The endless numbers of those reporters who have been injured or captured as hostages continues to increase.

Is it really worth it?

So why do correspondents do it? Go here for the answer.

Grand Rounds

This week's Grand Rounds are up at barbados Butterfly. I guess my submission got lost in the mail.

Monday, January 30, 2006

Perhaps We can All Work Towards This

How do you deal with all that happens and not get depressed?

This comes up a lot, usually from the friends not in the medical field. It goes hand in hand with questions like “Have you ever killed somebody?”

So I took some time off from actively killing someone and it occurred to me that, considering the circumstances, it is unlikely that many physicians don’t get depressed and that more don’t eventually commit suicide. So why don’t many more doctors get depressed?

Depression is a common syndrome affecting a large proportion of the constituency. One would think that all that pain and suffering witnessed on the job would induce depression even in Richard Simmons, Not to mention the experience of being an intern. Not to mention being MY intern.

Here’s the answer: They do get depressed, often, in deadly ways, and more commonly than the general population.

Most of the research of depression rates in physicians points to higher rates than the general population but predisposing risk factors which are the same as those in the general population. Surprising, as one would think that physicians are more prone to depression due to the nature of their profession. But this is not, and is, the case.

My only thought is that the rewards of medicine compensate somehow or that it becomes a “job”, and as a defense mechanism loses its magnitude in the eye of the practitioner.

There are some aspects of “the job” which do predispose physicians to depression, but they're not the ones you may have guessed. From an article published in the NEJM on physician depression and suicide:
Another way to view the problem is that the professional burden carried by doctors leads to social isolation and an increased probability of undergoing phases of disturbances in their social networks. It has also been noted that physicians tend to neglect their own need for psychiatric, emotional, or medical help and are more critical than most people of both others and themselves. They are more likely to blame themselves for their own illnesses. And they are apparently more susceptible to depression caused by adverse life events, such as the death of a relative, divorce, or the loss of a job.

There are few interventions in place to help prevent suicide among physicians. Such safeguards might include the provision of discreet and confidential access to psychotherapy and open discussion of the stress encountered in a medical career. The barriers that may prevent physicians from seeking help for mental disorders (such as the threat of losing their medical licenses) must also be addressed. In time, perhaps these and other measures will help doctors to do what they do best: save lives, beginning with their own.
From JAMA: Cross-sectional rates of depression (15%-30%) are higher in medical students and residents than in the general population.

It gets worse, medical personnel are more successful at suicide, which led to a consensus statement released in JAMA in 2003. Among the issues addressed was the difficulty that physicians face when trying to obtain help for mental health disorders:
Thirty-five percent of physicians do not have a regular source of health care, which is associated with less use of preventive medical services supporting the observation that the medical profession does not encourage physicians to admit health vulnerabilities or seek help.

It is reasonable to infer that physicians' concern about disclosure of mental health records is widespread, although studies are lacking. Breaches of confidentiality also are believed to harm openness between the physician (as patient) and the treating clinician and may result in needless disclosures to coworkers. Those concerns, coupled with professional attitudes that broadly discourage admission of health vulnerabilities, are likely the driving forces behind physicians' disinclination to seek mental health care.
Wonder what they were discussing? (From the same consensus statement)
The culture of medicine accords low priority to physician mental health despite evidence of untreated mood disorders and an increased burden of suicide. Barriers to physicians in seeking help are often punitive, including discrimination in medical licensing, hospital privileges, and professional advancement.
I know two physicians who committed suicide. And have heard of many more medical students who’ve succeeded as well.

If you are a medical professional and would like help you can find more information here: http://www.afsp.org/physician

Friday, January 27, 2006

Friday Intern Topic of the Day III: Hamas Wins Palestinian Elections

I had to do a doubletake but it is really true. After years of oppression the Palestinians finally get a taste of freedom and democracy. And as their first chosen leadership they choose a terrorist organization hell bent on the total destruction of Israel through whatever means necessary. Including, but not limited to, convincing young men and women to commit suicide for the sole purpose of murdering other innocent lives.

This was clearly a choice. Through a democratic process. Which means that it is the MAJORITY of Palestenians who prefer this as their way of life.

Pajama Media has a blog roundup:

Laurence Simon: "This is what happens when a Bush goes back on his word."

Powerpundit: "Complicate is an understatement, as this now presents a major roadblock to peace in the Middle East. Hamas is responsible for many, many Israeli civilian deaths, and if it has a major role in Palestinian government then it is highly unlikely that Israel will be able to bring itself to trust such a government enough to make any meaningful moves that will lead to the hope of a lasting peace."

Jay Lapidus notes what he sees the one good thing about the Hamas victory.

Israellycool: "[D]espite what many would have you believe, a majority of neo palestinians do not favor a two-state solution. Nor do a majority of neo palestinian people oppose terrorism."

Daimnation: "Considering the years of incitement and propaganda to which the Palestinians have been subjected, not to mention to corruption, incomptence and authoritarianism of Fatah, I can't say this result was unexpected. If the Palestinians believe they're better off with genocidal Islamofascists running their government, so be it. It's their choice, and they'll find out the hard way what it's like living under a Hamas government."

Clive Davis: "Hamas's new media consultant is already hard at work on that 'image problem'"

Truthdig: "A terrorist group will now be setting the Palestinian agenda. And with right-wing pretenders lingering over Sharon’s death bed, have prospects for peace in the Mideast ever looked more distant?"

Treppenwitz: "There can no longer remain the fiction of the the Palestinian majority who silently wish for coexistence with The Jewish State... if only Israel will allow them to fulfill their dream of self-determination. What these election results declare loud and clear is that the Palestinians intend to make their national dream Israel's worst nightmare. [...]
This victory doesn't now mean that every Palestinian is a Hamas terrorist any more than a Likud victory meant that every Israeli was in favor of Ariel Sharon's vision for Israel's future. In fact, we've all seen how people can vote for one thing and get quite another. However voting for a particular leadership places an electorate in the position of accepting the future actions of those leaders. That's democracy at work. So when the majority of Palestinians tell me with their words and deeds that they have committed their future to Hamas' vision of Israel's destruction... then I have no choice but to take them at their word."

Secular Blasphemy: "Will it be a disaster, or draw Hamas in a democratic direction? If Hamas is already calling the shots in the areas, they can just as well get control of the 'democratic' institutions there."

Jihad Watch: "The Tiny Minority of Extremists has won the Palestinian elections, which in itself is not actually a demonstration that the jihad ideology enjoys broader support among Muslims than most analysts would like to admit, since Fatah itself was not exactly an epitome of opposition to that ideology."

Roger Simon notes the reports that Hamas supporters have stormed into the Palestinian parliament amid clashes with Fatah loyalists, and writes: "Actually, on ten minutes reflection (it's pretty early here in LA), I am glad Hamas won. Elections should reflect the will of the people and this one reflects the will of the Palestinians. Now we know."

Austin Bay: "Hamas Wins– The Slow Civil War Takes A Twist."

As with nearly everything the future will depend on the money. Most of the foreign aid to the Palestenian Authority (Nearly 80%) comes from the European Union. My instinct is that the initial reaction will be strong but that it will quickly taper as this news leaves the spotlight.

Once again, when we have to depend on Europe we are all in big trouble.

Thursday, January 26, 2006

Widow Maker

I wrote this piece for the chronicles on my first rotation of my second year of residency. This patient eventually left the hospital, although, her quality of life was never the same again.

There is a young fifty eight year old mother of two currently walking the tightrope between life and death in my Coronary Intensive Care Unit (CICU). She had a massive heart attack earlier and was rushed to the angiography lab where one of the critical arteries supplying blood to the heart failed to appear on the monitor- it was completely blocked.

The “Widow Maker” was the affectionate name we give to a stenosis of this vessel. It’s all in the name, they say. Most commonly, this fatal stenosis usually affects fifty something year old men, fatally. But diseases never read textbooks and Ms. R had no idea of this horrible monster forming in her arteries. Now it threatens to end her life.

I told her family that the situation is grim, they cried, I had nothing to say to comfort them at all. She has a very slim chance of survival and they better be prepared.

At the moment she’s nearly maxed out on all the possible medication we could give her to raise her blood pressure and the only thing standing between her and the other Unit in Sky is the love of god and a resident with 14 months of experience.

I am scared.

Back to work!

For more information on the Left Anterior Descending arterys' nickname go here. Coronary artery disease is among this nations top killers. It is silent and deadly. If you experience symptoms of angina please go to you doctor to report them and have the appropriate work up.

Tuesday, January 24, 2006


Adrenaline intensifies the experience. Rather, “Epinephrine”, is the medically correct term.

It’s during a “code”, a word substituted for “cardiac arrest”, which is a descriptive term for the final common pathway for all causes of “death”, that one feels its effects sharply. It’s a funny word if you think about it.

My thoughts race as I run the white corridors. I am responsible for all that reside within the confines of these walls. Looking at them now as they surpass me by, one can’t help but make the heavenly association. My patient slowly drifts towards a white light and I run through it as fast as I can, fighting to save him, back to my white walls, my insane world.

“Attention, attention, attention, cardiac arrest five west”

Five West is the Gynecology floor and quickly I note to myself that they probably don’t know what to do in this situation. Doctors who care mainly for young patients rarely have to perform under the pressure of an arrest. Those more accustomed to this battle should volunteer to help.

So I did. Noting all the while, as I run full speed through the corridors, there is a young woman on the other end. White corridors, she is probably dead now. And I am violating hospital policy. “Slow down doctor, running is not allowed”. Who said rules are made to be broken?

“Epi, atropine, shock” I rehearse…

“Epi, atropine, rhythm” correcting myself. Sweat slowly accumulating on my brow. I need to join a gym. I can’t believe I’m thinking about this right now, distracted.

Chest compressions, intubate, continue chest compressions. I think codes look so great and exciting on television. Do we have a central line yet? Where the hell is Anesthesia?

The crash cart is open, there is blood on the floor, there is some on the bed and also on the doctors, their scrubs and the floor, again, I note. She is intubated and we continue chest compressions. There is some blood on my scrubs as well. Iodine is everywhere. Codes look peaceful on television.

Cardiopulmonary arrest is defined as the abrupt, unexpected cessation of spontaneous and effective ventilation and systemic perfusion (circulation). Cardiopulmonary resuscitation (CPR) provides artificial ventilation and circulation until advanced life support can be provided and spontaneous circulation and ventilation can be restored.

CPR saves lives. Certain states now encourage the purchase of an automated external defibrillator by allowing a tax credit for this purchase. Please take a CPR course so that one day you may help another, and get the word out so that one day, someone may help you.

Monday, January 23, 2006

Grand Rounds

Grand Rounds are up today at Kevin M.D. He blogs so much I'm convinced he's lost his actual job a long time ago. While you're there you can check out all the podcasts of your favorite med bloggers as well, just scroll down.

Need Help with Medlogs

So for some particular reason I can't get my feed accepted to Medlogs. The feed validator says it is invalid and after two weeks of trying I finally give up. Can anyone help. Jacob Rider is not answering my plead.

I Hate Spleens Too

Kim, at Emergiblog writes about an experience she had with a sickly spleen. I am rather vigilant with patients who may not have a spleen. They get sick so quickly. So any patients who has had abdominal surgery get extra attention coming their way.

An interesting trend I noticed. Most patients don't know if they've had their spleen removed during their old surgery. I usually make it a priority to know what vital organs I no longer have, I think you should adopt this sage advice. Oh, and good nurses aren't made that way by studying at home...and...you really do have to have at least a highschool diploma:

Be a nurse and make good money....why gosh it never occurred to me to be a nurse until I picked up these matches!

Kim has more.

Friday, January 20, 2006

Friday Intern Topic of the Day II: How to Get a Real Live Person

RLC has the facts about how to get a real live person on the phone when calling your local telephone/cable/electric/gas company. And by the way "This conversation may be recorded for quality purposes". So we can record everything you say and use it against you at a later date:

And thanks to the people of this country who take the time and make the effort to find and promulgate information to help others in every conceivable area of life. The sovereign individual is the most endangered species on Earth today, and people like these are keeping it from extinction.

Thursday, January 19, 2006

The Adorable Forgetful

This is an entry I wrote back when I started the Chronicles. I’ve re-written it here a a follow up to my previous post.

There are two types of demented elderly (of course there are many types of dementia, but for the sake of argument, let’s keep this simple). There is the angry demented and then there’s the pleasant kind. The angry demented upset everyone. Family never visits, no one calls, the home health aids are constantly changing.

The other is always smiling, even during codes, even during their own code. I love them. It's a blessing to be happily forgetful, constantly. They don't even know how much they don't know or how slow they've become or how incontinant. We love them because they make us feel like we're helping, even when we're not.

The truth is that I've resigned myself to a future of Alzheimer's. My memory is horribly bad and if I don't get it then we can junk the whole disease-progression theory.

I just hope to be Pleasantly Demented.

Wednesday, January 18, 2006


This week at Free Money Finance. Go grow you net self worth.

I never got Tagged

I keep getting requests for interviewes about my blog. It seems everyone wants to know who is behind the name and why he loves to blog so much?

I never thought it to be interesting at all. In fact, I don't even find myself interesting at all. the truth is I'd probably be a really boring interview with absolutely no insight into anything involving medicine. I feel sorry for the would-be callers.

but this is interesting:

An entertaining game of "tag" has been running through the online diabetes community (OC) in which bloggers hit each other up for "Five Random Facts About You." I did a little checking and discovered that the game is actually running all across the blogging world. No idea how it got started. Just for fun..

Diabetes Mine, an excellent blog, for the rest of the story.

Tuesday, January 17, 2006

Attending Effect

Those who have suffered through internship, any internship, can attest to what I like to term the “Attending affect”. An embarrasing event which happens after taking a thorough history from a patient. Initially you may have believed that he/she may have extremely worrisome disease but based on the answers the patient provided you’ve managed to rule out most of the more dangerous pathology. The next morning you give a great presentation to the attending pointing out how you’ve asked all the appropriate questions. And then everyone as a team, including the Attending, comes to examine the patient.

The entire story suddenly changes. Every lethal complication you’ve managed to rule out on the basis of history the patient manages to rule back in and all of your hard work goes out the window.

“What? Sure I had crushing chest pain and a very difficult time breathing. Of course I did!”

“No, it only happened to me one time before, you know, before I had that emergent cardiac catheterization I forgot to tell you about”

...As you feel the blood rush to your cheeks and the neck suddenly loses all ability to continue holding up your head.

How the same story changes overnight I’ll never understand. I can sympathize with the poor intern, just another victim of an undefinable phenomenon. This adds yet another challenge to the first year of doctoring. A year filled with unexpected obstacles.

No lesson, though, is more embarrasing than that of the “pleasantly demented” elderly. And every intern, on one occasion or another, will fall pray at the hands of the pleasently demented.

This newly demented individual is so slick that they can obscure this fact quite well, especially if a deeper investigation of the fact is not taken. Usually, the morning presentation is smoothless. The patient is “Alert and Oriented times three”. The intern rejoices in his own glory.

Later, when we find that the patient believes it’s 1969 and that the Mets are actually a good team, all accounts of the story can be filed along with the recycled trash being picked up in the basement. All the hard work for not.

When you “assume” you make an….

Once again, the intern has fallen pray to the adorable forgetful, the pleasently demented. And such a fall from glory, especially when your peers are watching, is always fun to watch.

Quit Smoking

I love reading Aiden:

She smirked at me, as if to say: Oh dear, how precious. You want to save me. But behind her cool blue eyes, under the silver cap of elderly hair that shaded her skull, I could almost see the nicotine devil in charge of her freewill. Its puppetry was masterful. The old woman’s yellow-stained fingers stroked her mouth as if searching for a phantom cancer stick.

If there is any one thing that you can do right now to dramatically improve your health it's to STOP SMOKING!

BTW, go buy the book. You cheapskate!

Grand Rounds

Grunt Doc is a blog devoted to the art of Emergency Medicine (I use that term "art" loosely). But no matter what my views on the subject I still enjoy reading what he has to say every week.

Today he hosts Grand Rounds. so go there and check out the week's best writing.

Monday, January 16, 2006

So it's No Babies or No Sex?

Now a controversial new study suggests that the pill not only suppresses desire, but can also do so for months after a woman stops taking it, by raising levels of a certain protein.

Just a little more incentive to substituting the wife's pills with some sugar caplets. Go to Rebel Doctor for the rest of the story.

Friday, January 13, 2006

Friday: Intern Topic of the Day

Every Friday these interns start arguing about some irrelevant issue, or rather, one that is unconnected to medicine. At least today they argued about something I care about. And yeah...how come superheroes don't die naturally?
I’m not saying this lack of aging heroes is wrong. Being a super-hero is a dangerous occupation, after all. Heroes are going to die in the line of duty or make enemies who will hunt them down after they retire. Frankly, I doubt there’s much interest in an elderly super-hero title, so I can’t blame anyone for not publishing one
Go read the rest here at Polite Dissent.

Thursday, January 12, 2006


his was one of the first entries I wrote for the Chronicles. I've changed much of it to reflect how I would have written it today

I’m re-reading, for the fourth time, the algorithm of a code. I remember nothing now. The churning of the metal in my brain slowly creaking as it comes to life again. My neurotransmitters begin to form as the body retrieves their original chemical formula; I realize I am facing an uphill battle.

Wish me luck my friends. Over the next 2 weeks my supra-tentorium should return to life, and who knows, maybe my blogging will be slightly more interesting

While for the last three months I’ve come to think of myself along the same lines as a Hula hoop instructor (I just finished three months of “Kick back” rotations), tomorrow, I become a real doctor again. Not just a real doctor in any old place, tomorrow, I’m the resident in the Coronary Intensive Care Unit (CICU).

Of course there is some good news involved. Although my first rotation is in the CICU, it’s one of the two rotations every year that we spend at a private hospital. And while rotating in the CICU is usually misery personified, serving in this Unit is nothing short of pure pleasure.

And I’ll tell you why.

The nurses are still motivated and practically run the place. Residents get to sleep (if we’re nice enough to them) and when we wake up they tell us everything they did, all by themselves. God bless their souls.

The nurses in the Mad House, on the other hand, are overworked and underpaid. Sometimes it feels that they’ve resigned themselves to mediocre work, just to protest the situation. Of course the residents are stuck in the middle, more specifically, the interns. Someone has to do the job correctly. And the patients don’t benefit greatly either. Sometimes we feel that the only thing watching our patient is the wall.

But all that is behind me now, at least for the next two weeks.

Wednesday, January 11, 2006


Maria has such a great way of putting things. I never thought about my patients this way:
“And yet, even though you know you know! that you are married, someone else is telling you that you aren’t, that it never happened.”
Go read the whole thing.

Carnival of the Vanities

Is up at The Hip and Zen Pen:

"And doctors go snarky on doctors over at a blog called, simply Doctor"

Interesting, does anyone feel "Snark-ied"?

Tuesday, January 10, 2006

New Links

I am writing this as a special request to those who would link here. First, I would very much appreciate the link and would be happy to reciprocate to help you with your traffic. Please, link under the term "Doctor" as that is the name of the blog and not "Internal Medicine Doctor", as many of you have been doing (I do understand the confusion with the URL). This is important in terms of Google finding my page.

Thanks again for any links I really do appreciate them.



She can't breathe now, again. Every attempt at oxygen begins and quickly ends with an inefficient wheeze. Draining whatever strength is left.

She is pounding the cement sidewalk flopping about like a fish out of water, the crowd gathers around her. She is slowly choking. Her fingers turn into various shades of blue. No oxygen. The execution has begun.

We are all praying for air.

Once again, her life is threatened by this monster that lives inside. The noose around her neck tightens, the future is questioned and slowly she drifts into the darkness. This vision now fades, slowly to black. She stares in her daughters' eyes.

She is only four now, she is panicked. "Mommy is in trouble", she thinks to herself. But she cannot speak. She cannot hold her daughter and calm her now. No air.

Again she tires the pump in her hand to no avail. Nothing helps! and the cold frigid air leaves no sign of the good fight. She feels herself slipping away now. The rumbling of an ambulance shakes the ground, slowly nearing. Benevolent in its intentions.

I admitted her tonight.

She was extubated in the emergency room and is doing well. My admitting diagnosis was “asthma exacerbation”.

I'm constantly amazed at the serenenity of our "admitting diagnosis" when compared with what actually happened. Or what could have.

Grand Rounds

This week's Grand Rounds are up at the Clinical Cases and Images Blog
work in a large tertiary care center which is probably one of the biggest and busiest hospitals in the world. There are doctors from all sorts of subspecialties, nurses, supportive personnel and, of course, thousands of patients who make this whole endeavor worthwhile.
Go check it out.

Monday, January 09, 2006

Introducing the new tool for the academic literature search: Google?

According to an article published in this week’s New England Journal of Medicine more (most) medical literature searches are being performed with the use of engines other than Medline. The most common of which, as you can see in the figure above is Google.

Among those searches which provide link referrals to Medical Journals, Google ranked number one, with Yahoo taking the number four ranking. Among other things, convenience seems to be the major factor.
The number of searches performed with PubMed has increased steadily to about 70 million per month. Yet at the same time, an increasing number of people are finding their way to citations and abstracts in PubMed through searches that begin with Google the largest single source of referrals to PubMed or with Google Scholar or Yahoo.
My thoughts of possible causes: Whereas Pubmed requires the user to understand how to enter a search term to optimize search results, Google requires no such understanding. In addition, Google Scholar, a new search engine specifically designed to search the academic literature further simplifies these requirements and optimizes search relevant results. But the article specifically points out that most referrals do not come from the Scholar search but instead from the general google search engine.

The article does cite a different reason:
Many articles are available through Web sites maintained by journals, although there may be charges or registration requirements. Some are also available without charge through nonjournal Web sites — sometimes with the permission of the publisher, sometimes without.
Kind of like what I'm doing here.

It’s an interesting trend though, wouldn't you say?

Friday, January 06, 2006

More on Sharon's Condition

From DB:

What should we learn? We must always remember that our treatments have both risks and benefits. Sharon’s physicians gave the right treatment - but sometimes the risks become complications. Unfortunately, Sharon has had a major unfortunate complication of a correct medication
As an Israeli I feel that the whole situation is unbelievably tragic. We've made such great headway and I fear that it may all be lost now. I can only hope for Israel.

The Chutzpa

The Fake Doctor (What's with people using a pseudonym with the word "Doctor" included?) writes a hilarious entry on Parenting tips. It reminds me of when we were trying to find a good name for Jordan:

So three cheers for all the Darcquan's, La Fawnda's (I guess that qualifies as a not-so-obscure movie reference), and Zzyzzx's out there. This is not about them. This about all the parents out there who have the chutzpah to pick out from among the vast landscape of potential names a small subset that are almost guaranteed to send that kid straight to the NICU with some sort of awful disease. Yep, this is a warning to all the future Miracle's, Destiny's, Hope's, and Prayer's out there
"Destiny" was actually in the running. I guess I can breath a sigh of relief now.

Thursday, January 05, 2006

Medical Consulting

This is a light hearted post I wrote back when I was on the consult service

Dear surgery intern: “give me your tired, your sick, your poor huddled masses yearning to be free”…of your horrible care!

As an exhausted and frustrated house medical consultant for all the surgical specialties during the last three days, I’ve come to this one conclusion: Every patient in the hospital deserves to be on the internal medicine service and all the other services should be strictly consulting.

In the Mad House, medical consulting is restricted to third year medical residents. I remember how during the second year my elders would tell us of the horrors they encounter on the service as they shared with us the full list of confusing and often conflicting orders they found in the surgical charts. I never thought these to be true, probably exaggerations added for comedic value.

Oh. My. God!

For the sake of the health of future patients I offer all surgical residents, or any other specialty for that matter, these informative suggestions as general guidelines for the future care of your most favorite patient. Consider yourself forewarned lest your name be mentioned behind the closed doors of our favorite call room.

-In diabetic patients, generally, 5% Dextrose (D5) is not a good choice of fluids. There are times when D5 would be appropriate, for example, if the patient suddenly became hypoglycemic. Otherwise, your overwhelming need to put the patient in a hypeglycemic coma is not a valid indication.

-If the patient requires pressors to maintain an acceptable blood pressure. Pushing beta blockers every six hours concurrently to slow down the heart rate is contra-indicated. There are times when tachycardia is a blessed thing.

-Bolusing patients with two liters of normal saline may not always be the best pre-op strategy, especially in those patients who have congestive heart failure. You may want to consider dialysis patients along these same lines.

Of course surgery has its perks. For example, every surgeon I know gets to ask his/her patient if they’ve “passed gas” yet. I think that’s wonderful. They have a license to ask patients if they’ve farted. Even more impressive, farting is good.

A day will come when internists will no longer need to apologize for inquiring about flatulence.

A Wonderful article

There is a wonderful article published in the NYT recently by Abigail Zuger, M.D. about the reality of hospital medicine versus how it looks in the medical journals:

It was 4:30 a.m., the hour at which, if you are up all night in the name of medical training, you begin to shiver uncontrollably no matter how many patient gowns you layer on. Just when it seemed there might be time for a little nap before morning, our fifth admission of the night rolled in
Hat tip to Shrinkette for the lead.

Wednesday, January 04, 2006

Ariel Sharon Suffers a Massive Stroke

Ariel Sharon suffered what sounds like a massive stroke two hours ago. According to the news he had bleeding into his brainstem, very tragic news.

My sympathy goes out to his family. I can only hope that everything he has worked to build doesn’t come to an end tonight.

The 77-year-old's powers of office were transferred to Deputy Prime Minister Ehud Olmert shortly after Sharon arrived at Hadassah Ein Kerem Hospital.

The stroke was Sharon's second in less than three weeks.

Sharon had been taken from his home in the south of Israel to the hospital, where doctors diagnosed a cerebral hemorrhage

Here for the rest of the story

Welcome to Doctor

So how do you like the new home?

Very similar to the old one wouldn’t you say? Same design with a new logo. But I like the new one better and I like the name better.

Although “Chronicles of a Medical Mad House” had a great ring to it, I’ve grown tired of its meaning. One and one half year later I have come to terms with the fact that it is the record of my residency and all of its wonderful experiences. I will never remove it from the internet. It will always be there for me to sift through when I become nostalgic.

This new blog called “Doctor” will have posts with the same sarcastic, dry, inappropriate humor you’ve come to expect of me. I hope to continue improving as a writer and a physician and I expect it will reflect in my writing and I really want you to be there to witness it all. I would also like to begin doing things I haven’t done on my site before.

The Blogroll is nearly identical to before and I would really appreciate if you update your blogroll as well with new blog name and address. It should help readers (and Google) know I’m alive.

Again, Welcome to Doctor and I hope you stick around.

Tuesday, January 03, 2006

Ruined by Reality

Was that me, dressed up in a dark suit doing my best not to look intimidated?

Three years have changed and these fourth year students filing into our conference room remind me of a younger self. How they shine bright with curiosity for answers only their future will tell. The prospect of a career in medicine is exciting for them now. It is the beginning of a new world. Everything, it was all for this. Again, with another September starts another match.

It is that time of year again, when a competition ensues to capture the most valuable of prizes, a medicine residency in a prestigious institution. There are only a handful of these and that makes each and every position precious. Each of these students knows it will be a critical steppingstone to a future glorious career, and so did I.

I had survived a breakup with my fiancé, struggled through four years of medical school in a foreign country, even found the love of my life while there and got married. I came to the Mad House is 2002 anticipating a day of sweating and squirming as I attempt to guess the most desired answer. I had the future in my hands, they wanted me, and the prospect of a career as an internal medicine doctor was exhilarating. I remember running home to tell my wife that I was offered a position, hardly able to contain myself.

So what happened?

That young man and this seasoned resident, they are such different people. In between them three years of an internal medicine residency that drove that same young man on a path to…well, you read this blog don’t you?

Unfortunately, the real world happened.

Saving a troubled father of two from a severe bout of congestive heart failure was rousing. Saving that same father from another bout and yet another simply because he refuses to take medications can be downright depressing. They say memory is selective, I find mine tends to select for depressing moments.

This is one of the reasons I never delete negative comments. They ground me. Often, they allow me to reflect on the true magnitude of what it is that we do. Somewhere and sometimes I make a difference. And that is essentially one of the greatest things anyone can do. But I’ve lost a large part of my former compassionate self.

At times though, I do miss that young fourth year. Would he disapprove of what he has become, a new breed of healer and warrior struggling with himself to survive?

Reading this you probably think my patients don’t appreciate my efforts. But, my patients actually do like me. I know you wouldn’t think so from reading this blog but judging from the comments and gifts I get at my clinic, they must.

So to all the fourth year students who have that jazz in their step, bouncing on clouds, hoping to high-heaven they do well. I wish you all the best. Moreover, I wish you the wisdom to know that what you are doing, as depressing and downright useless as it may sometime feel, is immeasurable good, even if your patients don’t know it.

Like well trained warriors, don’t let your compassion run dry, but do learn with who it’s worth fighting your battles.