Thursday, November 29, 2012

EMR Adventures

The hospitals I cover have all made the transition to electronic medical record  (EMR) documentation.  This means all our daily progress notes and H&P's have to be done using the templates in the EMR.  I'm fairly computer literate so the transition hasn't been awful.  I actually like being able to read the thoughts and recommendations of other physicians following  my patients.

The problem is my unease with some of the drop-down options for "physical exam findings".  When you click on "Cardiac", for example, a list of objective findings appears that you can choose to include in your note.  These findings include things like "S1 S2 normal, no murmurs, no rubs, no gallops, PMI location," etc.  I'll be honest--- I don't think I could reliably tell you what a rub or a gallop is.  What I can do is listen to heartsounds and determine if there is an arrhythmia or a murmur (in vague, nonspecific terms).  Beyond that, I am sort of flailing to describe what the hell I hear.  So most of the time I just opt for the blank option and manually type in my PE findings.  It's disconcerting using terminology outside one's comfort level.  It's sort of like a neophyte awkwardly trying to describe a wine to a connoisseur---this Pinot has a bold mahogany uplift with a sweet hint of, um, rosemary lingering on the palate, like a faint evocation of a youth spent in Tuscany reading Cicero...blah blah blah...pretentious vomit...  

Video Gamers

An experiment from the University of Texas at Galveston compared robotic surgical skills of three groups: high school students who played two hours a day of video games, college students who played four hours a day, and, finally, actual surgical residents.  The results indicate that moderate video gaming is predictive of superior robotic surgical skills. 
Specifically, the UTMB study measured participants' competency on more than 20 different skill parameters and 32 different teaching steps on the robotic surgery simulator – a training tool that resembles a video game booth complete with dual-hand-operated controllers a video monitor that displays real-time surgical movements. As a whole, the nine tenth graders participating in the study performed the best, followed by nine students from Texas A&M University and lastly the 11 UTMB residents; the mean age of each group was 16, 21 and 31 respectively.

Saturday, November 24, 2012


Carlos Hyde

Once again the Team Up North can go to hell. 

Drive Safely

Be careful out there.  This patient was wearing a seatbelt when T-boned on the highway.  The injury was a complete avulsion of a major branch off the ileocolic pedicle, along with complete shredding of the rectosigmoid mesentery.  All ended up well with timely intervention. 

Happy Thanksgiving Holiday Weekend. 

Mammogram Overdrive

A recent paper from the New England Journal demonstrates that mammographic screening paradigms have had little effect on ultimate survival.  Over three decades, screening all women from the age of forty on has identified 1.1 million more early stage breast cancers but we have not seen a concommitant decrease in the number of women presenting with advanced breast cancer.  This indicates that we are identifying a lot of non-aggressive, relatively benign tumors with little potential for metastatic extension.  The implication is that we are overtreating millions of women with unnecessary surgery, radiation, and chemotherapy for relatively benign, clinically insignificant mammographic findings.

Of course there are those who certainly do benefit from earlier intervention, just not to the degree we previously thought (old standards proclaimed that screening mammograms reduced mortality in breast cancer by 25%).   It is impossible right now to determine which women with microscopic pre-cancerous (DCIS) lesions are at higher risk for eventual transformation into aggressive, lethally invasive variants.  The direction oncologic research needs to be focused on over the coming years is in the realm of genetics so, through the meticulous identification of certain proteins and genes, we can more fruitfully identify which tumors need the bazooka in the armamentarium and which can be safely observed without interventional therapy. 

Are Doctors Rich?

A buddy of mine sent along an interesting link by a physician named Ben Brown that makes an argument that doctors actually aren't all that well off.   Salaries are down.  Education costs can exceed $300,000 over the course of college, medical school, and residency.  By the time you take that first job, you're on the wrong side of 30 and Wells Fargo is demanding $1800 a month for all your student loans.  It's a topic I've covered many times before.  If you are looking to make a killing in the world, to retire to some beach in the Caribbean at age 55, then medicine is not the career path for you. 

It didn't always used to be this way.  Medicine once was a very lucrative career tract.  All preening mothers wanted their little boys to grow up to be a doctor.  It was a ticket to elite status, country clubs, and three week summer vacations in Italy.  Such ideas are laughable now.  Mothers prod their sons to go into investment banking or become professional athletes nowadays.  Why spend 30 years in school and training just so you can be an employee for a giant health care conglomerate that may or may not renew your contract on a year to year basis? 

Tuesday, November 13, 2012


It has come to my attention that patients showing up in Emergency Rooms with DNR (Do Not Resuscitate) papers in place are nevertheless being aggressively treated for their latest acute medical crisis.  Sometimes the patient ends up intubated and on a mechical ventilator despite explicit instructions not to do so under any circumstances.  Rationale for ignoring DNR documentation invariably circles around to the idea that DNR engenders too much of a "gray area" in terms of how medical professionals are to respect the individual's wishes.  For instance, if a demented patient has a hip fracture and is in extreme pain, a daughter may decide to temporarily revoke her DNR-CC status and have the painful condition fixed.  Or maybe the 94 year old guy in the passenger seat is rear ended by a pickup truck and slams into the windshield.  He sustains a wicked scalp laceration and loses half his blood on the floor mats.  The trauma staff in the ER wastes little time closing the wound and transfusing blood products.  The tranfusions put him into failure and he is intubated.  The next day he is weaned and extubated.  He thanks the doctors and nurses for saving him.  He goes home.

Clearly, DNR status is not always an inflexible, dogmatic guide to patient care.  One needs to account for specifics and contingencies when composing DNR paperwork.  Here is a sampling of my own attempt in a living will to outline a protocol for my care, accounting for circumstances.  I have been as precise as possible only for the sake of clarity. 

Monday, November 12, 2012

Most Dangerous Drug in America?

Our trauma service has been seeing more and more elderly patients admitted for closed head injuries who are taking the blood-thinning agent Pradaxa.  As this NY Times article indicates, this is not a positive development.  Pradaxa is a direct thrombin and factor Xa inhibitor used in patients at high risk for developing cerebrovascular or systemic embolic events (i.e. patients with atrial fibrillation).  It is a newer alternative to the old standby, coumadin (warfarin) therapy.

Sunday, November 11, 2012

Post Trauma Redemption

In honor of Veteran's Day, I encourage everyone to read the story of Lu Lobello's atonement from the New Yorker a few weeks ago.  The consequences of War and the effects on both soldiers and civilians has rarely been written more poignantly.