Thursday, September 29, 2005

Grand Rounds -- This Week an Anniversary

Grand Rounds, so thoughtfully arranged initially by Nick at Blogborygmi, celebrates it's one year anniversary this week. Go to Family Medicine Notes and check out the best the medical blogosphere has to offer, and say "thanks" to Jacob for hosting while you're there!

Sunday, September 25, 2005

Pain Out Of Proportion

Part of the prolonged process of becoming a physician is learning to separate the wheat from the chaff --- getting down to the meat of what is wrong with patient, and putting aside other information that is distracting, or at least of lesser importance. This is a skill that is not instinctual, never formally taught, and is always in the process of being refined by the practicing physician. In many respects, it is what general surgeons must pretty much always do when faced with the patient in the ED.

Sometimes, we get clues that lead us in one direction or another --- certain typical complaints from the patient, worrisome lab or X-ray findings, etc. There are also specific phrases when spoken by the ED physician tend to make us pay a lot more attention --- like "free air under the diaphragm," "hypotensive patient with abdominal pain," and "get down here now!" One of these phrases that makes the hair on the back of my neck stand up when delivered by an experienced (old like me) ED doc is "pain out of proportion to exam." Quite literally, it means that the patient complains bitterly of abdominal pain, usually a gnawing and difficult to control pain, with a fairly benign abdominal exam.

WARNING! WARNING! DANGER WILL ROBINSON!

Pain out of proportion to the exam (POOP) can be a sign that a piece of bowel is on its way to dying, or may already be dead. It often means a trip to my favorite place, the cold room with bright lights, warm blankets, and your friendly neighborhood anesthesiologist.

So, when Dr. Smith (pardon the Lost in Space reference) called the other night and used the magical catchphrase, I was out of bed and in the ED at 2AM. He was very concerned about the lady in exam room 16, and thought she needed to be explored. I found there a very sweet little lady in her 70s, with a lot of good reasons for having ischemic bowel --- she was a long time smoker and resultant vasculopath, and she had undergone three or four abdominal operations. This means that she could have compromised bowel on the basis of [1] an adhesive small bowel obstruction or [2] mesenteric ischemia due to her vascular disease.

She was in a fair amount of discomfort, but had received only a small amount of narcotics at that point -- somewhat unusual for a patient with dead bowel, but not at all uncommon in the elderly. Her abdominal exam was pretty benign; although she did complain of diffuse lower abdominal pain, her abdomen was soft. Labs were unremarkable. Plain X-rays and abdominal CT also unremarkable. In fact, the only two things that were remarkable about this lady were her tears and her frequent repetition of the same question --- "Has my daughter gotten here yet?"

There are unfortunately not a whole lot of additional tests that help us decide which patients with POOP need to go directly to the OR, and which ones can be safely observed. This is where the experience of the refining process I wrote about above can come in real handy -- but it is by no means infallible. So, I left the exam room, telling her I would go review the CT with the radiologist; in all honesty, with cases where things are a bit murky, I need a few moments alone with my thoughts to help me make a good decision. Besides, the only thing the CT revealed was an abdominal aorta that contained enough calcium that it looked like a misplaced femur.

I returned and reexamined the patient, who if anything was more agitated and uncomfortable, perhaps crying even more --- with fear? pain? worry? Her daughter arrived, and she simultaneously lit up and sobbed a bit harder. I have been presented with this scene before, and am not such a cold-hearted SOB that I didn't leave the room to give them a few minutes together.

As they say where I grew up, "sumpin' ain't right here," but I wasn't convinced she needed urgent exploration. I had decided to admit her for observation and serial abdominal exams and was writing my notes & orders when her daughter approached me. "My mother has had a rough time lately. You see, my father died unexpectedly a few weeks ago, and Mom .... well, she's just .... just not doing well with all of this."


I probably spent way too much of my youth watching old TV shows and movies, but at that moment I felt like the two-bit safecracker in a black and white cop show who heard the final "click" while breaking into the big score. I also felt pretty stupid.

So, with a little help from time and an antidepressant, this nice but distraught lady was able to stay away from the OR. Her pain was out of proportion to her exam, but definitely not out of proportion to her exigency.

Friday, September 23, 2005

Inspired

Steve at The Llama Butchers has quite the inspired idea, and I like it!
Snake Plissken for F.E.M.A. No pansy-assed butt kissing, he just does the job and ignores the critics. Perhaps I might suggest in the same vein (sticking true on a gender basis):
Gunnery Sergeant Hartman for Chief of Police in New Orleans. What, you gonna argue with this guy? He'd kick ass and not even bother to take names --- I don't think New Orleans would see another looter this century.
General Maximus Decimus Meridias for Mayor of New Orleans. Yeah, he'd be a better governor, but let's face it -- he turned down all of Rome. Maximus could lead people in a crisis in his sleep better than Ray Nagin.
Lt. Ellen Ripley for Governor of Louisiana. Let's see....wishy-washy? Nope. Whiny? Nope. Able to tell folks the brown stuff is getting ready to hit the whirling air mover? Absolutely. Afraid of making a decision? Nope. In other words, she'd be everything that Kathleen Babineaux Blanco most assuredly isn't.

Tuesday, September 20, 2005

Simon Wiesenthal, Rest in Peace

A man who dedicated his life to finding the evil men that terrorized the world to justice died today. A hero to Jews and Gentiles, he was responsible for bringing some 1,100 Nazi war criminals to face the cold spotlight of truth. May he rest in the kind of peace he rarely, if ever, saw on earth.

Strike Michigan From The List...

...of states where I would consider practicing. It seems that the governor of Michigan sees physicians as an overly wealthy group of folks just ripe for the picking. An article in the September issue of Surgery News (not yet online; should be available soon here) describes efforts by Gov. Jennifer Granholm (D-Mich.) to pass a tax on physicians that would "help increase payments to Medicaid providers in the state."

Under the governor's proposal, a 2.28% gross receipts [not net] tax would be levied on all physicians in the state. The tax would raise $96 million, which would then be put into the Medicaid program and would increase the amount of matching funds the program receives from the federal government...."the state keeps $40 million, and then the $56 million left would be paired with Medicaid matching dollars, so we can return $125 million to providers, bringing [reimbursement] up to Medicare rates."
Hmm. A tax on gross receipts means taxing the income coming into a physician's office before paying any of the other overhead that physicians face --- it is important to remember that the vast majority of physicians are in private practice, running small businesses --- such as rent (rising), health insurance (rising), other taxes (rising), malpractice insurance (rising), and the costs associated with complying with Medicare regulations (rising).

I have a few obvious concerns with this approach, which is already in effect in Minnesota, West Virginia, and New Mexico (the latter two states have seen a net loss of physicians over the past few years):
  1. Why does the state keep $40 million, if this is all supposed to benefit state Medicaid recipients? What will that money be used for?
  2. Does anybody else live in a state where "lottery money" was originally earmarked for, say, education, but somehow ended up in the general fund (it certainly happened here)? Ditto with the tobacco lawsuit settlement money, which was always piously described as needed for health care -- and was used here as a ready piggy bank to raid? Anybody care to speculate how long it would take before the state dipped its hands into this pool of cash?
  3. If we are to levy a special tax on a specific profession for certain cash needs, why not expand the list? A tax on attorneys' gross receipts to pay for the legal expenses of the indigent. A tax on grocery workers' gross income to pay for food stamps. A tax on ambulance drivers' gross income to pay for the emergency transport of critically ill or injured patients who cannot pay their bill. A tax on the gross income of firemen to pay to rebuild the houses of those who could not afford fire insurance when their homes go up in smoke. A tax on writers' gross income to fund library districts. A tax on teachers' gross income to help pay for public school expenses. The list is endless.
You know, if Medicaid funding is a problem, it is a problem for the entire state to deal with. Saddling physicians, who are caring for these patients at very low reimbursement rates, with an extra, pre-standard tax, pre-overhead expense tax is essentially asking them to leave your state -- or simply never come there in the first place.

Grand Rounds #52

The 52nd edition of Grand Rounds is hosted this week by Dr. Bottles at SoundPractice.net. There are many great posts this week, so go take a peek!

Thursday, September 15, 2005

Cue the "Jaws" Theme Music

The older I get (and believe me, today I feel old), the less I find in the news that surprises me. In this morning's edition of The Dallas Morning News I find that the New Orleans swampwater has been invaded by sharks -- the kind that wear smart suits and who never miss an opportunity to point the finger of blame. That finger also happens to be connected to an outstretched hand, waiting to be greased. Despicable.

Wednesday, September 14, 2005

Grand Rounds

Long-distance blogging from a library in northeast Texas! Anyways, check out the week's best medical blogging over at Sneezing Po. It's worth a look!

Saturday, September 10, 2005

SWIMBO & DogSurg

Beautiful morning -- cool, sunny, with a slight breeze. The DogSurg and I got to go for a long hike in the hills this morning, helping both of us feel not-so-aggravated this morning. I have the next week off, and for the first time in memory, I am not leaving a slew of very sick patients in the hospital while I am heading out of town.

So, how does this morning turn to absolute crapola? I hear the words that strike fear into the hearts of married men; the words that would make single men (sorry guys, but you don't know how tough marriage can be until you've been there for 17 years) lose all sphincter control on the spot; the words that SWIMBO intoned this morning the moment I returned from my refreshing hike:

"There's a house that just came on the market I want to look at."
Gee, that sounds so simple. Why, then, did that little phrase give me chest pain?

"But SWIMBO, what about the idea of paying off our house and maybe retiring before the nest of hair now sprouting in my ears becomes as thick as the Forbidden Forest?"

Fortunately, the above question was asked only between said ears. Meekly, I called the Realtor -- "Hi, I'd like the privilege of giving you all of my savings. Can we arrange a showing?"

You see, I understand the pecking order in my house.....and I'm only one rung above poor DogSurg. And we both know enough to do as we're told!

Friday, September 09, 2005

Gastric Pacemaker for Gastroparesis --- A Positive Report

Every once in a while, a new therapy is offered for a difficult problem that has some real promise. Such is the case, I think, with a new device for use in patients with severe gastroparesis, which results in nausea, vomiting, and sometimes dependence on nutritional support (with a feeding jejunostomy). Gastroenterologists struggle caring for the patient with severe gastroparesis, most often due to diabetes but occasionally idiopathic (more info on diabetic gastroparesis can be found here, here, and here). There are occasional patients for whom no medical therapy works well, including alteration of dietary habits or prokinetic medications (Reglan); some are eventually even referred for gastrectomy.

A new device is available which in early trials seems to be very promising -- basically, it is a pacemaker for the stomach. Marketed by Medtronic, the Enterra Therapy Gastric Electrical Stimulation device is designed to provide low voltage electrical impulses to the stomach, restoring some semblance of normal gastric motility.
The two electrodes are placed into the stomach wall and are connected to the neurostimulator, which is then placed into a subcutaneous pocket in the abdominal wall. The procedure can be performed laparoscopically in most patients.

Interestingly, this device received a humanitarian device exemption for use in these patients on the basis of a single case report and a multinational, multi-institutional trial, both of which had promising results. Because there are relatively few patients with severely debilitating gastroparesis, accrual of large numbers of patients in trials has been slow. A recent US report from USC (Archives of Surgery, Sept. '05; not available online yet) gives results of 29 patients treated with the Enterra gastric pacemaker --- and they were quite promising:

  1. Median hospital stay of 3 days
  2. All patients tolerated an oral diet at discharge
  3. Symptom control (i.e., nausea and vomiting) was excellent to good in 19 out of 27 patients with follow-up
  4. Nutritional support was discontinued in the 19 patients dependent on supplemental feeding preoperatively
  5. Median BMI showed statistically significant improvement
  6. Gastric emptying rate was shown to be significantly improved
(Mason, RJ, et al. Gastric Electrical Stimulation: An Alternative Surgical Therapy for Patients with Gastroparesis. Arch Surg. 2005; 140:841-848)

There is no questions that these patients are quite challenging and time-consuming for gastroenterologists. Hopefully, this device will be a good alternative for many, especially those with diabetic gastroparesis. This study has its limitations -- it was uncontrolled and retrospective -- and the device is quite expensive, so there is no reason to adopt its use without reservation just yet. However, in the next few years, I would expect there will be some reasonable delineation of which patients will, or will not, benefit from gastric pacing -- diabetics, pancreatic malignancy, post-vagotomy, etc.

The University of the 4077th

I have this (old) love-(newer) hate relationship with the boob tube. Much of my misspent youth seemed to take place in the vicinity of the TV, and I have great memories of old shows -- The Outer Limits, The World at War, Monty Python, SCTV, Bob Newhart (ever play "hi Bob" in college? I sure did), etc. When I was a mere surgling, I watched my fair share of the Three Stooges and Gilligan's Island, and Bob Denver's recent death made me somewhat nostalgic for that time. Today, however, I can't think of a single regularly scheduled TV program (other than hockey, football, or Fox News) that I have watched in over 15 years.

I must admit, however, that one show probably had more influence on me than any other -- M*A*S*H. Yes, it's true: everything I learned about being a surgeon I learned at the University of the 4077th. It's even where I stole my pseudonym, the title for my blog. What aspiring, cheeky, flip and smart-alecky pre-med student wouldn't want to believe he could eventually become the glib and cheeky Benjamin Franklin "Hawkeye" Pierce? Not only could he operate in the chest and belly like a virtuoso, but he could talk back to the Colonel and charm the pants off any nurse in the unit -- at the same time! What a guy! Every week night in college we'd watch M*A*S*H at 10:30, drink a beer, and forget that tomorrow some paper was due or there was a big exam. The show was always funny, but Hawkeye got all the best lines:

"We try to play par surgery on this course. Par is a live patient."

"What a unique device, the human tush. An architectural marvel, one of a kind... actually two of a kind. Designed to support our weight for a lifetime of sitting, it also has the subtlety to do the samba. And when attached to certain members of the female species at a time when light summer dresses are worn can cause some of us to drive our cars straight up a lamp post."

"I'll stick with gin. Champagne is just ginger ale that knows somebody."

"As a doctor, I can assure you we'll all be a lot warmer if we press our bodies together. So let's all line up here: girl, boy, girl... and the rest of you are on your own"
Hawkeye even set me up for the martini habit I developed after turning 40:
“I’d like a dry martini, Mr. Quoc, a very dry martini. A very dry, arid, barren, desiccated, veritable dustbowl of a martini. I want a martini that could be declared a disaster area. Mix me just such a martini.”
So, when you raise a toast to Gilligan, I suggest mixing it with a little gin from the Swamp.




[Quotes from Television's Other 10 Percent]

Tuesday, September 06, 2005

Grand Rounds at the Corpus Callosum!

This week's edition of Grand Rounds is up and running, despite the long weekend (which certainly kept me from posting anything meaningful!). Check it out!

Saturday, September 03, 2005

Not much to add

With the devastation that hurricane Katrina has brought upon the Gulf Coast, it is hard to spend a little time blogging about medical issues. There has been an outstanding effort put forth by medical personnel in the region, especially in New Orleans. I am quite sure that the physicians, nurses and ancillary staff at Charity Hospital have been tested beyond their limits -- and have shown themselves to be men and women of iron will and determination. I suspect that we will begin hearing harrowing tales trickling out to the medical press over the next few weeks and months.

So many bloggers have listed places to go to offer donations that it is hard to keep up with them. For any who might be looking for places to donate, visit Hugh Hewitt, Instapundit, Michelle Malkin, or NZ Bear. I might suggest Catholic Charities (large number of Catholics in the area), Episcopal Relief and Development, or the Salvation Army. While cash is needed now, soon there will be needs for basic necessities, such as clothing and housing (the latter of which may prove to be the most difficult task of all).