Tuesday, January 25, 2005

Grand Rounds XVIII

Hospital Amphitheater Clinic (1927)
Early in the morning before the sun is up, the pre-rounds have already been done and the disturbed patients have returned to their slumber. No drug-rep money for this conference so the breakfast fare is the standard plastic cups of juice, bad coffee, and Sam's Club danish. The auditorium fills up with attendings, residents, and students. Their place on the hierarchy can be determined by their state of dress, (unless there are resident interviewees present and they will be the best dressed of all). At the appointed hour the presenter arises to the podium and Grand Rounds, surgical style, kicks off:

Dr. Charles treats a patient that conjures up a home remedy. He then counters with his own potion:
It was important that I leave the room as soon as possible, before the exchange of sorcery escalated any further. We had matched wits and I was satisfied that I had withstood her.
Calling Doctor Bombay !!! Calling Doctor Bombay !!!

The Medical Madman writes about what could happen if Scrubs met The Stepford Wives:Perfect-Resident Life:
I predict a revolution. By mid-summer, with a new model up and running, Perfect-Resident will be a reality, a reality which will shake Graduate Medical Training at its core. Get ready for the new improved prototype of graduate whose soul purpose in life will be to admit, obey and do as little thinking as possible
Consider the 80 hour problem solved.

Kevin MD shares the story of a patient with swollen shoulders:
A 66-year-old man presented with a two-year history of fatigue, paresthesia of the legs and feet, weight loss, and shoulder enlargement, with limitation of movement.
The diagnosis is not what you would think from looking at the photograph.

Medviews wonders if the advent of Medical Savings accounts will lead to hucksterism:
How will primary care providers behave if health savings accounts take hold? Some may advertise their services in the media, as in "I will give you a physical exam for $200, and I'll throw in a free nutritional evaluation for the first 100 cust..., I mean patients."

How about free toasters? I could give out Ginsu knives!!!

Saint Nate offers up a great moment in socialized medicine.
Also, what's with her needing a doctor's referral for an emergency where every minute counts? And then telling her to go to a different hospital ... I don't know how Mr. Wright took it so well, I'd be banging on whatever--paperpusher-told-me-that's desk demanding she be admitted.

A glimpse of the future?

Shrinkette offers up a link-filled tribute to nursing colleagues:
As a nurse you sacrifice a little of yourself: your time, your energy, your dignity, your lunch, your need to pee. But the end result, your impact on your patients and their lives, makes the job worth while.
The end result helps me get up the next morning, report to the unit at seven o' clock, and do it all over again.

One of those angels is Geena of Codeblog who falls into the tender trap of making it personal:
I have lost objectivity with this patient....... I am giving the patient the best nursing care that I know to give, but still the nagging in the back of my mind continues... I am not doing everything to help alleviate this patient's suffering. But who am I to make such a decision? They teach us about being a patient advocate in nursing school, to do what's in the patient's best interest. And I want to do that. Every single doctor and nurse on this case knows how this will end. Does this sound harsh to the lay-person or medical professional who is not intimately aware of the realities of ICU?
Sometimes we do treat the family rather than the patient.
Another nurse at The Write Wing relates how the simplest thing can bring back a memory:
When I left for the night, I stopped for a cigarette at the spot by the garden where I had found Jimmy. Some of the flowers were splattered with his blood.

I don't think I had thought about him until the other day when I picked up my child at school and a boy yelled "Jimmy!" -- that was all it took. I could see the flowers, and his blond hair. I took a deep breath, and went on with life.

My comrade-in-arms Orac shares his thoughts on the fact that denial is more that a river in Egypt, and sometimes the most obvious question is maybe not appropriate:
This patient was in her early 60's, most definitely not poor, and with a close family. She presented not just with a large tumor, but with a large, nasty, fungating, bleeding tumor that was eroding through the skin of her breast. It was a real problem, not just because it was a locally advanced cancer, but because it was intermittently bleeding a lot. Even worse, it smelled. Part of the tumor had become necrotic (dead) and was rotting....As a junior resident, unexperienced in these matters, at one point I asked her a very stupid question: "What did you think was going on here?"
His experience has taught him that the question can be best asked later.

Hey you in the back!!! Wake up!!!

The Cheerful Oncologist reminds us that healing is more than cutting out disease or repair of injury:
Healing is more than just a purging of illness...it is peace of mind, which provides a greater benefit than the doctor's potions. Peace of mind is the elixir of renewal, which lifts the sun up over the horizon in the morning, showing the world that we are ready to meet the day's challenges. It is the healing that once applied, never dies.
So physician, heal thyself.

Matthew Holt dissects the shutdown of King-Drew Medical Center in Los Angeles (which included a busy trauma center). An excellent discussion of a community's antagonistic relationship with "the man" as well as the hospital as political machine:
Finally, whenever you have a huge public health system like that of New York or Los Angeles, you are going to inevitably have to deal with the politicization of running it. Just understanding the bureaucracy of hiring and firing in these huge government departments boggles the mind of those of us used to the private sector. The delivery of favors and appointments in returns for influence, votes, and union members' electoral work continues to be standard practice in most city governments in the US (and has its direct equivalent at a national level!).
A problem not confined only to big cities.

Speaking of putting it to "the man" Mr. McBride embarks on a one-man crusade to shift thinking within the AMA:
So there you have it folks! You have to first join an organization with immoral policies that go against the ethics of the profession before having a prayer of changing said policies. And then, you only get one vote out of roughly a million. And you would be voting against people who are voting in self-interest. Hmmm…
Do you light a candle or rage against the darkness?

Dr. Centor takes another look at the problem of "cherry picking":
The idea behind report cards seems sound, but what are the unintended consequences. Is the public health better, or do we have cardiologists "cherry picking" healthier patients and eschewing the more complex? Perhaps the report cards create a Catch-22 for some patients!
Which is worse, a sin of commission or a sin of omission?

A bottle in front of me or a frontal lobotomy? Dr. Emer reports, you decide:
Women who consistently were drinking about ½ to 1 drink per day had both less cognitive impairment as well as less decline in their cognitive function compared to women who didn't drink at all," Grodstein said.
Bottle of wine, fruit of the vine.....

Speaking of happy hour: The Hospice Blog raises a glass to the availability of generic Duragesic patches:
Off the top of my head I’d say that over 50% of our patients use the patches at some point while on service. Few use as much as the example above, but if a hospice has 20 patients on patches their savings could be up to $2,000 a month. You can dang near hire another full time nurse for that!

Schools screen for hearing, vision, scoliosis and lead exposure. Dr. Baker explains why screening for mental illness may raise objections:
Why does the New Freedom Commission rec stir up such a fuss? One word answer: stigma.

In the words of one who lives with a mental disorder: "people don't feel like they've failed if they have asthma or diabetes, why should those of us who suffer from mental illness feel that, somehow, all we are is "crazy?"
Does this make ADHD a "stigma"?

The Journal Club takes issue with the NEJM report comparing aspirin versus Plavix:
This is a very unsatisfying comparison. On the one hand a drug, aspirin, that is clearly ulcerogenic and also promotes bleeding taken together with a drug that effectively prevents ulcers (omeprazole). On the other hand, a drug (Plavix) that may be less ulcerogenic but is even more likely to promote bleeding and given without any ulcer prevention. This comparison just muddies the waters. This study does not help distinguish the platelet-antagonizing effect of clopidogrel from any direct effect on the healing or ulcers.
The Rebel Doctor also weighs in. My use of Plavix is reserved for patients with new endovascular stents.

I don't submit "show-and-tell" posts since many of the photographs I post aren't suitable for work. This week's photo essays are
Doctor Bob's review of kidney stone treatment and the Grunt Doc's review of his antibacterial hand cleaner. Safe for work? Depends on the imagination of your co-workers.

The weekly lecture over, the masses in various states of somnolence, cleanliness, and attentiveness shuffle out of the room. Some to round, some to the OR and a lucky few to home, family, and a warm bed. Until next week.

Thanks to all who submitted posts. Grand Rounds XIX will be hosted next week by Ms. Pelletier at Daily Capsules. Grand Rounds are archived at an Undisclosed Location. A special thanks to Mr. Genes at Blogborygmi for starting the ball rolling.
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