August 22, 2008

Trauma Call

I had trauma call for my Surgery rotation last night. It was traumatic, all right. Not in the gruesome sense of the word, images of human flesh cleaved open by a car, or fecal matter spraying the walls of the OR or anything like that. Let's just get that out of the way.

It was intellectually traumatic.
Trauma situations require fast thinking, reflexive actions. They don't spare any moment for deep, ponderous considerations, my usual sort of cognition. I read through a few thick handbooks the night before, nodding off and on around 10-11pm in a meager attempt to prepare myself for the Trauma call.

We had a Trauma Simulation lab at my medical school in the afternoon, complete with ED physician teachers going through the routine of the Primary Survey: ABCDE -- airway, breathing, circulation, disability, exposure/environment... the stuff we've heard "since grade school." There were some fancy manikins (not mannequins) at the SimTiki lab with different critical conditions resulting from a car crash. Also present: ten medical students with varying degrees of ED experience (ranging from super-star ED ward clerks with trauma experience to ... me.)

One by one, we were pulled out of the lab to get an assessment with the surgery clerkship coordinator on our TEAM (Trauma Evaluation and Management) skills. I was the first one and we were only five minutes into the first training scenario.

... I totally let my simulated patient die in front of me.
It was tragic. There were some technical difficulties as the manikin needed to be restarted three or four times. In the interim, before the monitors were setup, the surgeon told me -- "continue with your primary survey."

It went something like this:
"Uhm... I hear breath sounds, but they sound weird. I don't know how to describe them. Rubbing? Clicking? It's ... not right. Where's my pulse ox and BP data?"
"The manikin is still being launched. What else are you going to do?"
"Uhm... I don't know. I can't figure out what those sounds mean. I'm going to continue with Circulation."
then Disability.
then Exposure.
Doh. I clumsily attempted to do some assessments, but I failed to provide any definitive treatment. When the manikin's eyelids closed, the pulse ox data disappeared off the screen and the BP dropped down to the 20s, the overhead voice said in a sardonic tone: "Blood pressure in the 20s is incompatible with life." My failure to diagnose a massive hemothorax with decreased breath sounds, as well as my complete inability to assess the patient properly, led to his eventual demise.

Luckily for me, it was just a fake patient.
The shame of the experience, especially with the surgery clerkship coordinator telling me that I needed to read and review everything really hit home. It's one thing to recognize the correct answers; it's another thing entirely to recall it under stress by yourself with a patient changing status before your eyes.


I spent my Trauma call reading through the TEAM handout and dreading the moment when a trauma call came in.

On the plus side (which is the whole point of the training sim) I learned the Primary Survey by heart! I'll spell out the basics just for fun.

A: Airway (head and neck)
-establish airway, put on c-spine
-foreign objects?
-if GCS <8, intubate
B: Breathing and vent (neck and chest)
-100% O2 for everyone, nasal prongs
-bag-valve mask if need be or ventilate
-if lung sounds are reduced, needle thoracostomy!
C: Circulation and control of hemorrhage (chest and abdomen)
-BP and EKG
-hemostasis with direct pressure, inflatable sleeves, etc
-place two large bore IVs, drop in 2L of LRs for hypotension
-type and cross for further blood loss
D: Disability (head and rectum)
-neuro exam: PERRLA, rectal tone, GCS (E+V+M<=15)
E: Exposure/Environment
-Strip clothing
-Logroll patient, examine back
-Warm patient (blankets, bair-hugger, fluids, lights)

SAMPLE history
Past history/Pregnancy
Last meal

CBC, Chem7
Type and Cross

August 11, 2008

Mini-Mental Status Exam: ORArL 2,3, RWD!

The components of the Mini-Mental Status Exam (or Folstein test) can be summarized in the quick and easy mnemonic: ORArL 2,3, RWD! It can be a part of a more comprehensive Mental Status Exam performed by psychiatrists as a screening tool assessing cognitive function.

O: Orientation to Person, Place and Time
R: Recognition (repeat three objects, i.e. balloon, Pong and happiness)
A: Attention (Serial 7s counting backward from 100 or spelling WORLD backwards)
r: recall (ask them to recall the three objects 5 minutes later)
L: Language
2: Identify the names of Two objects (pen and glasses/watch)
3: Follow a Three Step command (take this paper in your right hand, fold it in half and place it on the floor)
R: Reading (Read this statement and do exactly what it says: "Close your eyes")
W: Writing (Write a sentence)
D: Drawing (Copy a figure of two intersecting pentagons)

This is a useful series to memorize as you become proficient with various components of the MSE since it occupies the majority of your cognitive section. Most people will have a questionaire to fill out, but its easy to do it orally. I find it helpful to create mnemonics of all interview questions since a smooth Q&A session with your patients is a great way to imbue them with confidence in your skills (and any observing residents/attendings.)

August 10, 2008

10 parts of the Mental Status Exam (alt: ABC STAMP LICKER)

The Mental Status Exam is the psychiatric equivalent of a Physical Exam. I struggled to remember all of the components and I found it helpful to break it down into 10 parts for rehearsal. My resident told me about ABC STAMP LICKER after I developed my own method, but I'll share it with you as well.
  1. Appearance
  2. Behavior
  3. Cooperation (note eye contact, degree of friendliness/hostility)
  4. Mood/Affect
  5. Speech
  6. Thought (PCP: Process, Content, Perceptions)
  7. Cognition and Fund
  8. Abstraction (ask "What is meant by 'a rolling stone gathers no moss'?" or "what makes a table and a chair similar?")
  9. Insight
  10. Judgment

The alternate version (ABC STAMP LICKER):

  • Appearance
  • Behavior
  • Cooperation
  • Speech
  • Thought (Process, Content)
  • Affect
  • Mood
  • Perception (AH/VH)
  • Level of consciousness
  • Insight
  • Cognition
  • Knowledge fund/base
  • Endings (Suicidal, homicidal)
  • Reliability

Here is a sample student write-up from the UIC Dept of Psychiatry.

August 09, 2008

"Show, Don't Tell" Science Stories

Caltech's 2008 Commencement address by Robert Krulwich shares a compelling narrative (video here, skip ahead to 9:09) about the importance of conveying science stories to non-science people: your grandmothers, your friends, and friends of friends... people who will be politely asking you "so what did you study at Caltech?"
Because talking about science, telling science stories to regular folks like me and your parents, is not a trivial thing. Scientists need to tell stories to non-scientists because science stories have to compete with other stories about how the universe works and how it came to be….and some of those other stories, bible stories, movie stories, myths, can be very beautiful and very compelling. But to protect science and scientists - and this is not a gentle competition — you’ve got to get in there and tell yours.

He ends with a great story about evolution through a feathery dino/Robin and a Tyrannosaurus rex named Bob (after Bob Harmon). (@ 28:00)

This brings into focus the KEY thesis of my blog here... why have I struggled so long to come up with blog entries that I deemed worthwhile to post? I want to share these sorts of stories. Tales that enthrall and clarify the world around us, the world within us. I'd like to publish a paper someday that offers alternative metaphors and tales that explain difficult-to-understand concepts to patients. But first, I must struggle to understand them myself! An important part of that mission is to preserve my own memories of these difficult times. To recall the time of my own naivete and so-called "ignorance" of these myriad illnesses so that I can connect with people no matter what their background in science and medicine may be.

I have a few ideas brewing in my head and hopefully they will crystallize so I can share them in turn with you.

Hat tip to A Storied Career and the Frontal Cortex

August 04, 2008

PDA Resources

This is a list that one of my professors sent us. I've trimmed it down a bit to the things that I recognize and use (or will use, based on her recommendations.) I'm guessing it's very similar to my other list that I've posted previously.

Medical Applications - Johns Hopkins antibiotic guide. It used to be free, but now it costs money. - List of 1,500 common and obscure medical eponyms (e.g., Rovsing's sign, Virchow's node) with descriptions. Free! Excellent program. - iSilo document reader...many free medically related documents that you can use via iSilo. Partial reader is free. Full version costs $19.99 (Most platforms supported). I bought this and I use it from time to time... I don't really like the interface, but it is a nice reader for all of the files. - A number of different clinical reference programs. Most are FREE but some have a small fee. You need iSilo for most of these programs. The site also includes depot of many medical iSilo applications. (Pocket PC, Palm OS)
- Procedure series: steps for different surgical procedures (FREE)
- Quick tools: small, focused references summarizing a current practice guideline, journal article, or point-of-care tool. (e.g. antibiotic prophylaxis, topical steroids) (FREE if you are on mailing list)
- STD tools: Treatment guidelines. (Free trial version, $5.95 for full version)
- Dermmeister which includes more than 500 digital photos of 66 common skin disorders (FREE)
- Understanding and interpreting Fetal Heart Rate Monitoring – (FREE)
- Breastfeed – breastfeeding reference (FREE)
- Splinting Manual – (FREE)
- Papmeister – Includes screening recommendations, HPV testing, mgmt of abnormal smears, dx/tx of cervical cancer (FREE)
- Lytemeister - good program for analyzing electrolyte abnormalities. Goes through causes, diagnostic work-up, treatments, etc. (FREE)
- Asthmameister – Complete guide to the diagnosis and management of asthma (FREE)
- Lipids by – Guide to the management of Hypercholesterolemia (FREE) - APPRISOR software and Guidelines by AAFP, AAO, AASLD, ACCP, ACP, AHA, ASE, AUA, ACU, CCGC – MedCalc, a free medical formula calculator. (Palm, Pocket PC) - Multiple different tools for professionals (Free) - Diagnosaurus...a FREE ddx tool with 1000+ diagnoses (Palm, Pocket PC) Fun to use in the first and second year, but it's not as helpful in the third year (unless you're working on a presentation re: ddx considerations.) - MedMath, another FREE medical formula calculator (Palm OS only) It came highly recommended by Dr. O so I downloaded it. - Kidometer gives a wide-range of pediatric tools.(Palm OS devices only). Free trial then pay to use. ($17.95) A highly recommended resource. I'll probably download this during my peds block and use up my free trial then. :) - Centre For Evidence-Based Medicine, FREE EBM tools: NNT, likelihood ratios, etc. (Palm OS) - OB/GYN Stat tracker (collect delivery and surgery information) and Preg Calc Pro. (calculate due dates). Register for FREE use. – Download Medrules, clinical prediction rules. FREE (Palm OS only) - Shots 2008, ACIP immunization schedule from STFM with lots of vaccine information – FREE (Pocket PC, Palm) NO BRAINER. Get this and update it every year! :) – Tarascon pharmacopoeia for PDAs. Purchase for $39.95/yr. - FREE downloadable clinical references from the ACP. You will need some type of reading program (Palmreader, Tealdoc, etc.) to access them. - Clinical guidelines- Medical Care of the Pregnant Patient- Drug Prescribing in Renal Failure- Domestic Violence Intervention Tool- Commonly used ICD-9 codes- Gynecology Alerts- Calorie Savings Food List- Normal Lab Values from MKSAP12- Vaccine Specific Information- JNC VI Hypertension Management- USPSTF guidelines- Many more… - AHRQ PDA downloads – Interactive Preventive Services Selector and Pneumonia Severity Index Module. Free downloads. - Pubmed site where you can add it to your avantgo channel list to do medical literature inquiries at the point of care. (FREE)

Medical Websites - JABSOM Health Science Library PDA resource page – Hawaii Medical Library PDA Resource site - Will link you to sites that have downloadable PDA guidelines. - reviews, software downloads, hardware/accessories sales, AvantGo medical abstracts - general information, reviews and merchandise - reviews and discussions of medical mobile informatics topics - Ectopic Brain – Excellent resource for clinically oriented PDA programs and also includes an extensive list of links to other helpful sites for PDA applications and programs. Too bad this website shut down last year... :( – Pediatric oriented PDA program links - Pediatrics on-hand. Suggestions for pediatric PDA programs

Websites with freeware and shareware for download – some are predominantly medical, others are general - extensive medical software links with user reviews - Extensive database of downloadable FREEWARE for your PDA. It has a medical category with some useful apps. a range of medical software - Many medical PDA programs available. Freeware/Shareware/Commercial. Can get another free patient tracker through this site “My Patients”

August 03, 2008

TED Talk: Jonathan Harris -- The art of collecting stories

Artist, computer-scientist Jonathan Harris talks about some of his cultural projects traveling around the world and collecting stories. He starts off with his own and then talks about some ones online and then in the world.

My favorite one is hearing about the wishes and happiness of the people of Bhutan. I have a Bhutanese prayer flag that I made myself at Art After Dark several months ago and it flutters on the chains of my ceiling fan. My wish: to be content with what I get and happy continuing to do the things I do.

August 02, 2008

Knols and Medpedia to compete with Wikipedia

In the past two weeks, two new websites are rolling out to compete with the behemoth that is Wikipedia.

Wikipedia got its name from "wiki wiki", which means quick or fast in Hawaiian. It fulfilled its name as it rapidly overtook conventional encyclopedias as the internet reference source of choice with its ingenious Web 2.0 user-generated content, relative ease for public editing and dedicated volunteer/power users who keep an eye out for knowledge-vandals, countering deviously misinformative public edits.

So why has Google released its own version of Wikipedia?
The Official Google Blog has this to say:
The key principle behind Knol is authorship. Every knol will have an author (or group of authors) who put their name behind their content. It's their knol, their voice, their opinion. We expect that there will be multiple knols on the same subject, and we think that is good.

Clinical Cases and Images reiterates this view with its opinion:
Google Knol is a free online collaborative knowledge database or an experts' wiki but not an encyclopedia. Knol is not a direct competitor of Wikipedia, at least not in its current version. Wikipedia is anonymous -- there is no single editor in charge. In contrast, Knol includes the author name in the URL of the article. Google expects multiple knols on one subject rather than the current Wikipedia model of one article on a subject. The term "knol" ("unit of knowledge") refers to both the project and an article in the project.

There is a definite focus on medical topics -- most of the 300 or so starting "knols" are disease-based and authored by doctors. Will Google Knol be the mythical universal textbook of medicine that Wikipedia never became (and was not meant to be)?

In some ways, I think that this can be a good thing. There is a discrepancy among articles and I'm starting to notice a lot of them have tags saying things like "this article needs to be cleaned up/shortened/appropriately referenced/etc." Having authorship or ownership over a Knol will encourage the writer to have more careful maintenance over their content... but I wonder if it will differ significantly from Wikipedia if the SAME writers post content in both Wikipedia AND a Knol.

It will remain to be seen how effective this will be in the future... especially with another incoming competitor on the horizon.

Medpedia is slated to be released in late 2008 as the "WORLD’S LARGEST COLLABORATIVE ONLINE ENCYCLOPEDIA OF MEDICINE AND HEALTH:"
Physicians, medical schools, hospitals, health organizations and public health professionals are now volunteering to collaboratively build the most comprehensive medical clearinghouse in the world for information about health, medicine and the body...

Harvard, Stanford, the UC-Berkeley, the University of Michigan Medical School and dozens of health organizations around the world will be contributing. Many will seed content free of copyright. Harvard Medical School will publish content to uneditable areas that members of their faculty have created as part of a medical school wide effort. Others organizations, such as University of Michigan Medical School will encourage members of their faculty to edit Medpedia as individuals.

Other health and medical organizations like American College of Physicians (ACP), will contribute content and promote participation in Medpedia to their members. Medpedia is also receiving content and cooperation from the National Institutes of Health (NIH), the Centers for Disease Control (CDC), the Federal Drug Administration (FDA) and many other government research groups who are eager to have that public domain information distributed to both the general public and to healthcare professionals.

I don't want these websites to become copycats of each other the way simply cuts and pastes their articles direct from Wikipedia. That's a waste of time. On the other hand, I think a lot of users will be fatigued from the WEALTH of science and health knowledge that will be available. The important thing is communicability (aside from reliability and recency) -- the way these articles/knols/pedia entries can effectively share content with and capture the interest of the average Internet user, the guy with a 5 minute attention span at best and at least three browser windows open.

hat tip to Clinical Cases and Images and Medgadget