Inspired by Pixar

My two favorite companies are Google and Pixar. They have an amazing group of individuals with energy, passion and creativity that allows them to do things that have never been done before! I think it's absolutely incredible... and perhaps in another life, I would have loved to work for them in some fashion or another.

From watching a lot of special features from Ratatouille and Wall-E, I pondered a lot about the cultivation of the "culture" that Pixar has created for itself. Of course, the playful fun and games environment makes them LOVE working and so, they are all dedicated to seeing a project through to its completion. It is the sort of place that I'd like to work at... but really, can that exist in a hospital or a clinic in any form?

I am reminded of what one of my interviewers said to me. He inquired about my hobbies, my loves and I told him about my enthusiasm for the game of Dungeons and Dragons. How this alternate reality has given me a freedom to explore and understand characters... feel young with my imagination. "Don't lose that," he told me. "Hold onto that when you become a doctor." I guess I could have a pediatrics exam room decorated with anatomy of dragons and old posters of alchemical potions or something. :)

In all honesty though, it really gave me pause, trying to think of how my future profession utilizes creativity in an everyday sort of a sense. After all, a lot of what I spend my days doing is learning facts and understanding evidence, with the ultimate intent of practicing the best medicine possible. What room does that grant me? I can't be wild and crazy with my application of antibiotics in the treatment of cellulitis. I can't come up with some genius new technique for stitching up an incision.

Then, it hit me.

The art of medicine... that elusive thing that I realize each and every time I sit down with a patient, I really don't know anything at all. The art comes from a few things.

Elicitation - Asking the right questions to create a differential and swiftly narrow it down to a convincing diagnosis.
Elucidation - Clarifying the complaints and concerns of the patient.
Inspiration - Recognizing moments of connection and acknowledging them, chasing down a clue that a patient may have only hinted at by a small gesture, snapping on an excellent diagnosis and proper management
Exclamation - Conveying a diagnosis and educating the patient on his/her role in its management

and that's just the doctor-patient relationship. there's the nurse-doctor relationship, the insurance-doctor relationship, the wife-of-doctor relationship things that must be managed with as much care as the dr-pt.

This "art of medicine" may not have the same sort of creative energy that an "art of animated movie" has... but I'd argue that it's much more important, because its so fundamental.

'Bio-Beer' Designed to Extend Life

Nov. 10, 2008 -- Here's a reason to raise a pint; scientists at Rice
University have created beer that could extend your life.

BioBeer, as it's called, has three genes spliced into special brewer's
yeast that produce resveratrol, the chemical in red wine
that is thought to protect against diabetes, cancer, Alzheimer's and other age-related conditions.

The eight graduate and
undergraduate students created BioBeer as part of the upcoming International
Genetically Engineered Machine (iGEM) competition. The iGEM Jamboree, as the
annual meeting is called, took place at the Massachusetts Institute of
Technology November 8th and 9th.

Hehe, proof positive that GE foods CAN kill you! ;)

Head to Head: Hospitalists and PCPs

Dino seems to think that Hospitalists are equivalent to Subprime Mortgage lending... not sustainable and the bubble will pop eventually.

His reasoning?

My point is that if [Happy Hospitalist] cannot produce enough income to cover his salary, benefits, etc. and the hospital cannot find other monies with which to pay him, then eventually the same situation will occur at every hospital. It may take a very long time for this basic fact of economics to percolate through to the critical point -- perhaps longer than Happy's professional career, at which point he'll just retire and laugh at the rest of us struggling to take care of patients, who will always be there. But the situation is not financially stable. Eventually it will break down. It has to. It's just basic economics.

Look at the housing market. It took decades, but because of the fundamentals of subprime lending, it had to happen. You cannot go on indefinitely spending more money than you make.

http://dinosaurmusings.blogspot.com/2008/11/what-happy-hospitalist-and-subprime.html

Happy Hospitalist responds with his opinion.

Simply put, because the market says so. Hospitals are willing to pay for the services hospitalists bring to the table. I blog continuously about how hospitalist medicine has left the fixed pot of the failed economics of RVU/SGR engrained in the Medicare Part B. If hospitals did not value our service, they would not be subsidizing it, and they would not be paying an average subsidy of $100,000 per hospitalist.
...
DRG. Known as diagnosis related group, this is how most hospitals get paid by Medicare. If you get discharged with a diagnosis of chronic obstructive pulmonary disease (COPD), the hospital gets paid a fixed dollar amount for that diagnosis.
...
You see Dino, my value on the front end, doesn't even come close to the value I bring on the back end. Not even close. The millions upon millions of dollars in DIRECT money being paid to hospitals in terms of increased admissions/DRG's more than makes up for the several hundred thousand they pay out for the right to have me at their hospital.

What if the hospital isn't always at capacity? The decreased length of stay could potentially decrease their staffing/labor needs without any decrease in reimbursement.

So the DRG argument is a huge one. It brings in more money for the same labor. It allows much higher paying procedural admissions to have a bed and not get diverted to another hospital. It discharges the often money LOSING internal medicine admissions sooner and decreasing labor resource consumption on your money losing granny with COPD.

He goes on to cite Physician Satisfaction, Happy Staff, Happy Patients, Efficiency, Documentation, Unassigned/Uninsured, CPR response, Out of State Referrals as other reasons. I'm less inclined to talk about them because ... well, a good PCP has these same traits also.
http://thehappyhospitalist.blogspot.com/2008/11/hospitalist-medicine.html

Then, DB chimes in as well.

The Dinosaur, like many generalists, seems to write this rant with some anger. The rapid growth of hospital medicine has actually had a negative impact on family medicine and outpatient internal medicine. I understand Dino’s anger, but I really do believe that hospitalists are here to stay. Hospitalists are here for the same reason that ER physicians are here - because they are filling a role that no one else wants. Many generalists have ceded inpatient care to hospitalists. Many surgeons cede inpatient care of surgical patients to hospitalists. Many subspecialists would rather have the hospitalists provide the daily care and then they can just provide consultation.

http://www.medrants.com/index.php/archives/3908

I am just a mere bystander to this new up and coming Hospitalist field. I'm also at the cusp of deciding which path in medicine I will take, so their arguments mean a lot to me. My own worries about these fields diverge slightly from their concerns about economic sustainability though. I am witnessing a lot of graduates of my medical school in the IM program going on to become Hospitalists. It certainly is nice to run into them in the hospital, but I wonder what will happen to the outpatient internists and other PCPs.

I respect Hospitalists. They bring a lot to health care by providing care to patients IN the hospital. However, I've never heard anyone say "Ooohh... I love my Hospitalist at Queens. You should go to her!" Hospitalists do not have the same relationship with their patients as a primary care doctor. When they DO have continuity of care, it is almost a failing of sorts -- given their block schedule, a patient they've discharged (yay for DRG cost-savings with earlier Hospitalist discharges!) has likely returned with some sort of complication. Not necessarily by any fault of their own; patients like this are really sick. I was totally bummed out when some of my patients came back to the hospital.

I respect Primary Care Physicians. They have the ability to be the most cost effective doctors by providing early education, screening and intervention for preventable diseases. They have relationships with patients that are sustainable over time and are not based solely on the tragedy of illness. They have the tremendously difficult job of being the sentry on watch for ALL disease, filtering out which cases deserve specialist attention... and they take a brunt of the blame if something shows up inside the city. I've heard a professional bemoan "primary-care-ville" whereupon amidst the sniffly noses, hypertension and diabetes, someone missed the diagnoses of hemochromatosis and pheochromocytoma even though they had very benign presentations.


Hospitalists and PCPs follow different philosophies in their practice. I enjoy the academic side of inpatient hospital care. I enjoy the personal side of outpatient family medicine. Hospitalists take the thick slice of comprehensive care, seeing all sorts of patients in an acute setting. PCPs take a long slice of comprehensive care mainly seeing all sorts of patients in an outpatient, non-acute setting. Can they handle seeing their patients in the hospital as well, given the rise of the hospitalist specialty?

Probably not. I think Hospitalists are here to stay and trends in inpatient care management show it. The big question for me is... what do I want to become?

I'd like to think that it's easy to remain vigilant and spot that one zebra in a neverending horse show. I'd like to think that choosing a specialty is about more than the amount of money I'd make, or the money I'd save the hospital or the healthcare system. I'd like to think that I'll have a decent schedule and I'll get respect for my work no matter what I end up in.

I'm quite certain that these are all merely delusions of a third-year medical student and someday soon I'll be ranting as much as Dino and Happy.

Pondering on: Psychiatry

"Psych is a good break, so schedule it in between two hard rotations like OB/GYN and Surgery."

That's the advice that sage MS-3s will give the wide-eyed MS-2s as they plan out their schedules for third year. I wondered why this was so and whether or not Psych deserved the "bad rap" that they got for being easygoing slackers.

The wonder vanished when I entered Psychiatry. As a disclaimer, I am not saying that Psychiatry residents are trying to avoid hard work or do as little as possible for their patients. After all, they are still doctors and ALL doctors are caring and they all work hard (at least all of the ones I've met so far have upheld this archetype.)

I noticed that there is a certain aura that Psychiatrists try to cultivate. It is a very crafty and carefully created sense of ... relaxation. Low stress. The level of care for our med-student well-being went far beyond what was necessary and it was almost laughable at times. Here's a true story of something that happened to one of my friends:

"You rounded on your patients instead of having lunch?!? WHAT?!? Go eat! Go to the dining hall. We don't really need you here for our afternoon psych rounds anyway."

I would almost feel bad about hanging out with the residents in my attempts to soak up psychiatry when they were sitting around idly. I think the record earliest time I ever got out was by noon. Granted, this was after rounds with three separate attendings/groups and we rounded on a lot of patients, but that is really early. And I wasn't done for the day; I still went to school to read about psychiatry.

In my opinion, the reason why the psych residents were so aggressive about being so relaxed has a lot to do with their patient base. I was on the consult-liaison service at a large hospital in my state. There are a lot of patients who were admitted to the hospital and had psych issues come up tangential to their main diagnoses. We were called in to see them for the psych issues. It wasn't necessarily because the medicine or surgical teams couldn't handle alcohol withdrawal syndrome or depression or schizophrenia. They didn't have time to take care of these problems.

THAT is the crux of the psychiatrist. Their niche comes from having this precious TIME to sit down and talk with patient for as long as it takes to make a connection and help them feel better.

Even if they have a ever-growing list of patients on the service, the no-stress attitude keeps them from glancing at their watch or the clock (and undoing a lot of patient rapport when the patient feels pressured to "wrap things up" or what have you.)

5 Tips for Telling Better Stories

And how to apply it to your case presentations. The majority of these pearls are things I've gleaned from simply writing FIVE History and Physicals on some of my patients in the Inpatient Medicine block... my preceptor is very particular. She was very thorough in with her criticism, but as a result, I really felt the difference in my thinking. I'd like to send these tips along to you.

1. Keep it simple.
* A strong assessment needs to occur in your head FIRST, in order to frame a simple story, simply. I've made a lot of short stories much longer with my med-student induced compulsion for all details regardless of relevance.

2. Openings and closings are very important.
* Like an abstract for a research article, the first sentence should be the last thing you write. This sentence should give away your entire story and make the listeners feel smart for figuring it out so swiftly.
* Similarly, for the listeners that zoned out the whole time, you need to piece the whole thing back together at the end.

3. Be mindful of your story’s spine.
Keep in mind that EVERYTHING you say must come from the Patient-First Perspective. What does that mean? You need to pay attention to everything they say!
* Don’t interrupt the patient! There have been studies that show doctors interrupt the pt after only 18-22 sec (on average) after asking "so tell me what brought you here to the ED/hospital/clinic." However, given the opportunity, patients will only talk for 90 sec (on average) and no more than 2 min uninterrupted... much shorter than it feels I'm sure with the most verbose patients.
* Giving patients the opportunity to frame their OWN story before you stuff them into a boxed diagnosis gives you the chance to uncover something brilliant. I always make a few good observations on my team's behalf whenever I remember this particular rule and give the patient some freedom at the beginning of the interview.

4. Make sure not to alienate your audience.
* Residents, attendings and consultants are very busy people, I've learned. It's best to figure out EVERYTHING that's important before you dive in and present your case. The whole reason why med students are required to ask everything in the history, perform everything in the physical exam and present everything in a systematic order is NOT to bore people to death, though that's a major side effect. It's because we're dumb. We don't know what is important yet.
* Basically, as a med student, you should revisit this fact and remember who you're talking to. Sure, for the purposes of displaying your full understanding and adherence to procedure you can recite a HUGE laundry list in your review of systems... but the attendings will cut you off. Cater your speech to them.

5. Tell the truth.
* In rounds, I've frequently joked and said "oh, just make something up, they won't know the difference" whenever someone asks a solid question that wasn't investigated further as a query to the patient, lab data not collected or study left unperformed. But really, this negates the whole point of the rounding exercise. A patient's wellbeing is at stake.


References
Hat tip to A Storied Career
Gordon, GH. Defining the Skills Underlying Communication Competence. Seminars in Medical Practice. Vol 5, No 3. Sept 2002.

McCain Hates Science and Math. (My Biased Opinion.)

I am OUTRAGED that McCain has cited several items in SCIENCE as "pork-barrel projects. Nothing pisses me off more about his campaign than his blatant ignorance about the importance of science.

"[Obama] voted for nearly a billion dollars in pork barrel earmark projects, including, by the way, $3 million for an overhead projector at a planetarium in Chicago, Illinois. My friends, do we need to spend that kind of money?"

MY friends, we spent $3 million of your money to study the DNA of bears in montana. Now, I don't know if that was a paternity issue or a criminal issue, (LAUGHTER)... but the point is, it was $3 million of your money. It was your money. And, you know, we laugh about it, but we cry - and we should cry because the Congress is supposed to be careful stewards of your tax dollars."

On Science Friday and in the Scientific American, the scientists speak out.

They insist that the [Bear DNA] study is not only worth every penny but that the $3-million price tag cited in the ad is, in a word, wrong.

In fact, Congress over the past five years has forked over a total of $4.8 million to study the genetic material of Montana's grizzly bears, according to Katherine Kendall, a research biologist at the U.S. Geological Survey (USGS).

“This is not pork barrel at all,” says Richard Mace, a research biologist with Montana Fish, Wildlife & Parks (FWP). “We have a federal law called the Endangered Species Act and [under this law] the federal government is supposed to help identify and conserve threatened species.”

The fact that he calls it a "$3 million dollar waste of money" instead of the higher price tag goes to show that he can't even do simple MATH to criticize a program. Not only that, but it's evident that this program IS a paternity issue. It's studying the ancestry of an endangered species! DUH.

On ScienceDebate2008, McCain replied to the top 14 pressing questions candidates should answer. Here's his take on science and education. Funny how his actions diverge from his words. Or maybe its just his words contradicting his other words. Hypocrisy!

• Eliminate wasteful earmarks in order to allocate funds for science and technology investments;
• Grow public understanding and popularity of mathematics and science by reforming mathematics and science education in schools;
• Basic research serves as the foundation for many new discoveries and represents a critical investment for the future of the country and the innovations that drive our economy and protect our people. I have supported significant increases in basic research at the National Science Foundation. I also called for a plan developed by our top scientists on how the funding should be utilized.

UGH. I'm soo annoyed by this... on top of everything else that he's said or done so far this election. I must admit, I liked him a lot more when he wasn't running for presidency and merely keeping up his national image on the Daily Show and other shows.

(edit: And apparently, I hate english. I corrected some of my glaring spelling and grammar errors. It's been a while since I've written anything in proper English! *shakes a mocking fist at 5am Medicine Notes*)


Palin chimes in with her bit.

"Where does a lot of that earmark money end up, anyway? [...] You've heard about, um, these -- some of these pet projects they really don't make a whole lot of sense, and sometimes these dollars they go to projects having little or nothing to do with the public good. Things like fruit fly research in Paris, France. I kid you not!"

Wow. I'm sure that "fruit fly research" is EXACTLY the sort of waste-of-money earmarking that you think it is... and it has no impact on autism research.

Pondering: on Medicine

I'm busy on the Medicine service right now. It's by far, my favorite rotation so far in my third year as a medical student -- and I've done a month of inpatient OB/GYN, Psychiatry, Surgery and Medicine so far!

Medicine contains enough of what I learned as a first and second year that I don't feel totally lost in a new world of procedures (uncomfortable bouts of standing and trying not to infect patients in GYN/Surg) or protracted interviews (with difficult formulations in psychiatry!) Inpatient Medicine adds on a whole new level of intensity in admitting patients from the Emergency Department and caring for patients in the Intensive Care Unit, transitioning them down to the Progressive Care Unit and then out into the world. Surgery does this as well, but the majority of my day was spent in the OR rather than the ER or on the wards. To be quite honest, my favorite days of surgery were on the days when our general surgeons weren't in the OR and I had time to round on my patients and figure out how to manage their problems.

That must make me totally IM in the Medicine vs Surgery battle...

Best of: OB/GYN on HPV

In Grand Rounds for OB/GYN, a lecturer talking about vaccinations for young women said something that I thought was totally hilarious. My vague recollection of the quote goes something like this:

A study showed that 32% (95% CI 22.5-44%)of men in a university setting (n=240) had detectable HPV DNA on their hands. (1) That's not necessarily saying anything about their sexual habits...

He went on to say "It just goes to show that HPV is more prevalent than people think. And it can easily spread through hand-shaking." This does raise the distinct possibility of the hand-genital route as well, suggested in an earlier article. (2)

As funny as I found this initial statement to be, it's a serious and sobering topic. Especially since we have the HPV vaccine that can prevent cervical cancer with about 70% coverage. (Not good enough, by Dino's standards.) According to this week's Morbity and Mortality Weekly Report, "an assessment of HPV4 coverage, which is reported for the first time, showed that "25.1% of adolescent females initiated [Gardasil], the vaccine series (>1 dose) in 2007." Yay!

The Health Science Report shares information about the transmission of HPV in general, which can happen through other routes than sexual contact.

A report in 1/08 from the Journal of Infectious Diseases suggests that young women have an increased risk for HPV infection when their first male partner was sexually experienced with a Hazard ratio of 8.5 (95%CI 3.1-23) for 3+ previous partners, 3.6 (95% CI 1-12) for 2 partners and just 0.4 for 1 previous partner (95% CI 0-3.3) with 1.0 Hazard ratio as the reference for first sexual partner. (3)

References
1. JM Partridge - JOURNAL OF INFECTIOUS DISEASES, 2007. Genital Human Papillomavirus Infection in Men: Incidence and Risk Factors in a Cohort of University Students.
2. C. Sonnex. Detection of human papillomavirus DNA on the fingers of patients with genital warts. Sex Transm Infect. 1999 October; 75(5): 317–319.
3. Winer RL. Risk of female human papillomavirus acquisition associated with first male sex partner. J Infect Dis. 2008 Jan 15;197(2):279-82.

"When should I start teaching my children about sex?"

Dr. Karen Rayne has an excellent answer to this question that touches on the underlying implicit emotional issues that are often ignored in our often explicit and graphic culture. Here is an abbreviated version of her typical answer:

When you “should” start teaching about sex doesn’t really matter - you DO start teaching about sex when your children are infants.
...
You teach them what a gentle touch feels like and what it is to be loved.
...
We teach them the names of their body parts, and the names of everyone else’s body parts too.
...
We teach our young children how to be a good friend, how to share, and how to reconcile arguments and disagreements graciously and with love.

This is a wonderful lesson for everyone to have -- I think there are many ADULTS who still haven't been had proper sex-education in this context.

Read more from Dr. Rayne @ Adolescent Sexuality

DNR does not = Do Nothing

I'm finishing up my write up tonight and my last Problem to be addressed in the Assessment/Plan is a terminal condition. I found this article on the subject from Family Physicans/Residents pondering the subject. I'm wondering if this is something I should bring up with my patient since I've avoided it in all of my previous conversations with her.

Discussions of "code status" on a family practice teaching ward: What barriers do family physicians face?
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=80314

One of the things that bothered me when I was a hospital volunteer in high school was the very STRANGE pronouncement in my opinion, on the doors of some of the patient rooms: "DO NOT RESUSCITATE." Even as someone tangentially related to the healthcare field at the time, I thought it was an overtly insensitive and harsh statement. I think my reaction could be summed up as "Why are you banning people from getting healthcare?!?! Isn't that the REASON they are in the hospital?"

I'd like to emphasize that no decisions are final and “Do Not Resuscitate” does not mean “do nothing”. A term like “Allow Natural Death” is equivocal in meaning, but very different in the eyes of a patient and their family. It adheres to their wishes to have “everything done” so they do not feel like they are giving up, without prolonging their suffering with unnecessary and futile medical care.

Ultimately, “Allow Natural Death” is a permissive activity, asking patients if they feel at peace and are willing to let go.
“Do Not Resuscitate” is a dismissive activity and patients may feel ignored or that they would get worse care this way.

As an aside, this is a great example of connotation versus denotation. I struggled to remember these two vocabulary words for about half an hour now. Whew!

This is not the case! One thing I am learning right now by following my residents into the ICU is that many patients who are "Full Code", meaning they will be resuscitated to the fullest extent regardless of the quality of life and eventual outcomes for the patient receive TERRIBLE care as a result... getting hit with all sorts of hospital acquired illnesses from drug-resistant bacteria, thrashed with drugs that work so hard to provide blood to the heart and brain that they literally amputate limbs from within... my goodness.

What is necessary in the hard times when a patient is on their last limb before they go is an honest and heart-to-heart discussion between a knowledgable individual (the doctor) and the people who will ultimately have to make the decision for someone to die. NOT live or die. Just die. There's no other options for a lot of these folks and THAT is the concept that must be conveyed appropriately to the general public who don't know what tonic-clonic twitches are, the different categories of death ranging from asystole to brain death to cessation of all biological function and a shift to true equilibrium. I know I've made no effort of my own to define these words. That makes me a hypocrite (for now.)

Feel free to discuss this topic in the comments (and I'll chime in with my definitions later.)

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
S/sx
Allergies
Medications
Past history/Pregnancy
Last meal
Events

Labs/Studies
ABG
EKG
CBC, Chem7
Type and Cross
PT/PTT
UA, UDS
FAST/DPL
XR/CT/MRI

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.)

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.

"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

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

www.epocrates.com

http://hopkins-abxguide.org/download_center/main/palm/download_center_details.html?siteId=153 - Johns Hopkins antibiotic guide. It used to be free, but now it costs money.

http://eponyms.net/eponyms.htm - List of 1,500 common and obscure medical eponyms (e.g., Rovsing's sign, Virchow's node) with descriptions. Free! Excellent program.

http://www.isilo.com/index.htm - 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 www.meistermed.com files.

http://www.meistermed.com/ - 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 FPPalm.com – Guide to the management of Hypercholesterolemia (FREE)

http://www.apprisor.com/dlselect.cfm - APPRISOR software and Guidelines by AAFP, AAO, AASLD, ACCP, ACP, AHA, ASE, AUA, ACU, CCGC

http://med-ia.ch/medcalc/ – MedCalc, a free medical formula calculator. (Palm, Pocket PC)

http://www.nhlbi.nih.gov/health/prof/other/index.htm - Multiple different tools for professionals (Free)

http://books.mcgraw-hill.com/medical/diagnosaurus/index.html - 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.)

http://www.pdacortex.com/MedMath_Download.htm - MedMath, another FREE medical formula calculator (Palm OS only) It came highly recommended by Dr. O so I downloaded it.

www.kidometer.com - 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. :)

http://www.cebm.utoronto.ca/palm/ebmcalc/ - Centre For Evidence-Based Medicine, FREE EBM tools: NNT, likelihood ratios, etc. (Palm OS)

http://www.medicaltoolbox.com/ - OB/GYN Stat tracker (collect delivery and surgery information) and Preg Calc Pro. (calculate due dates). Register for FREE use.

http://pbrain.hypermart.net/medrules.html – Download Medrules, clinical prediction rules. FREE (Palm OS only)

www.immunizationed.org - 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! :)

www.tarascon.com – Tarascon pharmacopoeia for PDAs. Purchase for $39.95/yr.

www.acponline.org/pda/clinical_references.htm - 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…
http://pda.ahrq.gov/index.html - AHRQ PDA downloads – Interactive Preventive Services Selector and Pneumonia Severity Index Module. Free downloads.
http://cim.usuhs.mil/pubmed/PubMedClinQuery_pda.html - 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
http://www.hawaii.edu/hslib/subjguides/PDAresources.html - JABSOM Health Science Library PDA resource page
http://www.hml.org/WWW/pda.php – Hawaii Medical Library PDA Resource site
www.guidelines.gov/resources/pda.aspx - Will link you to sites that have downloadable PDA guidelines.
www.handheldmed.com - reviews, software downloads, hardware/accessories sales, AvantGo medical abstracts
www.pdamd.com/home - general information, reviews and merchandise
www.pdacortex.com/index.htm - reviews and discussions of medical mobile informatics topics
http://pbrain.hypermart.net/index.html - 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... :(
www.keepkidshealthy.com/pedipilot.html – Pediatric oriented PDA program links
http://www.dcchildrens.com/pdas/ - Pediatrics on-hand. Suggestions for pediatric PDA programs

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

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.

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 About.com 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

RIP Randy Pausch

Randy Pausch passed away from complications of pancreatic cancer on July 25th, 2008. He was 47 years old, but he lived to see everything he wanted for himself come true.

He was diagnosed with pancreatic cancer last year -- the 5 year survival rate is 5% -- and this gave him some time to think. He decided to participate in Carnegie Mellon's "Last Lecture" series with a truly great Last Lecture. He talked about Really Achieving his childhood dreams. It was a silly list, as children are prone to do, but it was inspirational to hear how it shaped his life. And the amazing things he was able to accomplish because he had it all written down.

His wishes continued to come true, even after his Last Lecture (Randy Pausch's homepage) as people heard his story through friends on email, youtube and even on TV shows like Oprah and the Dateline.


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I never had the courage to make a list like that as a child. I was a pragmatic and practical kid -- I didn't want to disappoint my future self by coming up with goals like "finding the cure for cancer" or "making sure the world never forgot me." (Which incidentally, were the sorts of things I thought about growing up.)

In honor of Randy Pausch, I'd like to state my future goals/dreams as a human, a student, a future doctor and a future husband/father (distant future for both) for all to see... and perhaps, I can live to achieve them as he had, in spite of the insurmountable odds. It will be just as fantastic and random as his list, I bet.

"The brick walls are there to show us how much we really want something. They
are obstacles only for the OTHER PEOPLE." -Randy

1. Make a movie/film/short about my personal vision OF the world and FOR the world.
2. Do something significant in the field of Science and/or Medicine -- a legacy for others to follow
3. Public service/public health/community building for the people I love in the place I live
4. Go SCUBA diving at the Great Barrier Reef
5. Make my children and my wife my #1 priority, even though other aspects of my life may take more time and be more pressing (at any particular moment in time) and make sure THEY KNOW IT
6. Learn to tapdance and perform a number from Singing in the Rain
7. Write a fairy-tale about my Dungeons and Dragons characters

Hm... I'll have to put an addendum to this list. I need to go to sleep so I can get "psyched" about my Psych rotation. :)

Rest in peace Randy Pausch... I pray that your family and friends pull through in these hard times. May you continue to touch and inspire people as I have been.

100 "Health Quotes"

via ShanelYang.com

I like to read Shanel's self-help stuff... she's got a great attitude. I don't necessarily agree with her list of "100 quotes about good health", especially since it follows a "20lb weight loss in just 15 days" (which can be hazardous to your health!)... Regardless, I thought I'd post a few of my favorites here.

22. Money is the most envied, but the least enjoyed. Health is the most enjoyed, but the least envied.
- Charles Caleb Cotton

33. The best doctor gives the least medicines.
- Benjamin Franklin

59. To insure good health: eat lightly, breathe deeply, live moderately, cultivate cheerfulness, and maintain an interest in life.
- William Londen

74. The … patient should be made to understand that he or she must take charge of his own life. Don’t take your body to the doctor as if he were a repair shop.
- Quentin Regestein

94. Be careful in reading health books. You may die of a misprint.
- Mark Twain

Multiple Gestations

Multiple Gestations

view presentation

A short presentation I put together for my OB/GYN L&D (labor and delivery) team's morning report. They really liked it and I worked hard to keep it succinct (printed it out as a handout, 9slides/page = 1 page, back&front).

The best thing about it was that we had two expecting mothers on the floor with twins and I got to participate in one of their deliveries (via C-section, a Twin A vertex and Twin B breech)! So I was ready for any "pimp" questions thrown my way by the attending. :)