Don’t fall asleep during the Sarah Connor Chronicles

For the benefit of Teresa and her son, here’s a description of a day in the life. This may not be all medstudents on the surgical rotation, but at the moment it’s what I’m doing.

I wake up around 4AM, put on scrubs (usually, but on clinic day you dress nice), and go to work. I spend about an hour going over labs, checking vitals from overnight, in and outs as they say, and visiting with patients to ask them how their night was as well as performing a brief physical exam. I then round with my team for about half an hour, and for the patients I track, I try to present them to the residents without making a total hash of it. A historical note, several medical terms come from Johns Hopkins, including “rounding” and “residents”. Rounds came from the fact that their hospital was circular, so you literally did a round of each floor when you visited each patient. Resident came from the fact that the doctors-in-training were worked so hard they lived in the hospital during this period. Hooray for the new hours rules.

6AM – morning report, a hand-off from the night shift of the cases from the last evening. Usually a great learning experience as the residents’ presentation is an opportunity to see how experienced docs present cases, patient histories, and make diagnoses.

7AM – class, a clinician visits the medstudents and gives us a lecture on something they know a lot about. This is often my favorite part of the day since the professor teaching is usually describing their job, and since they tend to love their jobs, they love teaching us about their jobs. Also you can eat breakfast.

8AM – unless it’s a clinic day, you head to the OR for cases. You observe, help in any way you can, and see what surgery is all about.

3-7PM – usually I’ve been out by 7 at the latest, but it’s hard at first staying on your feet for so long. After about 10 days you’re acclimated though and don’t mind anymore. You find your team, see your patients again, prepare for the next day’s cases and then usually go home unless you’re on call. Any time you have to spare you read.

You can try to study when you get home but more often then not I just fall asleep immediately. I tried watching the Sarah Connor Chronicles this week. It was an error. I fell asleep during the first 15 minutes then had nightmares all night that I would never amount to anything because no one has bothered to send a robot back in time to kill me. How’s that for low self esteem?

Surgeons have cool tools

Surely no one can be pissed at me for pointing out that surgeons have some of the coolest tools, so I think I’ll describe a few of them that I’ve seen used a great deal in general surgery.

The one most frequently in use is referred to simply as “the Bovie” and it is used for electrocautery. Named for William Bovie it was first used by the famous surgeon Harvey Williams Cushing almost a century ago. The patient in the OR is laying on a large conductive pad that grounds them, and the Bovie device, which resembles a little plastic pencil with a flat, rounded metal tip, generates an electrical current which is transmitted directly to tissues to cut like a scalpel.
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I can’t find a nice video of one in action, but it really is an interesting little device. By generating an alternating current at the tip it rapidly generates a great deal of heat in a very tightly-controlled location. Further, because you aren’t grounded, you can use it in close proximity to your fingers, or touch it to metallic surgical instruments to transmit the current to through the instrument to tissues without burning yourself. The effect of the device is dramatic. On one setting, the cut, a continuous waveform is generated that allows you to cut through tissue like a scalpel. The second setting, coagulation, turns the current on and off rapidly for a slower heat which coagulates while it cuts. The advantage of a Bovie over a scalpel is that a cut can be made that is clean and doesn’t bleed excessively thus maintaining hemostasis. One can also grasp a small vessel with a hemostat (or clamp) and touch the Bovie to the hemostat to rapidly coagulate the vessel to prevent bleeding.

More below…

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Finally, an explanation for my sneezing

Here I thought I was the only one but apparently photic sneezing has received enough attention to get researchers interested in it. Apparently it’s an ancient problem:

Aristotle mused about why one sneezes more after looking at the sun in The Book of Problems: “Why does the heat of the sun provoke sneezing?” He surmised that the heat of the sun on the nose was probably responsible.

Some 2 ,000 years later, in the early 17th century, English philosopher Francis Bacon neatly refuted that idea by stepping into the sun with his eyes closed–the heat was still there, but the sneeze was not (a compact demonstration of the fledgling scientific method). Bacon’s best guess was that the sun’s light made the eyes water, and then that moisture (“braine humour,” literally) seeped into and irritated the nose.

Humours aside, Bacon’s moisture hypothesis seemed quite reasonable until our modern understanding of physiology made it clear that the sneeze happens too quickly after light exposure to be the result of the comparatively sluggish tear ducts. So neurology steps in: Most experts now agree that crossed wires in the brain are probably responsible for the photic sneeze reflex.

It’s apparently an autosomal dominant trait, which would explain why other members of my family have the reflex too. Anyone else a photic sneezer?

2007 Holiday Card, A Bit Late

Those of you on my snail mail list receive holiday cards from me every December, but this year was so hectic that I never got to one. So, today (really tomorrow), I’m mailing my MLK Day cards, which will include A is for Abandonable, Chris’ Abecedarium of Dysphemisms (PDF). Use these words liberally to spice us your scienceblog!

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Medical Credit Stores: Sorry, You Only Qualify for Subprime Medical Care

Bob Sullivan reports at MSNBC on the early developments of a medical privacy score by Fair Issac, the same company that invented the credit score for lenders. This is somewhat scary, because the entire point of credit scores is to make decision making easier, so easy that people very low on the totem pole can make decisions about you without really thinking, and because it is a number, it is imbued with an air of legitimacy. Credit scores arose after Congress forced consumer reporting agencies to open up their files; scoring allowed companies to put their analysis back into a black box so you can’t tell for sure what information they use to evaluate you.

Several published reports have described Healthcare Analytics product as a MedFICO score, computed in a way that would be familiar to those who’ve used credit scores. The firm is gathering payment history information from large hospitals around the country, according to a magazine called Inside ARM, aimed at “accounts receivable management” professionals. It will then analyze that data to predict how likely patients will be to pay future medical bills. As with credit reports and scores, patients who’ve failed to pay past bills will be deemed less likely to pay future bills.

[…]

Tim Hurley, a spokesman for Healthcare Analytics, said criticism of the firm’s work is purely speculative, as its product is still in development. Even the term MedFICO is inaccurate, he said

[…]

Hurley did say, however, that hospitals will not use the Healthcare Analytics product before patients receive medical treatment, and it will have no impact on medical decisions.

[…]

The Healthcare Analytics tool will be used after patients receive care and after a bill is generated to help hospitals make better financial planning decisions, Hurley said. It will also help health care providers sort through patient records and potentially make it easier to write off some unpaid bills as charity cases, rather than delinquent accounts, which would offer the hospital some accounting benefits, he said.

The firm “is particularly focused on finding ways to help hospitals systematically allocate charitable resources, to make sure that patients who need financial assistance the most receive it on a consistent basis across the industry,” he said.

I guarantee you that this is not the primary function of medical credit scores, and that it will, one way or another, be used to get certain people out the door faster than others.

Back in the Summer of ’72

I’m willing to bet that you weren’t at Explo ’72, the “Christian Woodstock,” which received an encomium in today’s Journal by John Turner:

In 1972, Mike Huckabee — still in high school — followed the example of thousands of other young Americans. He went to a weeklong festival, waded through mud and listened to rock music. But the throng of students he was a part of was different from the youthful gatherings more often associated with the late 1960s and early 1970s. These young people were in Dallas for Campus Crusade for Christ’s “Explo ’72” — at “Godstock” rather than Woodstock.

It was the perfect trip for a young, conservative Christian like Mr. Huckabee, as Explo ’72 foreshadowed the subsequent emergence of evangelicals as a powerful voting bloc. The assembled students applauded a large contingent of military personnel and cheered the South Vietnamese flag. The Rev. Billy Graham read a telegram from Richard Nixon, and a survey conducted by a local newspaper reported that the students favored Nixon over George McGovern in the coming election by a ratio of more than 5 to 1. They also favored stronger penalties for marijuana possession and overwhelmingly believed that American attitudes toward sex were “too permissive.”

Wow, what a sucky party! I thought young Christians got together at these things and remained technically intact!

Bibliolatrists: Quickly Dial 911! That Woman Has Been Shunned!

The Wall Street Journal’s Alexandra Alter reports on the newest reason not to spend your money and time at church: shunning has returned, meaning that years of devotion to your religious institution can be cut off if you do something like gossip or dare to question the grand panjandrum:

On a quiet Sunday morning in June, as worshippers settled into the pews at Allen Baptist Church in southwestern Michigan, Pastor Jason Burrick grabbed his cellphone and dialed 911. When a dispatcher answered, the preacher said a former congregant was in the sanctuary. “And we need to, um, have her out A.S.A.P.”

Half an hour later, 71-year-old Karolyn Caskey, a church member for nearly 50 years who had taught Sunday school and regularly donated 10% of her pension, was led out by a state trooper and a county sheriff’s officer. One held her purse and Bible. The other put her in handcuffs.

The charge was trespassing, but Mrs. Caskey’s real offense, in her pastor’s view, was spiritual. Several months earlier, when she had questioned his authority, he’d charged her with spreading “a spirit of cancer and discord” and expelled her from the congregation. “I’ve been shunned,” she says.

Her story reflects a growing movement among some conservative Protestant pastors to bring back church discipline, an ancient practice in which suspected sinners are privately confronted and then publicly castigated and excommunicated if they refuse to repent. While many Christians find such practices outdated, pastors in large and small churches across the country are expelling members for offenses ranging from adultery and theft to gossiping, skipping service and criticizing church leaders.

The revival is part of a broader movement to restore churches to their traditional role as moral enforcers, Christian leaders say. Some say that contemporary churches have grown soft on sinners, citing the rise of suburban megachurches where pastors preach self-affirming messages rather than focusing on sin and redemption. Others point to a passage in the gospel of Matthew that says unrepentant sinners must be shunned.

The full article is free on the Journal’s site today, and it’s worth a read. I find it interesting that gossip plays such a powerful role in shunning–it’s pretty clear that gossip in this context can undermine religious leaders’ authority, especially when it appears that a leader may be up to shady financial dealings.

Skeptics’ Circle Number 78 – The Skeptical Surfer

This week’s circle is at skeptical surfer’s blog. Although I think Christian has made an error or two in his evaluation of the latest NHANES studies and what they say about obesity. For one, obesity has always been 30+ BMI, overweight was changed from 27 to 25 by one government agency responsible for surveillance of disease (CDC) to conform with other agencies’ metrics. Further as I explained, the NHANES studies are hardly single variable, and don’t take into account a change in medical culture towards better secondary prevention of comorbidity in the overweight and obese. It’s all good though. I appreciate an honest effort.

Wounds!

Despite the best attempts of the New York Times Wellness Blog to get me fired, I’m still here and doing fine. Somehow a post about how impressed I was with surgery, the professionals that practice it, and how many of my preconceptions about surgeons were incorrect, got all turned around into some “peak behind the curtain” into the secrets of the medical profession. This is terribly absurd and the article made a hash out of what I was trying to say. I was trying to relate some of the shock one experiences going from an academic setting into a clinical one for the first time, as a reminder to those who have done this before, and maybe preparation for those who have yet to make the jump. None of these things are secrets, and all could be culled from watching about 15 minutes of the Discovery channel or Scrubs.

But the confusion of some individuals over what I was trying to communicate is still my problem, even if I was quoted all out of context. Clearly the biggest issue is the change in audience, my sb audience includes a lot of scientists and doctors, and the way I write is somewhat geared to this group. Thus you’ll notice in my comments mostly positive responses – especially from medical professionals like Orac, PalMD and various others. When the NYT expands my audience to a group of people who don’t know my writing, my assumptions or my more egregious stylistic shortcuts, it is not surprising there was some confusion and hurt feelings, not to mention some people with absolutely no sense of humor.

This does not mean that there is no problem however, ultimately this is a sign that I need to remember that I am writing in a public arena and need to be more careful with the assumptions I make about my audience on any given day. Rather than clamming up for the next couple of decades until I’m tenured, instead I’m going to use this as an opportunity to broaden the appeal of the blog and help explain to a wider audience what evidence based medicine is, the process of learning it, and why I think medicine the best career in the world. Writing this way will help educate people about medicine and how its practiced, and at the same time improve my knowledge of medicine with the goal of making me a better doctor one day. So, back to basics.

First, an explanation of the role of a medical student in the arena of patient care. Medical students are being introduced into the profession of medicine. To accomplish this they take two years of some of the most arduous training imaginable, intensively learning about anatomy, physiology, pharmacology, biochemistry, genetics, pathology, microbiology, physical exam, history taking, and all the other knowledge that makes up the foundation of clinical knowledge. By the third year, which is what I am currently in, you have accumulated more knowledge in two years than you probably have in your entire life. You are tested, retested, observed, corrected, and tested again and after all this work you get the incredible privilege of participating in patient care in your second two years of med school. This does not mean your first week of patient care is any less of a shock to the system – it is very much different from the purely academic pursuit of medicine – it is more of an apprenticeship in which you learn by doing and is certainly the most important part of learning to be a clinician. At this point you are participating in patient care, usually at an academic setting, and you see patients, take histories and physicals, learn how medical decisions are made in the care of individual patients, and in the case of surgery, observe how operations are performed. While you are an important part of the patient care team, you are not responsible for clinical decisions at this point and are at the bottom of the proverbial totem pole. You work with interns, residents and attendings who are ultimately responsible for medical decisions. For the most part, you observe, participate, tell them what you would do, and then wait patiently as these more experienced clinicians explain why you are right or wrong and what is the correct course of action. It is training to develop clinical judgement and competence in patient care. Further, when I say that I “scrub in” to a surgery, it means that I am allowed into the sterile field (after scrubbing, gowning, gloving etc.) and am given the privilege of watching surgery up close. If you’re lucky you may get to participate, but in a very limited capacity, never beyond your abilities (usually just holding instruments, aiming a camera, applying traction, suction etc), always under the supervision of someone with between 5 and 40 years more experience than you, and in a very controlled environment. Always paramount is the patient’s well-being, and if it is ever in question you quickly find yourself shuffled back behind the doctors who are doing the very difficult and demanding work. Before you even step into the room one must remember the student has years of training to understand the pathology and anatomy of the case, the student has read up on the patients’ specific case, and has reviewed the surgical procedure, relevant pathology, anatomy etc. Before you work with patient on a medicine rotation you’ve done similar prep, and throughout the case are studying the patient’s case, lab results, textbooks of medicine, the scientific literature, etc., as part of your training. When you graduate from medical school and become an intern and then a resident you are still training for about 3-5 more years, you become directly responsible for patient care, and are under the supervision of an attending physician. This structure is ultimately very successful and academic medical centers provide the best medical treatment in the country, attract bright people, take all kinds of cases (the ones many other hospitals simply can’t handle), and constantly push the boundaries of medicine.

Now, onto the fun part. A clinical case. This is how we learn medicine, as being social animals, it’s almost always easier to remember medicine in the context of a person. You’ll always remember medical facts and treatments better if they are associated with an actual human being. And this is, of course, an artificial teaching case having nothing to do with an actual individual. I had a post all prepared describing a complicated procedure, but since we’re starting from basics, let’s begin with wounds.

The patient is a 52 year old construction worker who suffered from an open fracture (bones sticking out of the skin) of his left radius and ulna (bones of the forearm) from on-the-job accident. He was taken to the ER, his arm was evaluated with a plain X-ray film, and the break was cleaned, reduced, and set in the OR. He received prophylactic cephalosporin antibiotics before the surgery. 24 hours later he is on your floor, admitted to your service, and he complains of chills, and severe burning pain at the site of his incision. The patient is alert and oriented to time, place, and person, but is diaphoretic (sweating), pale and in some distress. He has a fever of 39.2, BP 140/90, and his heart rate 110 beats per minute. An examination of the arm reveals a brown, weeping wound at site of the repair, the arm is warm to the touch, and acutely painful. Physical exam and review of systems is otherwise unremarkable. Labs show an elevated white count. He has a history of type II diabetes and hypertension.

What do you do?
A) Treat empirically with a broad spectrum IV antibiotic like Cipro and culture the bacteria for a definitive diagnosis and sensitivity testing.
B) Clean and debride the wound.
C) Change the dressing and wait for the wound to heal naturally.
D) Send the patient back to surgery to debride (clean) the wound and start therapy with penicillin and clindamycin.
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