A Real "Good Friday"

Last Friday, Mr. Joseph Smith, an average middle-class suburban grandfather, was shopping at the local grocery store for a stuffed rabbit for his granddaughter's Easter gift. All of a sudden, Mr. Smith collapsed to the floor, flipping over the shopping cart, which his granddaughter was sitting in. As he lay on the floor, blue and lifeless, his 2-year-old cried, "Pop-Pop died!"

In comes the hero, Michael McDonald, the store manager.

McDonald, trained in basic life support "ripped back Smith's shirt, [applied the automated external defibrillator (AED)] then shocked his heart until it started beating." Subsequently, Mr. Smith was brought to the local hospital and stabilized. He is currently awake, doing well, and discussing his passion, the NY Mets.

Could there be a better example of why it is so important to have people trained in basic life support? Not just lifeguards, EMTs, nurses, and physicians...but everybody. Not too long ago, people like Mr Smith would not have received life-saving defibrillation. Why? Because AEDs were never installed in supermarkets. Like the national campaign for seat belt enforcement in cars, the push to place AEDs in public places certainly is a benefit to society.

For Mr Smith and his family, this weekend was a celebration of two resurrections.

For more details, you can read the article by Julie O'Connor

Censoring the Vagina...Anatomy or Blasphemy

Vagina

...the genital canal in the female, extending from the uterus to the vulva.
-Stedman’s Concise Medical Dictionary

"In the latest jaw-dropping educational idiocy, three honors students at a suburban New York City high school have been suspended for saying "vagina" during an in-school performance of The Vagina Monologues. The trio of 11th-grade girls from John Jay High were warned prior to the open-mic session that it would be inappropriate to utter that word while performing Eve Ensler's feminist play. But, rather than infringe upon Ensler's creative work, they decided as a team to disobey, reciting the naughty three syllables of anatomy in unison.

Thus far, Principal Richard Leprine has denied any censorship, instead claiming that the girls were punished not because of what they said but because they disobeyed orders not to say it. School Board President Peter Breslin abetted, stating that the decision to suspend was not about censorship but rather about insubordination.

Fine, I'm willing to except that cop-out on face value, but if saying "vagina" wasn't a problem, then why issue an order forbidding it in the first place? Was the school's objective to teach them that no matter how repressively backwards a rule is, it must be followed blindly? Or maybe its goal was to demonstrate how irony works by calling the event an "open mic" and then punishing those with the gall to speak into the mic openly?

Either way, it seems the only thing the school achieved through this fiasco was to educate students and remind parents that bureaucracies care more about protecting their authority than accommodating the public they were designed to serve."

Full article (written by Emil Steiner) about the the suspension can be found in the Washington Post

A Woman's Despair...

Dr Zaroff recalls one of her earliest experiences in clinical medicine...the emergency room at Mt Sinai hospital in 1956.

The same year Don Larsen pitched a perfect game to propel the NY Yankees to their 17th World Series win, and Dr Sheldon Jacobson started his first year as Chairman of the EM program at Sinai. (kidding)

The article captures the calmness of the experienced emergency personnel, the insecurity of the intern, and most of all the tragedy of the patient - who presented to the ER after jumping out of her psychiatrists window.

This seems like a good reason to keep psychiatric wards and offices on the ground floor. Here is an excerpt:

...The emergency room is a crush of activity — asking, receiving, checking, patients piling up. Its noises are important, compelling. Yet the focus now is on this one woman. The nurses, deliberate as a snowstorm, have seen it all. For them, this is just an iteration. They watch over the tyros: they will allow no serious mistakes.

The ED, It's not black or white...

Does race and gender matter when it comes to the treatment of chest pain in the Emergency Department? A study released yesterday by Drs Pezzin, Keyl, and Green in Academic Emergency Medicine evaluated the care rendered to patients with chest pain. They conclude that African-American men and women do not receive the same workup as non-African-American patients. Such deficiencies included delayed or absent ECG's, pulse oximetry, chest radiograph, and cardiac monitoring.

The study is retrospective and the patient population is drawn from the National Hospital Ambulatory Health Care Survey of Emergency Departments (NHAMCS-ED) for 1995–2000. I wonder how this population corresponds to New York City's?

FROM ABSTRACT
BACKGROUND: The existence of race and gender differences in the provision of cardiovascular health care has been increasingly recognized. However, few studies have examined whether these differences exist in the emergency department (ED) setting.
CONCLUSIONS: This study documents race, gender, and insurance differences in the provision of electrocardiography and chest radiography testing as well as cardiac rhythm and oxygen saturation monitoring in patients presenting with chest pain. These observed differences should catalyze further study into the underlying causes of disparities in cardiac care at an earlier point of patient contact with the health care system.

Reuters news service published a commentary about the study

Comments welcomed (click comments below)

Nice Pickup...A Glowing Intoxication

This week's New England Journal of Medicine published an image showing fluorescing urine from a patient who presented to a NYC Emergency Department. At triage, it was thought that he was one of the regulars who just drank too much.

There is some truth to that.

After his blood pH level came back at 7.0, Dr Chris McStay, seen below, realized this patient didn't just drink a pint of vodka. He took the patient's urine and shined a UV light on it (as seen in photo). The basin on the right shows a purple fluorescence - representing sodium fluorescein, a chemical that is added to antifreeze to aid in the detection of radiator leaks. Turns out, the patient's level of ethylene glycol was greater than 200 mg/dL.

Nice pickup, Dr McStay.

To listen to a short interview with Dr McStay on NPR this morning click here.



"Nice pickup" is a column designed to post cases seen in the Emergency Department that may otherwise go unrecognized were it not for the critical thinking of an EM doctor or nurse.

Comments welcomed (click comments below)

Did someone say...Trimspa?

Vickie Lynn Marshall, aka Anna Nicole Smith was found dead yesterday in her Florida hotel room. Reports state that her nurse found her unconscious on the floor and her bodyguard performed CPR. An EMS worker noted cardiac activity when they found her and attempted resuscitation...by placing transcutaneous pacers?

Could Trimspa have anything to do with it?

Trimspa shouldn't be taken with Monoamine Oxidase Inhibitor (MAOI) antidepressant drugs. MAOI drugs include phenelzine (Nardil), tranylcypromine (Parnate), selegiline (Eldepryl), and isocarboxazid (Marplan). These drugs react with foods containing tyramine, such as cocoa, and may lead to a dangerous rise in blood pressure, as well as headache, nausea, vomiting, rapid heartbeat, possible confusion, psychotic symptoms, seizures, stroke and coma when combined with MAOI antidepressants.

With the recent death of her son, was Smith on antidepressants?

What about the main herbal ingredient - Hoodia gordonii, an appetite suppressant

One of the theories about how hoodia works is that it tricks the brain into thinking that it has enough blood sugar. Without proper feedback regulation, it's possible that a person's blood sugar could drop dangerously low while taking hoodia. And with the regular hunger mechanism turned off, the normal warning signs may be suppressed, until it's too late.

Trimspa, I don't think so...

While we wait for the post-mortem, does anyone care to comment about the case (click comments below)?

A clean inoxication...

In this week's New England Journal of Medicine, Dr's Emadi and Coberley write about a patient with a history of alcohol abuse, who was admitted to their hospital for chest pain. After a negative workup, the patient was found hypotensive and delirious -- shortly after drinking the hand sanitizer in the bathroom. The culprit -- isopropyl alcohol. Intoxication may lead to dense coma and refractive hypotension. This patient was fortunate; he was resuscitated to the point that, when asked why he drank the hand sanitizer, he pointed to the label, which read,

"Active ingredient 63%v/v isopropyl alcohol."

He explained that this percentage is higher than that in vodka.

It's getting personal

More than just cutting funding from Medicare and Medicaid, Bush's budget (and Spitzer's) includes...

...deep cuts in spending to train young doctors, cuts that would hit New York especially hard, eliminating several hundred million dollars a year in payments to teaching hospitals around the state.

...in particular, the cuts would take money from the academic medical centers that teach new doctors and do a large share of advanced medical research. New York City has by far the largest concentration of teaching hospitals in the country, training about one in seven of the nation’s interns and residents, many of whom go on to practice elsewhere.

see the rest of the article here

A budget unfriendly to Bellevue

I met Hilary and Chuck today -- basically, they held a 30 minute press conference discussing Bush's new budget and how it impacts health care funding. The budget eliminates $70 billion in Medicare and Medicaid funding.

Here is an excerpt from a NY1 article

“To this president there are only two priorities as this budget shows: funding the war and cutting taxes for the very wealthy,” said Schumer. The middle class and those that hope to be middle class are left behind.”

America's XLI

Prediction
Colts 24
Bears 17

Global Warming is heating up...

It is long past due, but finally there is consensus among international scientists that global warming is real. Where have these people been? They now say that global warming is "unequivocal" and that humans are "very likely" responsible for the rise in temperature. I feel like we knew about this 10 years ago? Here is a piece from today's NY Times.

The average temperature graph of the world should not look like the Dow Jones Industrial average in a bull market.

Does she weigh enough?

Today is the opening day of Fashion Week NYC...Models are undergoing physical exams by physicians to make sure they are healthy enough to walk the walk. Currently, the accepted BMI is 18 - which translates into 123 lbs for a 5'9'' model. Spain's top model had a BMI of 14. That translates into 95 lbs at 5'9''.
Here is a video link and article from today's edition of NY 1...

Want to calculate your BMI? Click here

Lions and Tigers, and whales?

For those of you with little ones...the American Museum of Natural History has a real-life "Night at the Museum". The event is for kids 8 to 12 years old - with chaperone. Ever thought about sleeping under that huge blue whale? Eat your heart out Ben Stiller.

The Big 'Sweet' Apple

New Yorker's have a lot to be proud of - the best restaurants, the most museums, the highest rents. A study released yesterday, also labels us as one of the 'sweetest' in the country. The study found that 1 in 8 New Yorker's have diabetes.








"On Health" is a column designed to present the latest controversies and newest information regarding your day-to-day health. Please feel free to contribute a topic by sending an email to nyemergencymedicine@gmail.com

Medicalese

Remember learning a new language in medical school? Imagine what it is like for our patients - who may have no idea what we are talking about if we speak to them in our language. It happens more often than we think. Medicalese, the new Spanish...

Article from today's NY Times

How often have you left a doctor’s office wondering just what you were told about your health, or what exactly you were supposed to be doing to relieve or prevent a problem? If you are a typical patient, you remember less than half of what your doctor tries to explain...

The Evolution of Creationsim...

HBO has a documentary on Evangelical Christianity that is worth watching. It is a fascinating documentary - Here is a link to the video

A Bird in the Hand is Worth two in the BUSH

In case you happen to watch the State of the Union Address tonight - pay attention to what Bush is going to propose to help fund health insurance for people without it - essentially, diverting funding from federally subsidized hospitals (i.e. New York City Health and Hospitals Corporation). Aren't our city hospitals already underfunded?

EM RSS feed/Podcast

So for those of you who can't stand those emails from listserves which clog your inbox, here is a solution... an rss feed for emergency medicine abstracts.... If you know what that is, cool, if not, basically it's like a podcast which you can customize to receive any abstract or news update on any topic.

I noticed that there were a lot of news updates on this blog and for those of you who are interested there is actually a way to scan quickly through the most recent abstracts in most every journal or news service which would interest an em practitioner.

I collected these at a site which you can just cut and paste into your browser...

http://www.bloglines.com/public/emjournalclub

If you look at the pediatric emergency care abstract list for example, you will see the first article is an article by Beth Israel Pediatric EM faculty Drs. Dreisinger, Zane and Etwaru...

This is a relatively painless way to keep up to date, and for those of you interested in journal clubs, this is a great way to get daily updates on specific topics. For example, you can create an abstract feed which will tell you what new articles have been published DAILY on the treatment of sepsis, airway management, etc.

I created an example for intubation...

A technical note, I created most of the journal feeds though pubmed's rss feed service, the links expire after 6 months of inactivity.

From one doctor to another...

Just got back from Memphis - visited the National Civil Rights Museum (previously the Lorraine Motel) where Dr Martin Luther King was shot and killed. An amazing place to visit - check it out some time.

Here is a link to King's letter from a Birmingham jail - a call to action for those keeping silent. We, as Emergency Medicine physicians, should not remain silent in the struggle to provide health insurance for all Americans. Almost 47 million Americans, including more than 8 million children, are currently uninsured.

Paul Krugman of the NY Times Jan 1, 2007

Americans spend more on health care per person than anyone else -- almost twice as much as the French, whose medical care is among the best in the world. Yet we have the highest infant mortality and close to the lowest life expectancy of any wealthy nation. How do we do it? (login to Times Select to read on)

Airway courses

Being that managing the airway is an essential skill in Emergency Medicine - I was wondering if anybody attended one of the following airway courses and would like to make some comments?

The two most popular courses are
The difficult airway course (Walls)
Practical Airway management (Levitan)

I believe one of the most important skills to develop during residency is airway management - anything less than perfect can be catastrophic. I think in addition to our clinical experience with airway management in the ED, it is useful to attend one of the airway courses. Also, an elective at Shock Trauma, either the trauma elective or anesthesia elective is a good way to augment our airway skills.