I am tired (see MedPage).

I am skipping town this week to go to the ACP meeting in Washington DC (and am giving a talk on Saturday).  Any med blogger types going to be there?  There don’t seem to be a lot of IM bloggers (I guess we are generally too boring to be of interest to most).

Please drop me a line if you will.  I am planning on visiting the very famous Dr. Val while there (although I think she is just trying to meet a lobster).

My talk, by the way is entitled: Being a Real Doctor in a Paperless Office.

I am not sure they realize I am neither real nor paperless.

The above picture came up when I Googled "Dull and Boring."  Quite an interesting picture, with his eyes being kind of creepy-looking.  There are also some sort of ceramic pots in the background.  It seems that Humpty spends a lot of time in pretty bad neighborhoods.  It does not surprise me that he got cracked. 

Maybe he was doing crack.

But sometimes it can be exasperating. It infuriates me to be subjected to a system where quality is rewarded with less pay; where doctors are motivated to not communicate or cooperate. Especially when my patients pay the price.

I am not psychic. I cannot know what happened in a three month hospitalization by placing my hands on a patients head and reading their brain waves. My staff can’t know that a “hospital follow-up” visit is really a major dump because a patient’s “insurance ran out”. I don’t have the supernatural ability to slow time down so that I can decode the crying of a spouse and confusion of a sick patient and put together a good plan in fifteen minutes. I am not a faith healer. I have no crystal ball. I lost my magic wand. The kryptonite has sucked out my power.

I am funny this way. I like to be called on the phone, not read Tarot cards. I want to know what is going on. Discharge summaries are better for me than tea leaves.

Yet somehow the impossible is expected of me. I am expected to pull the rabbit out of the hat - and do so with a smile of appreciation of what a great job I have. But I don’t smile; I get angry. It is not fun; it stinks.

As much as it stinks for me, however, it is far worse for the patient. I can go home and complain about my day, but the patient has to survive when the system lets them down. The patient’s family has to live in fear when nobody can tell them what to do. Doctors get frustrated, but patients get sick and die.

And that makes me furious.

f-mt

-mts; fäm--tz, fm-

There was a study done recently regarding the cleanliness of computer keyboards (from Science Daily):

ScienceDaily (2005-04-18) — Some potentially harmful bacteria can survive for prolonged periods of time on the keyboards and keyboard covers of computers, a study conducted at Northwestern Memorial Hospital has found. Gary A. Noskin, MD, who is medical director of healthcare epidemiology and quality at Northwestern Memorial and who led the study, advises periodic cleaning of computer equipment and hand washing after every computer use.

"The problem is especially important in hospitals and other healthcare environments where patients are at risk of contracting bacterial infections from healthcare providers who use computers," Dr. Noskin says. He presented his findings at the 15th Annual Scientific Session of the Society for Healthcare Epidemiology of America (SHEA) in Los Angeles this week, and the study generated coverage from various news outlets including CNN, the Chicago Sun-Times and Reuters.

Noskin and his colleagues studied bacteria commonly found in the hospital environment. To determine the ability of bacteria to survive on computer keyboards, the researchers inoculated the equipment with three types of bacteria: vancomycin-resistant Enterococcus faecium (VRE), methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa (PSAE). VRE and MRSA are examples of bacterial strains that have developed resistance to the antibiotics (including vancomyin and methicillin) commonly used on them. Although VRE and PSAE seldom cause problems except in hospitalized patients whose immune systems are compromised by other disease or illness, recent outbreaks of MRSA skin infections in otherwise healthy persons (community-acquired MRSA) have raised concern among infectious disease experts.

 

I believe in Electronic Medical Records.  I believe they can save lives if used properly through better care.  We have been using EMR for the past 12+ years with terminals in every exam room.

While it is common to worry about patient contact with the computer and access to data (or little kids turning it off), I have honestly never considered the cesspool we may harbor in each room.  There are moments when I am tempted to swat people with the keyboard, but the risk this may expose patients to needs to be considered by anyone with an EMR.

Afraid of toilet seats?  Be more afraid of keyboards.

I see an opportunity for an entrepreneur here:  make a washable keyboard and market it to hospitals and doctors.  We really don’t need Electronic Medical Fomites.

Perhaps we need a sign that says:  Employees must wash their hands after touching the keyboard.

Really. I think we could prevent dementia if we only would go back to the good old days.

See MedPage for further Details

I looked at the baby in the basinet. I was tired, happy, confused, hopeful, and scared. He just laid there, barely moving. I thought to myself, this child will be in my life until the day I die. It happened in an instant. There was now a person for whom I would throw myself in front of a bus without hesitation. The child had done nothing except exist, but that existence radically changed my life.

My oldest turns sixteen today.

To say that it just seems like yesterday would be a lie. It seems like a long time ago. The cobwebs are creeping into this old mind (along with llamas and lobsters), and so it helps me to recount the whole experience. Here is how I remember it:

We are Pregnant!

We had just been married for a couple of years, but my wife and I were quickly approaching thirty and biological clocks are hard things to ignore. I was still in my residency, but we were living fairly comfortably and felt it was time to start a family. Somebody must have thrown Miracle Grow on us, because fertility was no problem.

I was suddenly living with a pregnant woman - an experience that one needs to go through to adequately understand. We could not store enough Popsicles in the freezer. Emotional? Yes, and changing without a moment’s notice. “That time of the month” for nine months. We did enjoy the kicking in the belly: the “Alien” movements I could see and feel.

Because it seemed the thing to do, I chose one of the OB/GYN attendings at my program for my wife. The visits seemed nice enough, but there was little bonding between my wife and her doctor. We got an ultrasound and found out it was a boy (even though we asked not to be told). We bought any and all baby supplies we could afford - and hunkered down to wait for the day.

Delayed Gratification

Finally, the day fast approached for the babe to be delivered (yes, I am referring to my wife). We reached her due date. Nothing. Days went by slowly, each day waiting for my beeper to say it was time. Still nothing. The office pool at my wife’s workplace was quickly losing possible winners. A week past the due date, and we talked with the OB about plans. It was the practice at the time to go as much as two weeks past the due date before forcing the issue.

So we waited more.

Day 12 past the due date was a Saturday. The entire previous night, my wife had contractions every ten minutes, sometimes closer. When the morning came, they all but stopped. To encourage our baby to come out, I convinced her to wash the car. We got a clean car out of it, even waxed, but few contractions.

The next night the same thing happened, but the contractions were more severe. The next morning, when they slowed down, we went out for a walk to try to encourage them again. It had rained the night before, and so the sidewalks were covered in worms. My wife hates to see worms die, and since the ability to bend over to pick up worms had left her a few months before, I became the official worm-savior. There were enough worms to practically put me into labor.

Still nothing happened.

Hard Labor

Day 14 finally arrived, only to see the same slow-down in contractions. I was not going to tolerate any more waiting, and the OB did say that two weeks was the expiration date on this pregnancy. So to avoid late-fees, we went to the teaching hospital where our son would be born.

Of course, at a teaching hospital, you get the guinea pig finest experience. We were met by interns and residents. The first check of the cervix showed she had gotten to two centimeters. Two? All of that work and only two centimeters? All of those contractions, lost sleep, worms, and all we got was two lousy centimeters? We demanded a recount, but no dice. We did, however, get a Pitocin drip.

For those who do not know, Pitocin is a hormone normally produced in a woman’s body that causes (among other things) her uterus to contract. My wife’s body was on week 42 of a Pitocin strike, so hooking up the bag seemed like a more likely solution than to negotiate a settlement. Once hung, it did quite well to increase her pain at more frequent intervals.

After a few hours of pain, walking the hospital (with no worms to pick up, thankfully), and more pain, she had progressed to a whopping 3 cm. The pain, however, was getting intense, so we asked for anesthesia. The anesthesia guy they pulled off the street resident came in to put the epidural in. Once in, we were assured that the pain would go away. She lay on her side, with contractions hurting more and the bozo resident blindly expertly putting the epidural needle in her back.

The pain went away…somewhat. It went away on her left side, but not the right. Now she was having hard labor pains on her right, and blissful pain-free labor on the left. She was not happy. We had, however, made it to four centimeters.

The nincompoop anesthesia resident came back sheepishly and tried to make things better by putting her on her side and doing something with a shrunken head on the end of a stick, but it helped little. By now the labor pains were getting difficult to stand. It had been nearly eight hours since coming into the hospital, and nearly three days since the labor process started, and we were all the way to five centimeters.

The Ice Man Cometh

My mother-in-law came with us to the hospital (did I forget to tell you?). She was a great comfort to my wife, and allowed me to take a break and go to the bathroom, eat, or find some worms to pick up. She held my wife’s hand, comforted, coached, and soothed her.

My job was to feed her ice with a spoon. Sure, I had trained to be a doctor and knew the anatomic reason the stupid epidural was not working, the physiologic reason the pitocin torture drip was making her hurt so much, and I was the one who knew everything there was to know about babies and children - after all, I was a resident. But now I was only the ice man. She would let out a pained moan that my MIL would interpret as a need for ice (through some psychic woman power, I guess), and I would jump up and feed her the ice with the expert precision afforded me by my extensive training.

It was getting near midnight, and we were up to 8 cm. Still the anesthesia wasn’t working on one side, much to the chagrin of the microcephalic anesthesia posse. The heart monitor was doing its usual “wooka, wooka, wooka” in the room between contractions. The nurse was repeatedly saying “push, push, push, push” whenever contractions came. I have never been to a delivery when someone did not say “push, push, push, push” in the exact same tone of voice. It must be part of the training of labor nurses.

Lizard Boy

Another hour passed, and we were finally getting somewhere. The repeated “push, push, push, push” must have been the key. I was now so good at ice spooning that I was teaching other fathers how to feed ice to their screaming wives (although I still needed my MIL to translate). We were complete and full.

My wife threw up.

“That’s a great sign” the OB resident reassured us. “It means she is going through transition.” Good. I thought something had gotten into the ice. I hoped that “transition” meant that the end was in sight.

Finally, at 1:23 AM, my first son came into the world. He was scrawny, wrinkly, and covered in goop. Babies get skinny when they spend too much time in the womb. He cried a pathetic little cry (the best sound I have ever heard), and everyone in the room commented on how wonderful he looked. I thought he kind of looked like Marty Feldman - skinny, with big eyes that bulged out. Yet I said to my wife, “He looks wonderful, honey” as I held him up for her to see for the first time.

She paused. “He looks like a lizard” she said in a voice that seemed to question if all the effort was worth it. I reassured her that this was due to placental insufficiency as the term of the pregnancy had passed the due date. She looked at me strange, and then looked back at our boy. “Awww….he’s crying. Give him to me,” she said as the look on her face softened. I handed handed him over and came close to her. We were a family now: mommy, daddy, and lizard boy.

The Aftermath

I got home after 3 AM, and fell on my bed exhausted. Three hours later, the phone roused me from my hibernation. I picked it up to hear my wife’s sobbing, “He’s crying and crying, and I can’t make him stop.” Being a resident, I was used to be awakened for lots of reasons, but I was far better at making children cry than stopping it. I decided that now was not the time to explain this, and went back to the hospital.

He was sleeping again. Somehow the thought of me coming to see him had convinced him to go back to sleep. I looked over at my wife, now sleeping without contractions.

Then I looked over at my boy.

Then my life changed.

Happy birthday, Lizard Boy.

As an internist, I am not a procedure guy. My job is to listen to people, make a list of the possibilities, and then make a plan to narrow the list. The two most important things I do when I see a patient are:

1. Rule out bad things - this is the most important thing. People come because they want to “make sure it is not X.” People with enlarged lymph nodes want to know it is not cancer. People with stiff necks often want to know it is not meningitis. People with sore throats want to know if it is strep. You rule things out that would require immediate intervention.
2. Make a person feel better - Once I have ruled in/out the serious possibilities, I figure out what intervention will make the person better. Sometimes that “intervention” is doing nothing and letting the body do its own thing.

Notice that making the diagnosis is not always the goal. As long as you rule out bad stuff and make the person feel better, finding the diagnosis is gravy.

So the goal of testing is to make a decision: is there a serious problem? What needs to be done to make the person feel better? The goal of testing is not generally to make a diagnosis. If someone has sciatic nerve pain, I order an MRI scan only if there is an intervention needed: so I ask myself, is this person a surgical candidate (the main intervention)?

A few cases I saw recently show that this is not always straightforward.

The first was a man without high risk of colon cancer who asked for a colonoscopy. He had a friend who had it diagnosed at a young age, and was worried about this. Cost was not an issue. So I asked myself:

• Would a negative test adequately reassure the person that he did not have colon cancer?
• What is the chance of a false positive test, causing unnecessary worry, and more testing?
• What is the risk of the test?

A colonoscopy is a good test - it has a very low chance of false negatives (so a negative test is reliable), and the likelihood of a false positive is near zero. In the hands of an experienced gastroenterologist, the risk of the test is fairly low. I ordered the test with a warning about the small risk.

The other case was a woman who was fairly low risk for heart disease who presented with chest pain. My partner saw her earlier in the week and ordered a stress test. The cardiologist actually performed a myoview stress test, which looks at images of blood flow to the heart at rest and with exercise, looking for changes with exercise. The test came back negative.

She came to the office yesterday still having chest pain. She had a few more episodes; one time the pain was worse when she ate a big meal and exerted herself. It went away after resting for five minutes. In this case, I asked myself:

• With a negative stress test, what is the chance that she still has heart disease?
• What other diagnoses are possible?

In her case, there was very few other possibilities. I did a lung-function test to rule out asthmatic type symptoms. It was negative. The symptoms were so classic for coronary symptoms, I had to entertain the possibility that the stress test was wrong. There are a few cases when this can happen, either if the blood vessel narrowing is at the back of the heart, or it is very early in the coronary vessels, and so the whole heart was symmetrically decreased in bloodflow. These are causes of false-negative stress tests.

Since this was a significant thing to rule out (potentially a “widow-maker” or left-main coronary), I called the cardiologist and he agreed that the patient needed a catheterization. He called me today and informed me that she had a 95% lesion on the right coronary vessel. He placed a stent.

This demonstrates that stress tests do have a false-negative rate which is not insignificant.  It also showst that the clinical picture should always trump the test in this setting. In this case, the stress test should have been positive, with the lesion. If the catheterization was negative, then the chance of her still having significant heart problems is much smaller, and other possibilities should be pursued.

So for any test, there needs to be a good understanding of:

• The chance of a false positive
• The chance of a false negative
• The pre-test probability of the person having the disease (based on risk factors and the story the patient gives)
• The risk of the procedure (and the cost).
• The risk of not making the diagnosis.

Each time I order tests, I think about these things (as should any doctor).

This is why I get frustrated when gnomes from the insurance company say they won’t pay for a test. Do they know all of these things on this patient? They just sit in front of a computer and plug the data into a program. They have no idea.

This is a picture of the group, Goober and the Peas. See if you can pick out which one is Goober.

Apparently this song is a Civil War song that was very popular in the Confederacy. I have never seen this sited as a reason the south lost the war, but I suspect this song was running through their head so much that it was better to run in front of a union cannon than continue to have this song running through one’s head.

Why does that happen? Why does my mind devote some of its ever-decreasing number of neurons to save this information? Here is what my extensive research (Google) found:

The vast majority of people say they have been mentally tortured at one point in their lives by a song that keeps repeating itself over and over in their heads.

And new research shows that people most frequently plagued by this phenomenon are those with slightly neurotic tendencies , and people who enjoy and listen to music often.

These mental broken records are also more likely to play the first or last song we hear in different situations, such as the first song that comes on in the morning alarm, or the last song playing before we turn off the car, study findings show.

Songs that topped the list as being most likely to stick around in someone’s head included the Baha Men’s “Who Let the Dogs Out?” and the Chili’s restaurant jingle about Baby Back Ribs.

But the number one song rated most likely to cause this phenomenon, referred to as an “earworm” in Germany, is “other”–indicating that many different songs can become stuck in our heads.

“Just about anything can get stuck in people’s heads,” study author Dr. James Kellaris of the University of Cincinnati told Reuters Health.

“We each have our personal demonic tunes that get stuck in our heads, I guess,” he added.

From Reuters

They don’t mention Goober Peas. I find it interesting that it says that those with slightly neurotic tendencies and people who enjoy and listen to music often are the most afflicted. What if you are musical and more than slightly neurotic? I think I am in trouble. I have stupid song flypaper in my brain.

WebMD ran an article that also calls these songs “earworms,” which reminds me of the movie “Star Trek: The Wrath of Khan,” where they put a worm in a guys ear to make mind control possible. I think this happened to me at some point when I was not looking.

Here is a list of the top-10 earworms (from WebMD):

1. Other. Everyone has his or her own worst earworm.
2. Chili’s “Baby Back Ribs” jingle.
3. “Who Let the Dogs Out”
4. “We Will Rock You”
5. Kit-Kat candy-bar jingle (”Gimme a Break …”)
6. “Mission Impossible” theme
7. “YMCA”
8. “Whoomp, There It Is”
9. “The Lion Sleeps Tonight”
10. “It’s a Small World After All”

Still no mention of Goober Peas (or the tenacious March of the Baby Elephants).

I started thinking on this goofy train of thought when I was in a room with a patient who had just moved back into town after being away for a number of years. I remembered all sorts of information about her and her family, surprising her. My mind is very good at remembering little details. For instance, I remember what room I saw every patient in last. I find that when I see a patient on my schedule, I can picture them in the room I last saw them.

I want to know why this happens? Why does my brain dedicate its precious scarce resources to remembering things like this, and not remembering where I put my keys? Why do I have to put out an APB every morning, calling on the State Police and National Guard, to find my keys?

If someone can figure this out, I suspect most of the problems in this world would go away. I wonder if Osama Bin Laden has “YMCA” going through his head, which causes him to label the US as the “Great Satan”.

I would actually agree with him on that one… if I could only get “Goober Peas” out of my head.

I like her already.

She is hosting Grand Rounds this week and is doing so as a “Smack Down.” I am impressed. It is worth the read.

There are a few other blogs I would like to give a nod to. If you haven’t read them, be sure to do so.

The first is the Derm Blog. This blog is extremely well written and answers the types of questions most people have in dermatology. I think he wants to be on Oprah some day.

The second is Neumed. This is a new blog by a medical student. Again, I appreciate the sense of humor (which may be the kiss of death coming from me). He tells of his plan for world domination, which will probably mean that we will one day clash, as I have similar plans. But for the moment, I find him a good addition to your blogroll.

Finally let me recommend The “blog” of “unnecessary” quotation marks. I am “thrilled” to have found it.

I remember when my first son was born I looked at him and was overwhelmed.  This person was my responsibility.  Even as a pediatrician, I felt a sense of being lost in the sea.  Remembering this feeling makes me have much more compassion on my patients.

The incredible fear the can carry into the office is palpable.  I think you have to be a parent to understand.  Most of the time I can find ways to diffuse the fear - through reassurance, diagnosis, or making a plan to come to a diagnosis.  This is true in about 99% of the pediatric cases I see.  Most kids aren’t really that sick, and those who are can be treated easily.

There is one type of visit, however, that stops me in my tracks.  It is called an Apparent life-threatening event or ALTE.  UpToDate defines an ALTE as:

ALTE is the abbreviation for "apparent life-threatening event", a poorly defined term to describe an acute, unexpected change in an infant’s breathing behavior that was frightening to the infant’s caretaker and that included some combination of the following features:

• Apnea — usually no respiratory effort (central) or sometimes effort with difficulty (obstructive)
• Color change — usually cyanotic or pallid, but occasionally erythematous or plethoric
• Marked change in muscle tone (usually limpness or rarely rigidity)
• Choking or gagging

Unfortunately, an ALTE is only observed by the parent at the time of the event.  They present either to the office or the Emergency room understandably panicked.  Their baby has stopped breathing, turned blue, went limp, or choked.  If a parent is not upset, I get really worried.

So the reaction of the parent is extreme.  But what really happened?  Nobody knows.  Did the child really stop breathing, or is it an over-reaction to something that was a little scary?  How do you reassure a mom when you don’t know what really happened?

The good news is that there is no clear relationship of ALTE and SIDS (Sudden Infant Death Syndrome).  The bad news is that it is very difficult to figure out what to do.  Studies show that about 50% of the time, a diagnosis can be reached through exam and a careful history.  The most common cause of apnea-like symptoms is reflux (that happens in nearly 75% of babies).

Even with a child who refluxes, however, there is often doubt in the back of your mind as a doctor that you are taking a risk at calling it "just reflux."  So more studies are usually ordered.  Here is a list of possible tests from UpToDate:

In one review of test results from a consecutive series of 243 infants admitted to a tertiary center with ALTE, 3776 tests were ordered, of which 18 percent were positive and only 6 percent contributed to the diagnosis

In the consecutive series of 243 infants with ALTE described above, among 171 infants in whom a particlar diagnosis was suggested by the history and examination, the following tests contributed to establishing the diagnosis:

• Blood counts, chemistries, and cultures
• CSF fluid analysis and cultures
• Metabolic screening
• Screening for respiratory pathogens
• Screening for gastroesophageal reflux
• Chest radiograph
• Brain neuroimaging
• Skeletal survey
• Electroencephalogram
• Echocardiogram
• Polysomnography

Among the 72 infants in whom the history and examination were noncontributory, only the following tests contributed to establishing the diagnosis:

• White blood cell count
• Screening for gastroesophageal reflux
• Urine analysis and culture
• Brain neuroimaging
• Chest radiograph
• Polysomnography

This means that there is an average of more than 10 tests ordered per child, with only 6% of them actually helping.  Great.

Most of the time, the kids do great.  Sometimes you put the baby on an apnea monitor - a device that lets out a shrill sound when the breathing rate goes down or the heart rate goes too high or low.  The vast majority of alarms on these devices are false-alarms and can make an already anxious parent become even more anxious.  But what else can you do?

I have never had a bad outcome with an ALTE.  Most of the time the child does just fine.  So when will the good luck end?  It just puts a bad feeling in the pit of your stomach.