Trauma II

I’ve been absent, I apologize, but my last rotation in medical school has been a sub-internship in Trauma surgery. Aside from work, sleep, eating, and buying a house in Baltimore, blogging has necessarily suffered.

I will say a few things though that should be a public service message on the TV. People need to wear helmets when driving ATVs. I’m sorry I know I’m repeating myself. As before, I’d say any time your going faster than 10-15mph and not enclosed and belted in steel cage you should be wearing a helmet. That includes on bikes, on motorcycles, scooters, go-carts, ATVs, skis whatever. It’s just a damn shame when people who are otherwise healthy and independent hit their heads and end up permanently disabled, or seriously injured. We can put a lot of other stuff back together, but once you conk your noggin we’re a little bit helpless to do anything about it. And these days ATVs are replacing tractors as one of the most dangerous vehicles on farms, and are responsible for about 800 deaths a year and ~150,000 ER visits.

And how is it possible in this day and age people are driving around without their seat belts on? It’s just so stupid. It seems almost every seriously injured driver or passenger we get wasn’t wearing their seat belt.

I realize working at a level 1 trauma center I end up with a bit of selection in terms of the patient population. After all there are tons of accidents every day, lots of injuries in those accidents, and most are taken care of by local hospitals. We tend to get the most seriously injured, which tend to be the motorcyclists, the unrestrained drivers, and those unlucky enough to have done more serious injury. But it is disappointing to see anyone come into the ER after an accident where they weren’t wearing their seat belt. It’s such a simple intervention that really can make the difference between life and death.

So buckle up people.

This is my very last week of medical school. Regular blogging will resume after that.

Rating your doctor online – is this a good idea?

I have just finished taking my last major exam of medical school – Step 2 of the boards (including Step 2 Clinical Skills, or CS, which costs 1200 bucks, requires you to travel to one of a few cities in the country hosting it, and is sealed by a EULA that forbids me from talking about what the test was like), and am winding down my medschool career in the next few weeks. It’s about 2 weeks from Match Day (the 19th), when I’ll find out for sure where I will spend the next 5 or so years of my life. I’ll be sure to have a post up a little after noon that day when I find out what the answer is. And then, around May 17th, graduation day, I’ll be a medical doctor, ready to start internship (also known as the hardest year of your life).

One of the things I’ve found universal to all medical students is that we really want to be good doctors when we are finished with our training. I don’t think I’ve ever met a medical student who was in this career for the money (you’d be crazy), or for other selfish reasons. They tend to be hard working, dedicated, humble people who, if anything, are sickeningly sincere about wanting to help other people. Maybe that’s just my school, but my experience is, these folks want to do good in the world.

But another universal is that not all doctors will be able to avoid making mistakes. Doctors are human, they all will eventually make errors, and the goal of any profession dedicated to improving the human condition should be constant self-reflection and efforts at self-improvement. This is not a simple thing to do however. Medicine is complex, and quality of medical treatment is very difficult to assess. We’ve discussed before, using metrics in medicine is challenging, and often rather than studying medical quality you end up merely assessing the social demographics of the physicians’ patients.

So it is with interest that I see reading boingboing that lots of people are upset because some doctors are forcing their patients not to rate them on sites like by having them sign a contract forbidding them from doing so.

The arguments for and against this practice are fascinating. We tread into the mucky waters of free speech, free enterprise, the practice of medicine, and the practical problem of assessing physician quality…

More below the fold…
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Antidepressants, physical dependence, and semantics

Antidepressants are a very useful class of medications. With the introduction of the first modern antidepressant, fluoxetine (Prozac) in the U.S. in the late 1980’s, the pharmacologic treatment of depression has undergone a revolution (and an enduring controversy). Older classes of antidepressants were often effective, but came with a host of unpleasant toxicities—MAOIs can lead to potentially fatal interactions with certain other drugs, and even foods, and tricyclic antidepressants, when misused, can lead to fatal overdoses. Prozac, the first of a new class of medications known as SSRIs (later followed by similar classes such as SNRI’s, etc.) appeared quite safe and effective. Side effects were minimal, and overdoses were rarely fatal. But as newer SSRIs were introduced, it became apparent that while treatment with these drugs was quite safe, stopping these drugs was not always pleasant.

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Smackdown, please (yes, Egnor, I’m talking to you)

Arrogance. It’s always about arrogance. Arrogance is the Great Distractor in science. It is a half-a-dozen logical/rhetorical fallacies rolled into one—argumentum ad ignorantium, non sequitur, tu quoque, ad hominem, straw man (yes, that’s not six yet, but I gotta give myself some flexibility here). These fallacies aren’t just rhetorical toys to play with in the blogosphere. They can be simple mistakes made when discussing an controversy, or they can be weapons used in place of a valid argument. They are particularly important when dealing with reality.

Reality. I’m not talking about a stoned, midnight bull session about whether dialectical materialism accurately describes the relationships between groups of people, or other such (sometimes interesting) nonsense. I’m talking about this table, this PC, this cup of coffee. Reality. Truth.

There’s a great blogger out there who is fond of repeating the fact that “the truth is consistent with itself.” Sure, we can argue the philosophy of reality, truth, perception all day and night, but in the end, in the real, practical world (the one doctors deal with), the truth is consistent with itself, and reality is that which we can observe. Reality is, by definition, everything.

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What is an internist, and why should you care?

A (long) while back, I gave you a brief explanation of what an “internist” is. I later gave you a personal view of primary care medicine and some of the challenges involved in creating an infrastructure of primary care (only 2% of American medical grads are going into primary care). We also had a little chat about medical mistakes and medical training.

No matter what changes we ultimately make in the way we train internists, one of the lessons that residency teaches is to identify who is truly sick. I don’t mean who is faking it, I mean being able to look at someone briefly and decide whether or not they need your immediate attention. It may seem obvious, but it’s not. Objective factors can sometimes be deceiving. For example, an asthmatic may have perfectly normal vital signs, including a normal oxygen level, and yet be moments away from needing a breathing machine. For an asthmatic, a normal respiratory rate may indicate fatigue rather than health, and absence of wheezing my indicate such severe airway obstruction that wheezes aren’t even possible. The ability to recognize severe illness is one of the critical goals of residency.

This is one area in which the so-called alternative medicine folks can really be dangerous.
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It’s back! Get ready for the flu


Yes, it’s that time of year again. Last year, I gave you weekly flu updates from the CDC and from my position on the front line.

So far, it’s still quiet. I haven’t personally seen any cases yet, but I’m sure to soon enough.

It’s not too late to get vaccinated. Wash your hands frequently.

Remember what the flu is and is not. Influenza is characterized by the sudden onset of high fevers (usually greater than 102), muscle pain, and sometimes runny nose and cough. If you can get to your doctor within the first 48 hours, there are medications that may help you get better a little bit faster. Best, though is prevention.

Improving medical care—arrogant doctors are a distractor

(Tangentially related podcast here)

Here’s the thing: all this talk about arrogance in medicine is a red herring. It’s distracting us from the real question that we should all be asking: how do we improve quality medical care?

The personality of individual physicians is important, but not very, just as the medical mistakes of individuals have limited significance. As medicine has become more science-based, we have learned some important lessons about how to prevent and treat disease, and while the physician-patient relationship will always be important, as will the relationship between physicians and other professionals (see this discussion), implementing what we know about how to improve health care (and have known for years), will render much of it irrelevant.

Take the Keystone program. This simple program, developed at Johns Hopkins and piloted in Michigan, as well as a few other places, uses mandatory checklists for certain hospital procedures, and has been shown to reduce complication rates of these procedures. Unfortunately, bureaucracy threatened to strangle this program in the cradle, but that particular storm has apparently passed.
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Choosing a medical specialty III – applying, interviewing and matching

Aside from taking 4th year medical school classes it’s also the time of year that medical students who plan to graduate in 2009 (like me) are applying to residency programs across the country. This is an interesting process and one that many people outside of medicine are unfamiliar with, and quite surprised by. For one, did you know that we don’t have final say on where we train in residency but that the decision is made by a computer?

It’s true. The process is called “the Match” and it’s a time of great excitement and anxiety for 4th year medical students. For one, there are far more applicants than there are residency positions around the country – largely due to application from foreign applicants. Also, depending on which field you’re applying, there may be many more applicants for each given position than there are positions. So let’s look at some of the match data from the National Residency Match Program that they publish each year (Charting Outcomes in the Match 2008 – PDF) to give you an idea of what a 4th year medical student is facing. Table 1 of the report is enough to give many students palpitations.


Divided by US vs other applicants, this is what your chances are as a 4th year senior for getting into the various medical specialties.


So, now that you’ve chosen your medical specialty what kinds of things can you do to make your chances of matching better? And what’s it like applying for these programs even though you can’t outright pick them, and conversely, they can’t directly pick you? How does this crazy system work? More below the fold…

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Credulous medical reporting

Science and medicine reporting is hard. In this space we’ve dealt with some of the problems that arise when “generalist” reporters try to “do” science and medicine. And now, CNN has shut down its science unit. Given the increasing complexity of medical and scientific knowledge, this is very bad news.

As a fine example of poor medical reporting, let’s look at a local business magazine. The article, called “The Fatigue Factor”, is about fibromyalgia, and manages to get it wrong from the very beginning.

Some medical reporting is destined to be bad simply because the topic is too complex for a generalist reporter. But sometimes, a reporter succumbs to journalistic sloth. In this story, for instance, if the reporter had spoken to a recognized local expert rather than a self-proclaimed expert, she would have written a much different article.

Let’s start with the headline:

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H. influenzae—it ain’t the flu, but it’s still pretty cool

This was first posted at Science-Based Medicine on Monday, but I can’t seem to keep myself from cross-posting. –PalMD

I’ve been thinking about an interesting organism lately, an organism that illustrates some basic principles in science-based medicine.

The organism is called Haemophilus influenzae (H flu), a gram-negative bacterium discovered in the late 19th century. H flu has a great story, both in historic and modern times.

The brilliant microbiologist Richard Pfeiffer isolated H flu from influenza patients in the late 1800’s (hence its name) and for many years, it was believed to be the cause of the epidemic illness, and when the flu pandemic of 1918 hit, researchers worked tirelessly to develop anti-sera against H flu.

But some things weren’t adding up. As thousands died of the flu, doctors were isolating H flu from victims, but also other virulent bacteria such as Streptococcus pneumoniae. Influenza was decimating military camps, and was seriously degrading our ability to fight in WW I, so military bases were a focus of research. Doctors looked for H flu in patients, but could not find it consistently. For example in Camp Dodge, Iowa, an autopsy series showed H flu in only 9.6% of victims.

Some researchers were focusing on something else.
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