Grand Rounds V. 5, No. 27

Now that I'm posting with a little more frequency, I submitted one of my recent entries to the bloggers' grand rounds. They're up to Vol. 5, No. 27 over at Code Blog, and since I was linked, I'm glad to be able to send some readers in that direction. Enjoy this week's best in medical blogging.

Back at Clashing Culture

It's been a little while since I've posted anything at the science and religion blog Clashing Culture. But my co-bloggers over there have kept the place free of cobwebs. I spent a little bit reacquainting myself for the ever-present creation vs. evolution issue this weekend. There's a Texas School Board meeting this Friday to decide science standards for the next 10 years. And of course, some last minute insertions by the board's chair have the scientific community worried that creationism will find its way into science text books... It turns out that the chair of the board Don McLeroy has written an anti-evolution book Sowing Atheism and calls clergy who accept evolution morons. Sounds like the typical anti-intellectual name calling that makes this issue so frustrating to folks like me who just want to get along. In not very related news, one of creationism's champions, Ken Ham, has taken to leveling hypocritical complaints about radio interview ambushes. Read more at Clashing Culture.

Read more about the Texas School Board issue here and the Clergy Letter Project here.

Thoughts and Prayers

There are some news stories that demand your attention. Those of us who gather information online are used to seeing the eye-catching news stories (like in the column of story links on CNN's webpage) that keep you from surfing to the next site. It says a lot about the media that headlines like Woman on horse shops at Target are adjacent to 3 Oakland police officers killed in shootings. I admit that I typically avoid the news stories about killings equally with the stupid sounding ones. So why did I read the articles about the tragedy in Oakland?

I think it was the personal connection.

1. In my career as an EM doc, I will see plenty of shootings.
   
2. I've already been a part of care for a man down.
   
3. I admire how firemen, police officers and medics put themselves at risk for a greater good.
4. In the recent match, I ranked the emergency medicine residency at Highland Hospital (in Oakland) very high on my list.

That I had already imagined myself living in Oakland, working at Highland and being a part of the trauma team that received victims like this struck a chord with me. Unfortunately this is not the last time I will face a situation such as this. Part of me believes that reading about this, reflecting on it and greiving in absentia will help me prepare for when I'm the one applying pressure, pushing fluids and wheeling the patient to the operating room as soon as possible. Would I also be among this group? Police officers, ministers, community organizers, political leaders and concerned citizens are gathered all around Oakland in groups shown in this photo. This scene just happens to be in an ER waiting room that I've walked through. A different kind of mourning was no doubt going on behind the waiting room walls.

Photo: Justin Sullivan/Getty Images

Is there is also a role for EM docs outside in the community talking about violence, safety and emergency response? I'm sure the answer is yes. I wonder what that would look like.

In Case You've Not Seen It...

This video has surfaced at several of the blogs I read. In case YOU haven't seen it, this is worth a few minutes of your time...



There's really no reason for me to post this here except that I tend to post things that I think are interesting...

Match Day

We have 3 months to finish medical school and move to New Haven. Ready, get set, GO!!!

Is Match Day Overrated?

I think it is. We're waiting the extra hour to check my results from the comfort of home. So be patient, family! Since I believe in both free speech and the possibility of reform, I went ahead and listed a few reasons why the emphasis on the Match (even I use a capital letter) could be misplaced. You'll have to go over to The Differential to read it. And yes, you will still need your free login.

One of my blog friends recently asked me if the same computer that compares my rank list with 30,000 other lists and the lists from thousands of programs was the same that made Bowl Championship Series calculations. I am inclined to think that this present figuring very well could be an off-season task for the BCS brain. Like the bowl placements, there will be folks happy with the outcome and folks that are not.

By the way, which are the other professions than medicine that use similar systems for job placement as that for medical residents?

• The Military
• Professional Sports
• Anything else?

Match, Smatch... They should just call it what it is. Today is Draft Day!

Gifts From Patients

Last week, one of my patients gave me some elk jerky cured from a buck his 14 year old grandson shot last season. Read about my experience at the Medscape blog. Of course you'll need to use or sign up for a free login to read it.

Better Than Stem Cells

I don't mean any direct offense to John Marburger by re-posting this cartoon by David Horsey, but today's stem cell announcement reminded me just how lame science had become in the executive branch over the four years.


The coolest part about Obama's speech today was not the stem cell part. It was:

Promoting science isn't just about providing resources -- it's also about protecting free and open inquiry. It's about letting scientists like those who are here today do their jobs, free from manipulation or coercion, and listening to what they tell us, even when it's inconvenient -- especially when it's inconvenient. It is about ensuring that scientific data is never distorted or concealed to serve a political agenda -- and that we make scientific decisions based on facts, not ideology.

That's the part that will actually change how politics uses the information science offers.

Bad Economy = Abuse

It troubled me to learn that rates of non-accidental trauma has risen by more than 2-fold at Seattle Children's Hospital. Non-accidental trauma is the medicalized word that describes injuries incurred by children that are the result of abuse. This trend is evident across the country.

This reminds me of a theory I once read about kids born in the Great Depression. When money got tight, parents fought and drank more, leaving children bewildered and often alone. Many kids' childhoods were remembered as periods of unpredictability; in their high school years they lacked direction or a sense of confidence.

Childhood depends on a sense of security. I'm guessing there are a lot of parents who will need to work extra hard to provide that emotional support even as the financial backing has failed.

The Open Laboratory 2008

As you may recall, one of my posts from last year was selected for the Open Laboratory 2008 compilation, which gathered 50 posts from the science blogoverse for a print edition that you can buy. It may seem backwards to take internet material and print it on paper, but there's a good reason for it. The collection's proceeds go toward supporting ScienceOnline'10, a science blogging conference next January. The book is also a nice way to see how bloggers make legitimate literary and journalistic contributions to whatever conversations are being held on matters relevant to science, society and beyond. I've had only a few sciencey things published thus far, so will probably permit vanity to reach into my wallet to buy a print version. It's also available in .pdf. And if you wish to read each post in its original context, each one is linked at A Blog Around the Clock. If you do buy it, do so from lulu.com. The conference organizers get more funding that way.

What's Wrong?

If you couldn't tell from my post yesterday, I approve of the president's impending action to lift funding restrictions on human embryonic stem cells. While, I've not had the time to post much about this issue, I have been reading others' takes. The Washington Post has a nice blog/column about religion and gives good time to science and religion bits. A piece likening stem cell ethics to organ transplantation caught my eye, because I've thought about this connection before and wanted to read what an 'expert' would say about it. I'd recommend you check out the article by Susan Brooks Thistlewaite, and the counterpoint by Thomas J. Reese, but what I did a doubletake on was this image:
This type of tube is commonly used to store frozen cells, including stem cells. The tube is thawed, because the red media is clearly not a chunk of ice. I'm thinking the photographer wanted an illusion of pipetting into the vial. But in the picture, the scientist is actually pipetting into the cap. There is a good chance that the diagonal tube is a forceps (tweezers), but with the cinematic techniques used so often on CSI and other science-enriched TV shows, I'm still putting my money on the theory that we're supposed to think there's pipet action going on.

Which is all to say, LOL.

This Just In!

Obama to Lift Ban on Funding for Embryonic Stem Cell Research.

Evidently, he will sign an order on Monday to reopen federal funds for ES Cell work. Read all about it in the Washington Post.

Access to Care

The five or six readers who have stuck with me these last few months and haven't banished me from their readers will know that the claim to health care is one of my personal, ethical and political interests. Which reminds me that I need to read up about Health and Human Services nominee Kathleen Sebelius. But one of the reasons I've not been able to do my homework on her, or write in this blog is the Ethics in the ER course I'm teaching this quarter. I've been using a blog to move the discussion beyond the classroom. I think it's been working. The students who post comments have shown great insight and offered poignant reflections.

Anyway, while researching this week's topic, I ran across a couple of media clips that could be interesting to folks who think health care reimbursement needs to be reformed. Remember Harry and Louise? They were the middle class couple in the mid '90s who didn't take very kindly to the Clinton health care plan. Last year, a consortium of lobbying groups turned that technique on its head. I think they even found the same actors. It's worth heating over to the Ethics in the ER blog to check them out side by side!

Rounds!

My latest essay at The Differential makes the rounds on rounds. For this emergency medicine bound medical student, I am glad that rounds will not be a big component of my future career. They make me dizzy.

Rounds is an element of medical culture that is core to medical education, but in my opinion is rarely done well. Fortunately for you, I don't go into my criticisms in this piece...

If you haven't yet, you'll need to sign up for a free account with Medscape. Sorry about that. And if you have had trouble with the links before, I think that problem's been fixed, too!

Hospital Diversion

Is it wrong for a university hospital to turn away a patient because he doesn't have insurance? What if it was a kid attacked by a pit bull? There's been a big splash in Chicago about a child with dog bites to the face being sent home to follow up at a different hospital. The situation has drawn criticism from the American College of Emergency Physicians, but the University of Chicago is defending its position to divert uninsured patients. This story's juiciness is enhanced by the direct connection between Michelle Obama and hospital’s Urban Health Initiative (UHI), which has as its goal to divert non-emergency patients away from EDs. It’s supposed to make the system more efficient by freeing up ED staff to treat the most urgent cases. But ACEP likens it to dumping unprofitable patients.

This creates a tough challenge for me. As the newspapers and ACEP present it, this policy clashes with my reasons for choosing a career in emergency medicine. But I've also held that innovative solutions for improving access to medical care should be able to be implemented from within the ED. I didn't hear much about the UHI when I interviewed at the University of Chicago. But in a recent email to applicants, the U of C emergency medicine residency program director did say that training will actually not be very much different because of the University's policy. This makes a lot of sense, given that training occurs at four hospitals around the city and there are always patients in urban ED waiting rooms. And as Ben points out below, it is important to see both sides of this story. But the impression of the program will suffer. Is that a risk I want to take in assembling my rank list?

If you're in my ethics class, we'll be focusing on this issue in two weeks.

Pet Therapy

A few months ago, we had a different sort of patient show up to the psychiatric emergency department. It had brown hair, floppy ears and four legs.

Read about it at my article on the Medscape blog. You'll need a free Medscape account if you don't already have one.

Residency Interviews

Finished with interviews for 3 weeks and I'm still brimming over with thoughts about the process. This time, I'm concerned about my horrible carbon footprint secondary to traveling to so many cities. Read about it at The Differential.
You may need to sign up for a free account.

NTSB vs Flight Medicine

There are a few emergency medicine programs that require residents to fly on helicopters. I will not be ranking those programs at the top of my list. MedEvac is an important part about emergency response and I respect the folks who fly a great deal, but I'm not sure it is a necessary part of my hospital training. Especially when more that 35 people have died in the last year on medical helicopter flights. The National Transportation Safety Board is hearing testimony about this issue this week.

Privacy

I'm finishing up preparations for a lecture on confidentiality and privacy for my Ethics in the ER course Wednesday, and came up with what I think is a great hook for discussion about a topic that is usually greeted as dry by many in the medical field. Here goes:

Who remembers their online HIPAA training course? If your experience is like mine, the topics of privacy and confidentiality seem like boring topics. This week on the blog, several of you posted very interesting accounts of dilemmas concerning confidentiality. If you didn't get a chance to read them yet, I'd encourage you to do so. So perhaps privacy isn't as dry as I first thought? Let's say you're not convinced by your classmates' challenges.

I'll step back a bit. Our medico-legal system may reinforce privacy as a topic learned by rote and repetition, but it gets a lot more interesting when you consider that this issue is at the core of the arguably most controversial Supreme Court ruling in the last half century. Can anyone guess what I'm talking about?

Roe v Wade was decided not based on statutes governing assault, or autonomy, or even Aquinas' principle of double effect. You couldn't guess that from the expressions, “right to choose” or "right to life."The case was decided on matters of privacy. Roe v Wade held that a woman's decision of an abortion falls well within privacy afforded by the 14th Amendment and the Bill of Rights. And since abortions these days are almost always in a medical setting, it's easy to see how the privacy from the state bleeds into the confidentiality afforded by patient-physician relationship.

If you are in the course and happened to find this post early, consider yourself a planted answer if no one responds to my question!

Straight from the Medical Record

Sometimes information in medical records cracks me up. Take for example these excerpts from a note for a patient I helped care for:

Interval History:
Had a good day, with an especially lucid morning. Enjoyed throwing rubber chicken into sink. Family pleased with progress.

Exam:
NEURO: Continues tremulousness, is mostly non-verbal (per family, is exhausted and getting cranky after busy morning). Throws rubber chicken onto attending physician and into sink.

ATTENDING STATEMENT:
I personally saw and evaluated the patient. She did seem to enjoy throwing a rubber chicken at me and into the sink. I discussed the patient with Dr. XXX. I agree with the findings and plan as documented in his note.

The moral? Rubber chickens never fail to amuse.

Critical and identifying information has been changed to protect this patient's privacy.