Grand Rounds (4) 38

When Dr Crippen was a hospital doctor, he enjoyed rushing round to emergencies and officiating at cardiac arrests. Just like on television except in real life most patients do not survive cardiac arrests.

Dr Crippen was particularly addicted to ER as are a lot of British doctors. What would Mark do? we always asked when there was an emergency. Sadly, suddenly Mark was no longer with us. Medical life has not been the same since.

Happily, Dr Nick Genes, the founder of Grand Rounds, is still with us and still in an ER if not in the ER.

He has been taking a look at the "Demand a CAT scan" campaign in the USA. Can you imagine advertising copy like this in the UK?

"5 out of 5 lung cancer survivors recommend a CAT scan"

Nick goes on to say: "Ok, so, remember when those outrageous subway ads asking passengers to "demand a CAT scan" appeared, and prompted me to suspect, offhandedly, that the group behind the ads was receiving funding from GE or another CT-scanner manufacturer? And when the awful truth came out, that the Lung Cancer Foundation was actually funded by a tobacco company -- a firm likely invested in the notion that smoking-related cancer is preventable and thus limits their liability -- well, I fretted that I wasn't cynical enough -- that it would be a far more straightforward and relatively benign conflict of interest if the funding just came from GE.... (Host defence activation)

Let's continue on a happer note, with Dr Nick Riviera from the Simpsons, surely the model of the consumerist physician.

In the UK, Dr John Briffa is promoting diets for the "treatment" of ASD. Anthony Cox at Black Triangle takes a look:

Recently The Daily Mail has reported on the industry that hawks autism “cures” to vulnerable parents. The suppliers of such cures are often critics of MMR vaccine. Edzard Ernst has also noted that providers of alternative medicine are often skeptical of MMR vaccine. Fitting this general pattern, Dr John Briffa is a doctor who has gravitated towards “nutritional and naturally-oriented medicine”, and he is also skeptical of MMR vaccine’s safety. In the past he has written on nutritional approaches to autism. The following is a guest post from Holford Watch. Autism and the GFCF diet

Dr Aust takes a look too in Who needs facts? These vaccine conspiracies write themselves.

"As I write this, Chief PR Man and Publicist of the “New Wave” Vaccines-Cause-Autism-No-They-Really-Do movement, David Kirby, should have done his turn in the House of Lords and be winding up his “free public lecture”. I won’t wish him the stocks and some rotten fruit - that would be churlish - though I might hope his audience includes some of the London-based Badscience fraternity, and/or a few sceptical scientists and doctors.

(Sadly, an audience of rabid mercury obsessives, anti-vaccine nuts, ambulance-chasing lawyers, credulous journalists, nutritionistas, Patrick Holford and Dr John Briffa seems more likely. But let’s hope I’m wrong)."

Earlier in the week, Rachel North, a near miss survivor of the 7/7 London terrorist bombing was talking on BBC Radio 4 (see here) about the now almost obligatory offer of therapy. In the USA, they talk about CISD. Critical Incidence Stress Debriefing. Wow. But does it really help? An American psychiatrist discusses the problem in "I don't need to talk"

A consultant psychiatrist considers a psychiatric registrar personally involved in the King's Cross Fire.

"He became interested in PTSD (Post Traumatic Stress Disorder) and did a fair bit of research on King’s Cross and other disasters. He quoted a number of cases, including the Herald of Free Enterprise disaster. There were those who despite help of all kinds would commit suicide. Many were heroes in that they saved many lives. Yet the feeling that they did not deserve to live eventually overtook them and they committed suicide. What was most surprising was how the group that had counselling generally faired worse, much worse than those without any counselling". (The Cockroach Catcher)

Ian Furst is a MaxFax surgeon in Canada thus working in a hybrid private/socialised health care system. Ian discusses the capabilities of the doctor as businessman.

"I’ve listened to my accounting and financial friends tell me how inept my colleagues are when it comes to economic matters but I stand before you today to say that I’ve seen very few doctors and dentists fall into the social safety net. In fact, I find most have better control over their businesses’ than the typical accountant....." (Ian Furst)

A subject dear to Dr Crippen's heart. The misappropriation of battle-field vocabulary for cancer patients.

"Should patients diagnosed with a deadly cancer be encouraged to fight their disease, or should they focus more on quality of life and the journey towards spiritual—if not physical—healing? The “fight” proponents use the vocabulary of warfare: “vanquishing” the cancer “enemy” with every available “weapon” in the “arsenal.” One problem with this approach is that if you fight and lose, there may be guilt: perhaps you didn’t fight “hard” enough." (Own your own health)

Off to a tropical island (sounds good to me) for "a Saipan blog about life on a tropical island through the eyes of “not your average" eye surgeon. Here find island adventure, food, culture, humor, travel, medicine, and random thoughts about living a fulfilling life (along with an occasional gory eye picture thrown in, just to keep things fresh.)" But, if you bump into David when you are on your tropical island holiday, don't call him doctor.

"As I was driving to work today I passed a field of horse and their gangly-legged babies. The babies were all laying over flat on their sides, twitching their tales. It was apparently nap time in the nursery. My third patient of the day called me a "fucking cunt" when I refuse to give him any narcotics until he produced a ride.
I parked by a Jasmine vine that smelled so heavenly I just wanted to sit there forever and breath that wonderful scent. While I was helping another nurse clean an incontinent, demented 92 year-old nursing home patient she somehow managed to..." (ER Nursey)

An Aero Med helicopter on a safety inspection flight crashed atop Spectrum Health in downtown Grand Rapids Thursday, injuring the pilot and a passenger. An official with the FAA in Chicago told 24 Hour News 8 the helicopter was practising approaches - known as "touch and go" - when it crashed at 11:02 a.m.

The full story here

Ben Goldacre at the ever excellent Bad Science looks at the power of medical bloggers and their role in ridding the UK of another bit of medical wibble. There was not much help from the main stream media.

"This whole issue bas been covered remarkably well, extensively, and in real time, by a wide range of bloggers (extensive symmary of all posts courtesy of gimpy). I think the most fascinating thing about this story is that the mainstream media has been so fawning, encouraging people to part with their cash even as the programme was going under, while the bloggers have been dissecting the scientific evidence, even dissecting the accounts, predicting the financial problems, and reporting on events as they happen...

So far - and I think I should start keeping a proper score here - that’s mainstream media 0, bloggers 10." (Ben Goldacre)

I just got an email news report from a conference, where one of the speakers rebukes pretty much every ophthalmologist for not using a certain type of vision correcting lens. The speaker is a leading name in refractive ophthalmology. But there is one big problem. The speaker is also a consultant for the company that makes the lenses. (Medical Whores)

A family member once told me she was afraid that symptoms she was having indicated something serious, and she was afraid to become like me—"devastated" by illness. Huh? Do I LOOK devastated to you? I thought this was hilarious, and told all my friends. Now they ask things like, "Can you and your devastating illness come for dinner tonight?" or "Do you think your devastating illness can be cured by this chocolate cake I baked?" (Chronic illness can be sexy)

Despite our preoccupation with armed conflicts and the economy, the environment is perhaps today’s most pressing global issue, as it contributes not only to direct effects, but to other situations of concern, such as economic decline and civil disobedience. Environmental conditions contribute to the presence or intensity of many medical conditions, such as temperature-related morbidity and mortality, health effects of extreme weather events (e.g., storms, floods, tornadoes, hurricanes, and precipitation extremes) and their sequelae (e.g., oceanic algae blooms), ecological change (e.g., the potency of certain harmful plants, such as poison oak), starvation, allergies, pollution-related health effects, water- and food-borne diseases, and vector- and rodent-borne diseases. (Outdoor Medicine)

Where is the NHS going over the next few years? As always, it pays to cast an eye across the pond to the colonies.

"In the decades before managed care, patients’ insurance followed them and they could choose any physician and doctor’s fees weren’t set by an insurer, but by what he and the payer agreed was reasonable, customary and prevailing. Referrals could be based on the doctor’s knowledge of the best specialists and prescriptions were written based on what doctors believed best for the patients, writes Dr. Gaulte. All that changed when managed care became the middleman... (Sandy Szware)

The government is keen to let private enterprise into primary health care and encourages GPs to set up shop in supermarkets. What's the experience in the USA?

"We already know that the FTC believes that retail clinics have the potential of "making basic health care more accessible and affordable." This is the worst piece of hocum perpetrated on the American people since the war on terror."
(Retail clinics in the USA)

It seems the baby-boomers are falling to bits. Too much exercise. "A Reuters news item last week reports that "baby boomers" are accumulating wear and tear injuries, and they should consider cutting back on amount and type of exercise they get. The article points out that contributors to injuries are biomechanics, poor flexibility, and "pounding" or stomping down unnecessarily hard when running, jumping, walking, etc" (Jolie Bookspan)

Beneath the "all is happiness in the NHS" government policy, more trouble is brewing.

"A woman dying of cancer was denied free National Health Service treatment in her final months because she had paid privately for a drug to try to prolong her life."

Outrage ensued. The leading UK political swear blogger reached for his dictionary of Anglo-Saxon. The Rant Foundation, led by increasingly famous Dr Frank Rant, did not mince their words either. Meanwhile, Unity, at the Ministry of Truth looked at the real value of these expensive "front line" drugs and then moved on to launch a devastating attack on the motives of Doctors for Reform. Essential reading for those interested in the murk of so called socialised medicine.

Bongi is a general surgeon working in the notorious South African province of Mpumalanga.

... I did something that i had never done before and have never done since. i went into the second operation without examining the patient myself. i just took my colleague's word for it. i then scrubbed in as assistant and told my house doctor to go for it. She did a mcburney incision and slowly worked her way into the abdomen (it was her first appendisectomy so everything was a bit slow). as soon as the abdomen was open some turbid pussy fluid came pouring out... (gee thanks)

"Doc, if anything like that happens to me, or if it looks like I'm going to die, I'd like to donate my organs."

It struck me as rather odd that he would say that. I am sure that he had his own reasons, and I was not all that interested in why, but it made me think... would there ever be a situation where I would seriously consider referring his organs for donation? We often consider patients who present with major trauma and sudden death for organ donation, or those in ICU with head injuries and effective brain death, but patients who die as a complication of elective surgery? ("I'd like to donate my organs..")

What would happen if Precious Ramotswe of the 1st Ladies Detective Agency were to write to Patrick Holford for dietary advice?

"I am a traditionally-built lady, as you know. Most of the time, this is of great advantage to me (e.g., snakes know where I am and I can cast shade for small children), but I am subject to much advice on the topic of weight-loss. Patrick Holford has sent me an email about his eating programme. He exhorts me to “Be proud to be seen in [my] bikini this summer and switch to a low GL diet today”. I have looked through it but there is no mention of cake which makes me a little sad. However, it may be possible to put something together from oats and fruit, although that may make me sadder as it does not resemble cake." Patrick Holford and the Bikini Diet

How do you want your medicine? Socialized and run by the government, or privatised and run by the insurance companies? Would you rather get sick in the USA or the UK? Would the answer to that question depend on whether or not you had private medical insurance?

"...the US system is largely private sector driven, whereas the UK system has got a lot of government initiatives. There are two components, one is the financing the other one is the provision. And in the US you find that a lot of the financing and the provision is by or through the private sector, whereas the UK is driven largely by government or government agencies. In Singapore, it is a cross of the two because the provision of health care is largely private because even the public sector hospitals –the hospitals that are created and run by the government– are run as private limited companies."

Have they been able to get the best of both worlds in Singapore?

A staggering revelation from the United States.

UCLA Medical Center has been bumping legitimate, deserving, long-suffering American organ transplant candidates in favor of yakuza, members of Japanese organized crime groups. The surgeries, conducted between 2000 and 2004, took place while there was a distinct shortage of qualified organs, exacerbating an already-critical problem. (Insureblog)

Insite Injection room

Vancouver Coastal Health (VCH) in partnership with the PHS Community Services Society opened North America’s first legal supervised injection site (Insite) scientific research pilot project in September 2003. Since opening its doors, Insite has been a safe, health-focused place where people can go to inject drugs and connect with health care professionals and addiction services. It is an integral part of Vancouver Coastal Health’s continuum of care for people with addiction, mental illness and HIV/AIDS in the Vancouver community.

The Canadian government did not approve and passed the Controlled Drugs and Substances Act to stop it.

Canadian Government Drug Policy

But the battle was not over. Off to the Canadian Courts. How independent of government is the Canadian judiciary? Is Montesquieu still remembered in Canada? Find out what happened from Canadian Medicine on 28th May, 29th May and 30th May. It is worth reading all three posts, in full, sequentially.

Don't ever be rude to the waitress. You never know where you might meet her next...
Dr. Jan Gurley is a Board-certified Internist physician and the only Harvard Medical School graduate to have been awarded a Shoney’s Ten-Step Pin for documented excellence in waitressing. Having achieved this pinnacle of greatness early in life, Doc Gurley inevitably spiraled downward. Jaded, and afraid of becoming known as a waitressing has-been, she tried years of basic science research in labs (graduating magna cum laude from Harvard), then did a residency at UCSF in Internal Medicine, then received a Robert Wood Johnson Fellowship in epidemiology, public health and public policy. Like many teen-waitress-celebrities, Doc Gurley eventually matured enough to realize there could be more to her life than a polyester apron, an order pad and a pitcher of sweet tea. Today she looks at West Nile Disease

Diagnostic thought processes don't reduce entirely into algorithms, and--I suspect--that an incalculable element of gut instinct goes into every diagnosis we make. Here's a recent example I diagrammed in my journal. I was following a woman we'd admitted onto the hospitalist service with altered mental status. I got a call from the RN that her heart rate was in the 180s.... (Rural doc)

Dear Dumbass on the Internet,

I have just been diagnosed with a herniated disc at L4, L5 and my orthopaedic surgeon is recommending a microdiscectomy. What should I do?

Sincerely,
Fred

The Back Pain Blog is looking at the merits (or not) of surgery.

How do you manage Type 1 Diabetes on your wedding day?

"But diabetes was a part of my wedding day. We did our best to keep it quiet and unnoticed, though, using several tricky methods. I'm like a diabetes wedding magician ... sort of.

First things first: the dress. Wearing an insulin pump is the easiest and least intrusive way for me to take my insulin, and I wasn't about to go off the pump just for the sake of fashion. The pocket itself was underneath the main fabric of the dress, attached to the petticoat. It was sized to be about half an inch bigger than my insulin pump, leaving room for my hands to reach in and access the pump. We stuck a safety pin to the top of the pocket so that.... (Diabetic wedding day)

I'm a 28-year-old writer and college writing instructor trying to balance multiple chronic illnesses (PCD, bronchiectasis, celiac disease, etc) with, you know, the rest of my life....and the good news is that Laurie has come across Anheuser-Busch who have launched Redbridge, a gluten-free beer: relief. After all, if a mainstream beer company embraced the needs of the gluten-free consumer, didn’t that mean others would soon follow suit?

Time now for some international wibble.

"As was first reported by KOB-TV, a group of people in Santa Fe, New Mexico, is trying to get the capital city to ban WiFi from public buildings. They claim they are allergic to electromagnetic fields and suffer an array of physical problems when exposed to wireless technology — symptoms that range from headaches to chest pain, “depending on where their weak spots are.” They say that WiFi in public places discriminates against those with their sensitivity and violates the Americans with Disabilities Act..." (Junkfood Science)

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Thanks to all for your submissions. Next week's Grand Rounds goes tropical. It will be hosted at Marianas Eye