Current Issues: VAC

V.A.C. is also known as vacuum assisted therapy. This treatment involves placing a foam dressing on the wound that is then attached to suction. The wound is then suctioned continuously for the first 48 hours, and then intermittently thereafter. In theory, the procedure hastens cleaning by removing harmful substances including bacteria. The 11 major studies advocating V.A.C. have major flaws however. For example, many of the studies showing a benefit of V.A.C. compared the device to older therapies such as wet dressings. Recently, however, the therapy has come under attack and has been shown to be not as effective as other therapies and in some cases may be more harmful in subjecting the wound to suction. In addition, the device is costly, and therapy requires each patient to be immobile and attached to device for long periods of time.

There are many issues that may be addressed in this case. The primary one is our enthusiasm to jump to newer therapies that may not be fully studied. Is it our obligation to adapt to the newer therapies once the research has begun to show a benefit. Should we remain with the older therapies until definitive research is available. If we remain with older therapies, are we negligent in not using what may possibly be the best treatment?

Case 4

A diabetic patient presents with a foot ulcer and the following Xray. What is the recommended initial treatment?

A:


IV Ciprofloxaxcin for 48 hours,

followed by 12-14 weeks of oral therapy may be adequate therapy for a diabetic foot ulcer that involves the bone. Of course, the therapy may need to be changed to be specific to the culture and sensitivity obtained. Surgical treatment may be required if there is not adequate vascularization or if there is not adequate response in the bone involved.

National Healthcare

National Healthcare

Michael Moore's Sicko is a treatise for a National Health Service Program. It sounds good on the surface, to use tax dollars as a means to improve the health of the country. However, if you are an otherwise healthy individual, why should you participate? Granted, as a physician, you applaud the implementation of a plan that would allow everyone the access to health care. However, maybe you feel, as a new graduate at the age of 27, that you shouldn't be paying for a new defibrillator for Dick Cheney or for Bob Dole's erectile dysfunction. Also, with an eye towards history, maybe you think by paying for a health benefit now, you will be paying for a program that will be phased out by the time you really may benefit. But, in a civilized society, what is the option? Do we move towards a nationalized health care system or not? So often these topics are infused with special interest groups and millions of dollars, but as a purely ethical question, is health care a right?

Case 3

This patient comes to your ER complaining of joint pain. On further questioning, you also find the patient complains of pain on urination and matting in her eyes in the morning. What is the diagnosis?


A geographic tongue is a loss of pappillae in the tongue that often changes with time. In general, the patient is asymptomatic, and the patient has spontaneous resolution. The georgrapic tongue may be due to psoriasis, Reiter syndrome, lichen planus, herpes simplex virus. systemic lupus erythematosus, drug reaction and leukoplakia. In this case, the other symptoms of arthritis, urethritis and conjunctivitis comprise the triad known as Reiter syndrome. In a related note, the medical establishment is moving away from the term Reiter syndrome as it is named after Nazi physician who described it after experimenting on unwilling patients during World War II.

Issue 2

Anticoagluation Medication



Often, treatment with anticoaugluation drugs are recommended in individuals to guard against clots resulting in heart attacks and strokes. Aspirin has been advocated as a useful initial guard against these devestating diseases. Recently, however, many NSAIDS such as VIOXX and Celebrex have been shown to actually have an increase in CVA's and MI's. One theory is that ASA inhibits platelet coagulation. Any other NSAID the person may be taking interferes with the action of ASA. Thus, any NSAID will intefere with the action of ASA and result in more cardiovascular events than ASA alone. However, many of these patients suffer from pain, such as the significant pain asssociated with arthritis. If a patient is taking ASA, would you recommend any pain reliever to further decrease the pain experienced more than the action ASA itself would result in. If so, which pain reiever would you recommend in this hypothetical patient?

Case 2

What are the likely responsible organisms?






Staghorn calculi are often the result of urea producing organisms such as Klebsiella and Proteus.

Case of the Week 1

Which group of people do not get these fractures?
The fracture of the 5th metatarsal is known as a Boxer's fracture. Ironically, boxers do not often get this fracture, as they know how to land a punch.

Current Issues 1

I wanted to change this around a bit and make it a bit more accessible.

Current Issues

The USA Today rerports the sutdy of a 14 month examination of behavioral therapy versus pharmaceutical treatment here. The Journal of the American Academy of Child and Adolescent Physchiatry reports that children with ADHD often recover in a few years of treatment. Behavioral therapy or medication seem to be equally effective. A further interview with Dr. Peter Jensen reveals that the medication offered childred afflicted with ADHD may not necessarily be effective.

In primary care, we are often asked to prescribe medication for children thought to be afficted with ADHD. How do you feel about prescribing medication to treat these children?

Bariatric Surgery

Last year, over 175,000 patients had bariatric surgery. This surgery is generally seen as a last resort, for people with a BMI over 40 or over 35 and a co-morbid illness. As the surgery becomes more common, I worry about the repercussions. During medical school, I assisted on three gastric bypasses. One had a standard recovery, one had a painful and long recovery necessitating additional surgeries, and the third died on post-op day three. While I know that obesity is a major factor in many diseases and losing weight is incredibly difficult, it must be remembered that this is an elective procedure!

Time summarizes a report by NEJM. Between 1984 and 2002, over 15,000 obese patients were studied, half of whom had gastric bypass. In a mean follow up of 7 years, the group that had surgery was:
92% less likely to die from diabetes
59% less likely to die from coronary artery disease
60% less likely to die from cancer

Another study in Sweden of 4000 patients, half who received surgery had a 10 year mean follow-up. In the 10 years, the study group had:
24% decrease in all cause mortality
58% increase in mortality from accidents and suicide

I don't know what the answer is. I don't want anyone to die from an MI, or to suffer from diabetes complications. However, I'm not sure this is the answer. Even with the nutrition and psychological counseling most bariatric centers provide, surgery only perpetuates the idea of a quick fix. In addition, like most of the treatment in medicine today, the cures have side effects that may be worse than what they are treating, and that can't be taken lightly.

Cure for the Common Cold

I enjoyed this recent article by the NY Times regarding OTC meds in kids. However, like the AAP, I feel even new warnings will not go far enough.


I'll admit that I hate being sick. If I could, I would take NyQuil starting at the first sniffle and wake up when it was over. However, it often doesn't work out that way. Many times I'm stuck working, or at the very least I'm stuck with the symptoms. I don't like the symptoms, be it cough, congestion, runny nose, aches, fever, exhaustion, well, you get the idea. I don't expect any one else likes it either. Unfortunately, most adults get sick a few times a year, and, even worse it will most likely be a virus. This means that you can't really do anything about it. You can take antibiotics that won't help. If you get the flu and catch it early, you can start tamiflu which may decrease the duration by one or two days but comes with fun side effects like psychosis. Generally, the option is symptomatic treatment such as nyquil, dayquil, tylenol cold, whatever.

For reference, I never buy the brand names. If you are comfortable doing so, read the ingredients and compare with the much cheaper generics. Same medication, same effect, less dough.

So, in general, adults want at least symptomatic treatment. What happens when your kid gets sick? They feel miserable too. They also tend to get sick much more often, since they are building up their immune system to the more common bugs. Should kids get the same symptomatic treatment?

This blog isn't meant to diagnose or treat anyone, especially the peds population. I only bring this up because I think it is natural for parents to want children to suffer less. This may work for children over 8, it may even be appropriate for children over 2, but symptomatic treatment is generally not acceptable for children under two. It makes no sense to challenge this delicate population with a medication unless it is ABSOLUTELY needed. By all means treat your child as appropriate, but otherwise wipe the snot, listen to the cough, put up with the diarrhea as long as the child isn't becoming dehydrated.

publix

So, I got a piece of mail today. Publix thought enough to spend money on a piece of mail that would inform me of their new policy of free antibiotics. Purely on their own initiative, Publix has decided to provide the free world with needed antibiotics. I should be happy. Obviously as a physician, I should be ecstatic. I must routinely prescribe antibiotics for sick individuals with a bacterial infection that require antibiotics but can not afford them.

Then why does it tick me off???

Because Wal Mart came out with a plan 6 months ago to provide low cost generic drugs to the population for $4? Or because now people will expect antibiotics to rain from the heavens as water.

I'm a physician. As such, I have pursued a craft that allows me to follow my internal calling. My calling is to help as many people as possible. Now I will have the poor as advantaged as the more insured to request and demand antibiotics for every viral infection that occurs.

First off, how many people that really required antibiotics have not been able to afford them?? I have worked at Grady in Atlanta, and in South Central Los Angeles. If you need antibiotics for a life threatening infection, you will receive them no matter your ability to pay.

So who is this appealing to? The new initiative is appealing to people who want antibiotics for any infection that may occur. Instead of requiring a sacrifice and an attention to health, antitbiotics are now free. I do not mean to isolate the poor, who will now have free antibiotics, I mean to isolate all who do not see antibiotics as a VERY expensive treatment. Anyone with a viral infection (cold, cough, sniffles) has the right to symptomatic treatment. They do not have the right to an antibiotic. In contrast, people who are quite well off do not have the right for an antibiotic, no matter how much they can pay. If you have a viral infection, you do not need antibiotics!

But I still have patients that demand them. Why do I refuse? Why do I continue to educate, knowing that I'll just get a poor evaluation on whatever JHACO score of the minute exists? I know they'll go across the street, so why do I waste my time? Because I know that antibiotics that are unnecessary lead to resistance. I know that a patient that requires a z-pack 3-4 times a year for their "sinus infection" will at some point actually need antibiotics, and will therefore be unresponsive to a Z pack. Amoxil is already a moot point thanks to enough parents that want to cover any eventuality. How many more will remove from our arsenal as people demand them? Luckily now, at least they may be free.

Panacea and Hygeia

In ancient Greece, Asklepios was the god of healing. In fact, the classic symbol of medicine is a staff around which is wound one snake, the staff of Asklepios. Asklepios had two daughters, Hygeia and Panacea. Hygeia was the guardian of health and champion of common sense practices as the basis of wellness. Panacea, greek for "all healing" was primarily responsible for the use if interventions such as surgery and the use of chemicals with curative properties.

Today there is the continued dichotomy of Hygeia and Panacea. As a physician, I am more likely to be a hand of Panacea. Public Health is the acting arm of Hygeia. I see many patients each day, and I would like to think I have a benefit in lives. Hygeia is at an entirely different level. No matter the amount of work I do, the number of lives I save will never be equal to that saved by simple practices such as mosquito spraying, water filtration or appropriate garbage treatment. Hygeia has the possibility of saving untold numbers of lives. Imagine being at the forefront of the discovery of the link between fleas and the bubonic plague, or contaminated water and cholera.

Unfortunately, the relative importance of Hygeia versus Panacea has never been reflected monetarily. Treating individual patients is more lucrative. A surgeon that removes one tumor or a physician that prescribed one round of chemotherapy is rewarded much more than the number cruncher that connects bladder cancer with analine dyes and then increases the protection of those that work with the dyes, possibly saving thousands of lives.

The most pressing problem with Public Health is that it is designed to self-combust. With each new disease outbreak, the populace presses for an answer. The tireless soldiers of public health may isolate the contagion and then work endlessly to inform the public and reinforce preventive measures. If their work is successful, they are put out of business. The disease in question decreases in prevelence, public worry decreases, and funds dry up.

Such is the case in Winston-Salem. The pathogenesis of syphilis is treponema pallidum, and treatments have been available since 1908. We know how the disease is spread. By all accounts, syphilis should have gone the way of smallpox by now, almost 100 years after the definitive organism was found and a treatment made available. Unfortunately, syphilis is an STD, and as such, will always have a stigma. Not allowed in popular conversation, syphilis is a disease that must not be advertised. In addition, it is a disease that most people assume has been eradicated and so they do not seek medical care for the treatment of what is seen as a disease of an old world. Combine this with HIV, and syphilis is on the rise. In Winston-Salem and 9 other N.C. towns, syphilis rates have been 10-20 times the national average.

With the high rate of syphilis against national averages, the public health threat was noticed. Money was funneled into syphilis education and an education campaign was instituted to inform the population of these affected areas. As you can see from the graph, in 1998, money began to be funneled into educating the public in Winston-Salem about syphilis. The results were remarkable. The rates of syphilis dropped to less than 1 case in 100,000.

What was the reward???

Money spent towards education about syphilis has been moved elsewhere. As such, the rates will begin to rise. Money spent towards Public Health was successful, so much so that it will now be removed, to the detriment of this area.

However, the issue is not as cut and dry as it may seem. Yes, the disease is now on the rise, but the money is now being spent in other areas of the country where it will begin to decrease. In addition, continuously reminding a population with advertising of a disease will begin to have less of an effect as time goes by. Would this increase in syphilis (and thus the activities responsible for same) have occurred anyway, just as a corollary of our brains' tendency to focus on that which is new? Are we destined to always play with prey in the microbe predator-prey relationship? Does Panacea exist to save the individuals that fall in the cracks of Hygeia?

Torture from the Experts

Say what you may about the AMA, but the organization has gone on record against docs participating in torture in this war on terror. The APA, however, has not been so steadfast. Salon has uncovered psychologists that have been working to develop new and improved torture methods. These methods include waterboarding that simulates drowning, and a dog box designed to foster "learned helplessness." Many of these studies have been variants of experiments used in the past to help protect American soldiers from torture. Vanity Fair and the New Yorker have corraborated the story.

While the AMA has an explicit policy against participating in torture, the APA does not. This topic will likely be a popular one at the APA's annual meeting August 10th. President Koch has selected 10 psychologists to draft a statement, however 6 of these psychologists have direct ties to the military and 4 had been involved with detainees at Abu Ghraib or Guantenamo. It remains to be seen if the new policy will prohibit members from participating in torture.

A central tenet of medicine (psychology included) is "First, Do no Harm." Any participation in developing or implementing torture goes against this most basic of ideas.

Ether

In 1842, Crawford Long became the first physician to use ether as anesthesia. He used the medication to remove a tumor from a patient's neck. Crawford Long was born in Danielsville, Georgia, shared a room in college with Alexander Stephens, and his cousin was Doc Holliday.

In his early twenties, Dr. Long was a single partier. He noticed at many of the ether parties he attended that most participants would bang themselves up quite a bit. Despite developing large bruises, the partiers felt no pain during these frolics. From this recreational use of the drug, he wondered if similar benefit could be found medically. The rest is history.

SNAKES!!

The other day we had a guy come in after being bitten by a copperhead on his hand. The pain and swelling were spreading rapidly, making him a candidate for antivenin. I had never realized it, but that is an amazing expense. Consider that the average dose is 6-20 vials, at a cost of approximately $1000/vial. So, consider: you are out mowing the grass and are bitten by a snake. Next thing you know, it's a 20,000 bill just in CroFab. Of course, in my instance, practically seeing a snake may lead to an MI, so my costs may vary.

bovie

The Bovie electrocautery tool was developed by William T Bovie between 1914 and 1927. Dr. Bovie was an inventor with a doctorate in plant physiology. Dr. Bovie worked closely with Dr. Harvey Cushing at Harvard University to develop this tool used to pass high frequency electrical currents in to tissue. The first use of the Bovie knife was in 1927 by Dr. Cushing and was initially used on previously inoperable brain tumors. Most physicians today have been exposed to the Bovie, however Dr. Bovie himself did not benefit. He sold the patent on his machine for $1 and was not granted tenure at Harvard.

Unusual Presentations

A 45 year old hispanic female reports to the ER complaining of right sided abdominal pain. This is her third visit to the ER. The first visit was by ambulance one month previously, and she was discharged after observation and treatment for nausea and constipation. Labs were insignificant except for a UDS of methamphetamines and opiates. The second visit occurred two days later, with treatment of nausea and discharge. This is her third visit, she reports nausea, constipation and abdominal pain. Physical exam shows minimally distended abdomen that was tender to palpation. Labs were ordered, as was an abdominal CT. Labs were essentially negative, including the HCG. However, patient did have cholelithiasis and nephrolithiasis. At this time, patient is discharged with pain medicine and follow up.
Now she is in your ER the next day complaining of right sided abdominal pain. She has a history of diabetes and hypertension. She has had one laparotomy and an appendectomy. She denies taking any medication but the pain medication given. Vital signs are stable. Abdomen is diffusely tender, worse over the right lower and upper quadrant. What do you do?

Patient was discharged with follow-up, and returned the next day. At this time, she was admitted for pain control then discharged. She returned once more and expired.

I'm sure most people have heard the story of Edith Rodriguez and King-Harbor. I present this, not to discuss the many socio-economic factors involved, but to highlight the medical pathology. The autopsy report is at: http://www.latimes.com/media/acrobat/2007-06/30524153.PDF
According to the autopsy, the patient's death was caused by a ruptured colonic diverticulis. This is an interesting presentation, considering the patient seemed to only complain of right sided pain, and most cases of diverticulits result in left sided pain. Also, the case is a classic example of not "marrying a diagnosis." The patient did have another cause for her pain- multiple gallstones. The CT, a major tool for evaluating the abdomen, also seemed to be otherwise negative from the report, so how should further evaluation proceed? On ER visits and during the admission, should she be expectantly managed with serial exams, or would an ex lap have been appropriate? Assuming the exam did not show an acute abdomen, would surgery have been recommended, or would medical management with pain medicine and a surgical follow up have been more appropriate. Did the patient continue to not exhibit a classic acute abdomen? Were there signs of infection that we would have expected with diverticulitis?

We do not have information other than the autopsy and news reports, and cases are easier to examine in hindsight. However, often in medicine, the way to learn is from your mistakes. Right sided pain due to diverticulitis is an unusual presentation, and it is also wise to note that diverticulitis can lead to bowel perforations and can be fatal.

Sermo

WWW.Sermo.com is a website that has been up for about nine months. Sermo means conversation in latin, and is meant to be an online version of the doctor's lounge. I've been on it for a few months, and have enjoyed it. Not only have I been able to offer up a few cases and get some feedback, but I have been able to comment on cases others have brought up. This is something I have missed. I'm an ER doc in a few smaller cities, and for the most part, I'm pretty much the only doctor around. Sometimes during the day, there are a few others during lunch, and someone is always available for a consultation, but it is different that just having someone to bounce ideas around with in a casual atmosphere. I generally log on a few times a week (or more!) and take in the newest posts, then follow up on some of the more interesting posts I've commented on recently. In addition, I like to share interesting cases or observations.
Sermo makes money at this time by allowing financial clients to observe these conversations, and to occasionally create posts of their own. For now, this has been fairly unobtrusive. It is interesting though. Apparently there is a huge market on doc's opinions of certain drugs- which will be taken off market, what will be approved, etc, and stock decisions etc are made accordingly. There is some discussion to allow pharmaceutical clients access, but it remains to be seen how this will happen.

Medquizzes

Hello. Welcome to the new website. This is just an opening blog to say hello. Welcome to the new site. Please feel free to offer up any suggestions.
H.