raising my blood pressure

One of the commonest traps for young players is the urgent treatment of blood pressure.  There is a lot of pressure from non medically trained people (especially nursing staff) to pay attention to hypertension.  On one of my  after-hours shifts during the start of internship, a job was left in the book regarding a patient's blood pressure of 170/90.  I glanced at it, said hi to the patient, and crossed the job off.  Thirty minutes later it was rewritten in the doctors' jobs book.  I crossed it off again and went off to theatre.  Just after the case, I was paged with an angry accusation that i was crossing off jobs without actually doing them.  I said that I didn't really care about a blood pressure of that level.  I later saw that an entry had been made in the patient's notes:  "BP 170/90.  Dr paged and said 'I don't care.'".  At this point I learnt the essential order of internship:  "treat the notes, then treat the nurse, then treat the patient".

The first thing to realise is that there is little need to treat a number overnight.  Go and see the patient and assess them for end organ damage:  when called, ask for an ECG and a urinalysis.  Headache does not count as end organ damage, but encephalopathy does;  you must distinguish hypertensive encephalopathy from delirium, dementia, or other causes of AMS.

If the patient is alert and orientated, not in distress, and pain free, you are home and hosed.  It is not a hypetensive emergency.  Write in the notes:

ATSP re BP 180/80.  A&Ox3.  No signs of target organ damage.

Plan:  team r/v mane.

Otherwise call for help.

Everyone has a number that they will treat.  I joke that my number is "10 more than what the patient has", but in reality it is somewhere around 200-220.  In this situation, giving a dose of something safe makes everyone feel good.  I like DHP CCBs;  there are no real contraindications, they work well, and are now off patent.  Cardiovascular Guidelines 2008 suggests amlodipine 5-10mg as the top of the list, and I'm too illiterate to read the rest of the list, although I hear that there's an ACEI somewhere there too.

The only reasons to use nitroglycerin (other than a bomb threat) are myocardial ischaemia and pulmonary oedema, which come under "target organ damage" above.  All it does is raise my blood pressure when I see it in the morning.

takoyaki good

... takotsubo bad.  unless you're a japanese octopus fisherman, in which case you want your takotsubo to be filled with tako to make takoyaki with.

in a medical context, however, takotsubo refers to a cardiac condition typified by recent emotional stress and ventricular apical dysfunction.  life in the fast lane has an excellent overview on this topic.

the reason for the post is hopefully self-evident.

Le Deuxième Sexe

Recently at work we got a new spirometry machine.  The old one looked like it had been built in the 70s and was a classic pencil-point machine which drew on a card;  it is so old that the best picture I can find is a hand drawn thing from the Merck Manual home edition:

These old machines work on the principle of measuring displaced volume;  you can draw a time-flow curve by taking the derivative of this.  The new machines measure flow, typically with a turbine vane or similar.  They then calculate the classic spirometry curve (time-volume) by integrating the time-flow curve.

All of this is a distraction (and I am almost as distractible as the llamadoc himself) from the original point of this post:  the new spirometry machine.  It asks for patient specifics, such as age, sex, height and ethnic group, to be able to calculate predicted lung volumes, since a large part of interpreting spirometry data is comparing to the predicted volume.

To enter sex, it gives the following prompt:  "Male Y, Female N".  This is vaguely reminiscent of Simone de Beauvoir's classic work Le Deuxième Sexe, or The Second Sex.  This book takes its title from the old practice on French IDs of having the sex written as 1 for male and 2 for female.  

Perhaps women will now become le sexe négatif.

FIGJAM

One of the facts of life for junior doctors where I work is term assessments.  These go through all the way until adulthood (ie getting your FRACW*), but the prescribed form is different depending on your level.  I've only been in generalist jobs so far so none of this post applies to specialist training jobs.

Part of the process of evalution is trainee self-evaluation.  There is an episode of Scrubs

which highlights the objectives of this.  The NSW assessment form has a range of categories in which trainees can be 

• clearly below standard
• borderline
• at standard
• clearly above standard

Previously in my assessments I have just ticked myself as being at standard in every category.  As Cox says, I'm not great, I'm just ok.   I've never had anything below "at standard", thankfully, and in most terms my supervisor will pick a couple of categories and put them as "clearly above".  Usually these are the same few topics, and by now I have a clear sense of my strengths and those areas which, while not exactly weaknesses, aren't things areas where I should necessarily be giving tutorials.

This week I was pretty fresh from remembering that patient, so I gave myself a few extra "above standards" for things like clinical knowledge and managing acutely ill patients.   I went to my evaluation...

and my assessor just agreed with me, checkbox for checkbox. 

I wonder if I should have given myself a few more.

* Fellowship of the Royal Australasian College of Whatever.

hey, remember that patient...

I read about the effects of this phrase on emergency physicians at http://thecentralline.org/?p=568, but I'd never really seen its effects.  I've been working in emergency while my life in on hold, and I saw one of the attendings from last week in the office, so I said:

"hey, remember that patient from last week?  Jeremy Smith?"

and I could visibly see him work through the algorithm in his head...

"no, remind me again?"

"85 year old, went into resus for hypotension;  from a nursing home, acute on chronic renal failure..."

"oh yeah"

"anyhow, she had a hemicolectomy and is doing well.  A save."

"not just a save, a resurrection!"

Although calling it resurrection may be hyperbole, the dood was ASA 5E, surviving a condition with 50-90% mortality.  and I owe it all to Bongi and one line in that blog post, which made me think of the right diagnosis a year later.

them's fighting words

Auscultation, once thought to be the exclusive province of the physician, is now more important in surgery than it is in medicine. Radiologic examinations, including cardiac catheterization, have relegated auscultation of the heart and lungs to the status of preliminary scanning procedures in medicine. In surgery, however, auscultation of the abdomen and peripheral vessels has become absolutely essential.

The above is from Current Diagnosis and Treatment: Surgery.

Once upon a time, the lovely folks at PagingDr and I had a polite debate about the usefulness of auscultation in the context of how expensive a stethoscope should be purchased.  I still think that auscultation of the heart as part of the daily examination is not particularly useful - the likelihood of developing an abnormality that can be picked up on auscultation is minimal - but I do not believe that auscultation of the lungs is a preliminary scanning procedure;  it is essential in the early diagnosis of fluid overload and pulmonary oedema, much more than the chest radiograph or any other investigation.

Being a ward resident/intern is quite different between medical and surgical teams.  On my medical rotations, I would politely stand and scribe while the registrar examined and dictated.  I would rarely if ever lay hands on the patient;  the ED resident or registrar did the initial examination, and the ward registrar did the daily examination.  On a surgical firm, the ED resident would often not bother documenting a cardiorespiratory exam, and the surgical registrars were never interested in what someone's chest sounded like, front or back.  After the "wave" round at 7am, I would go back between 8-9 and have a listen to the chests (back only).  I would suggest that new interns on surgical teams get into the habit of doing this, and documenting it every day.

I used to listen to the front, but I never picked up a thing.  This may just be a reflection of my (lack of) cardiac auscultation skills.

Less is more

I was investigating the Walmart $4 prescriptions program, and was somewhat dismayed and angried by the treatment of oral contraceptives. Both ethinylestradiol and levonorgestrel have been off-patent for years, and the various combinations of them are quite cheap. To establish how cheap, I looked it up at a local online pharmacy.

Microgynon is a monophasic oral contraceptive pill which contains levonorgestrel 100mcg together with a varying amount of ethinylestradiol: 50mcg in the original formulation, down to 20mcg in the newest formulations. It's not as though it costs them more to make a product with less EE. Why, then, is the pricing

Microgynon 50	35.97
Microgynon 35	68.97
Microgynon 20	123.99

These figures are for a year's supply. These pharmacies are making a profit on these prescriptions; there is no loss leader effect like with Walmart. There is no government subsidy on these medications.

There are two lessons here:

• Walmart is lying when it says that the reason for $9 OCPs vs $4 other pills is because it needs to be profitable. Logynon-ED (generic of Triphasil) is 34.99 for 12 months supply. Why aren't they offering 3-month supply of Sprintec/Tri-Sprintec?
• Big Pharma is really out to rip us off for all we are worth. Reducing the amount of active ingredient and charging 4x as much? Priceless.

(All prices are in Australian dollars; multiply by .8 to convert to USD.)

h/t to tbtam for encouraging OCP affordability for all women. If I could arrange to send pills overseas to needy women, I would.

but not in Soviet Russia

Outside emergency department, you go down tubes. Inside emergency department, tubes go down you!

Reform, rationing, swine flu, and futile intensive care

Nobody knows how bad Pandemic H1N1 2009 will be when it returns to the northern hemisphere at the end of the year, but it's reasonable to prepare for the worst, especially when the experience in the southern hemisphere has been somewhat difficult:

http://www.telegraph.co.uk/health/healthnews/5887477/Swine-flu-intensive-care-beds-will-be-swamped-experts-warn.html
http://www.dailytelegraph.com.au/news/nsw-act/westmead-hospital-caring-for-25pc-of-swine-flu-patients/story-e6freuzi-1225752418671

(I am not endorsing either the Torygraph or the Daily Terror with these links)

See http://www3.interscience.wiley.com/journal/122520541/abstract for the actual article.

The United States has one of the highest number of intensive care beds per capita in the industrialised world. This may be partly definitional: most intensive care units elsewhere are 1:1, with 1:2 units being described as "high dependency", and partly due to the proliferation of subspecialised ICUs. Current bed usage is about 65%, so there is room for a 50% rise in the number of ICU beds needed without going into bed debt, although of course not all those beds are ventilator beds, and ventilators seem to be what is needed right now.

However, there is the possibility that there will not be enough ICU beds for everyone. Daniel Sokol addresses this here.

In a country with a large amount of government control and payment of healthcare, like the UK or even Australia, the decisions are hard enough to make. When money comes into the equation, it may become even harder.

If a hospital is running out of ICU beds, should it be forced to give charity care through EMTALA for the people presenting with novel H1N1 pneumonia requiring ventilation?

Will a well-insured futile-care ICU patient take priority over a young and previously healthy uninsured H1N1 pneumonia patient?

Will hospitals be able to stay afloat if, instead of filling a cardiothoracic ICU with well-insured and high-paying CABG and MVR patients, it is filled with uninsured and never-planning-to-pay H1N1 pneumonias, each consuming a course of Xigris as per the SSC guidelines, and then staying on the vents forever?

How many patients will be bankrupted by a stay in the ICU, a course of Xigris, whatever fancy new antibiotic they decide to administer, etc?

Even ignoring money/insurance issues, is H1N1 going to be the tipping point, where hospitals decide that they will not take futile care patients into the ICU anymore?

I wonder if these relatives, gung-ho to go full-code, will regret the decision -- or even put down granny -- when they need a vent and cannot get one.

Carrots and sticks

A young man presents to casualties with asthma that seems reasonably severe, with poor oxygenation despite 15mg of nebulised albuterol. He is still tight and has fairly horrible PFTs (FEV1/FVC of 44% post-albuterol) so I commence him on an albuterol infusion.

Several hours later when I discuss the need for admission, he declines and I convince him to at least allow us to wean the infusion before he walks out. He signs out AMA eventually after the infusion is weaned. He then comes to me and requests an albuterol puffer.

I mention that it is available OTC; he states that he cannot afford it. I offer to write a prescription (which reduces the cost from $11 to $5). He states that he still cannot afford it. I decline to provide him with hospital-stock albuterol. He threatens to make a complaint.

I am of the opinion that at the point at which he signs out AMA, he is no longer my patient and my duty of care is discharged. I have told him why I think he needs to remain in hospital and he accepts the risks of leaving. He makes his choices and he lives with them.

Should I have given in? or is this acceptable use of a carrot?

A crisis in confidence.

Most of the time, I'm awesome.  I diagnose, I treat, I bristle with self-assurance and my colleagues come to me for assistance.  I exude it enough that about a month into internship, my senior thought I was a year more advanced than I was, and it pays off;  I get to do procedures that my colleagues of the same level don't get to do because they're not pushy or confident enough.

Sometimes, though, I'm reminded, by myself, of how junior I actually am.   The thing that being a gunner (and I have to admit, I was a gunner to some extent) is that it doesn't prepare you for the real thing, for life at the coalface.  You know how to treat textbook presentations and complications, and you learn how to perform procedures competently by the textbook, but life's not textbook, especially not life at a hospital system that owes its suppliers 40 million dollars.

The patient (unimportant details changed for privacy) was a NESB pleasantly demented elderly person who'd fallen, hit their head, and sustained a blunt laceration to the head.  After doing the falls workup and admitting the patient to the geriatrics service, the end of my shift was coming and the lac, which was nonurgent, should be sewn up before the pt goes to the ward (don't trust geriatrics residents to do any procedures at all).

I infiltrate the would with some 2% lidocaine with adrenaline after being told that bupivicaine (my first choice) is overkill.  The would is explored and after finding that it goes down to bone with no fracture evident, I give a gram of cefazolin and wait for adequate tissue levels since I don't want to be suturing up the galea with a cutting needle and making little microfractures that can become osteomyelitic, not in a 90yo with DM, 3V CAGS and CCF anyhow.

Resus call, resuscitate resuscitate resuscitate.  Stable patient, goes to another doc.

I look for sutures.  My personal preference is for 3/0 vicryl deep, and 3/0 blue nylon at the surface.  There's 3/0 blue polypropene which is an acceptable compromise, but the only absorbable suture on the shelf is 5/0 PDS.  I spent twenty minutes searching the storeroom because the nurses are short-staffed and can't/won't help me (understandably, since they think I'm just being pedantic).

I splash some more betadine down and put down a fenestrated drape.  The patient's child -- a dentist -- moves the drape by grabbing the top surface with their hands.  The area near the fenestration's still good, so I ask for another fenestrated drape to put on top in an X pattern to have a smaller field.  The would edges are freshened into a nice lenticular pattern, they don't come together so I undermine the layer between the galea and the periosteum a little and it comes together with minimal tension.

Obviously too much tension for the 5/0.  or maybe I'm just blaming the suture for me being a clutz, but I've been awake for 17 hours at this point and I get a needlestick.

Unscrub, wash wash wash wash wash.

It's now an hour past home time.

Ask the charge sister to call theatres and get me some 3/0 vicryl.  While this is happening, see the young woman with chest pain sent in for ?PE.

Vicryl arrives.  I look at it and there's no description of the needle, but in my mind-addled state I assume that I'm looking in the wrong spot.  I don't really care anymore.

Scrub in again, irrigate some more, open the vicryl.  IT'S A VICRYL TIE.  What do they think we're doing, vascular surgery?

I unscrub, find some plain gut (a suture I have NEVER used before - I like my synthetics).  Try to work out if it's acceptable.  Decide it's not.  Try and find a reference that supports using nonabsorbables deep (I remember seeing one as a student).  Pt's child complains about how the pt is old and having back pain from the positioning required for the procedure.  On how the procedure is taking so long, and that the lignocaine has worn off (it hasn't).  On how the patient has an open wound on the head.  Never mind that the pt refused to be positioned prone (the ideal position for an occiput laceration) in the first place and I'm only doing this in the left lateral position because of that.  Never mind that I'm now two hours past the end of my shift, we're down a doctor and a nurse, the waiting room is full, and if you want me to actually apply the working hour limits and sign out to the night guy, your parent will not be sutured for another 5 hours.  Never mind that I have myself to look after here.

Anyhow, enough whining.  The crisis in confidence is that I don't know how to make do.  I don't know what's acceptable, what's not, and how to make the best of the crappy resources we're given;  when fighting for the patient to have what's proven by evidence, or at least taught in the textbooks, is more important than keeping the nursing hierarchy onside.

I used to give Hartmann's solution (lactated Ringer's) routinely to all my patients, and the nurses complained.  They like to use gelofusine (a gelatin colloid) for patients, and I don't like to do that.  I now back down, in the absence of clear harm.

It's easy to know what to do when you've been taught it.  It's hard when you just have to fumble through.  Maybe I should have done that elective in South Africa after all.

On actually blogging.

I never published any of the posts in my old blog, but it serves as a snapshot of that terrifying time that is the start of internship.  The name has changed because I'm no longer that cocksure ortho wannabe, and indeed, as the time comes to apply for jobs for next year, I don't know what to apply for.