neon burning up above

I'm just high on the world....  

I quite enjoy teaching medical students, and recently went on a course espousing teaching on the run as a way of teaching.  Thus, when I recently got a paediatric elbow injury misdiagnosed as a fracture I used it as a "teachable moment" to talk about the ossification centres about the elbow.

The first ossification centre to appear in the humerus is the diaphyseal (shaft) one, after which the proximal epipheseal (head) ossification centre appears.  At birth both of these (and no others) should be present in the humerus.  There should be radial and ulnar shaft centres and epiphyseal centres at the wrist.

The elbow, however, is a different story.  An X-ray of a newborn elbow should be basically black.  At about six months of age the capitellar centre appears, and then every two years or so a new centre appears (roughly).  The age isn't particularly consistent, and varies between boys and girls, but the order is quite consistent.

When I was a brighteyed and bushytailed medical student, I learnt the mnemonic CRITOE for the order of the centres:

• Capitellum
• Radial head
• Internal (medial) epicondyle
• Trochlea
• Olecranon
• External (lateral) epicondyle

and this is the version I taught.  It has the flaw of using internal and external rather than medial and lateral, but the biggest flaw is that it isn't exactly memorable;  CRITOE after all does not spell a word.  A carebear paediatrician offered up his more memorable version of this:

Come Rub My Tummy Of Love

which works quite well and is the version I think I will teach in the future.

The elbow injury was duly referred to the orthopods and if you have ever seen The Todd in Scrubs, you will know orthopaedic humour.  Part of it is the implantation of hardware;  many jokes can be made with the words "screw", "hammer" and "nail":  "I helped the boss screw a fifteen year old boy with a displaced scaphoid";  "Did you nail that girl already?"

The orthopaedic registrar of the day (and his offsider, since orthopods hunt in packs) offered their version:

Come Rub My Tree Of Life

Come Rub My Trunk Of Love

Come Rub My Thruster Of Love

When I complained about the androcentric nature of these, they offered the (not much nicer)

Come Rub My Tunnel Of Love

which of course brings us the the classic Dire Straits:

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.