The View from The ICU

I've noticed that different medical centers, even in the same city, may have significantly different procedures for admitting patients to the intensive care unit. In some institutions, everyone is admitted, regardless of how sick they are or how likely they are to recover. As a result, the majority of patients in these ICUs eventually die, and many physicians caring for them develop pessimistic attitudes, like in this well-written but grim assessment of ICU care in Slate. In other institutions, before patients can be admitted to the ICU, they receive an "ICU consult." This consulting physician may make the determination that the patient is extremely unlikely to recover -- for example, if they have end-stage cancer and end-stage congestive heart failure. These patients, who "would not benefit from the ICU," may be intubated and receive aggressive medical care (if their families wish), but they receive it on a general medical floor. As a result, patients in the ICUs in these institutions seem far more likely to survive, physicians seem less likely to develop pessimistic attitudes, and (I presume) fewer resources are spent on patients who have no chance of surviving. From Slate:

Located deep in the bowels of every big hospital, often behind locked doors that open only to the swipe of a key card, is the medical intensive care unit. Known as the MICU, this is where the hospital's sickest patients are brought for the most aggressive possible care. By the time patients need to be in the MICU, several organ systems are usually failing, and there is little chance of a good outcome. Some MICU patients have fixable problems, such as bleeding from the stomach or a sudden blood clot in the lungs. But many have relentless diseases that make decline irreversible and a decent quality of life irretrievable.

Doctors typically ask the person least able to make a clearheaded decision—the closest relative—about the most important choices regarding a desperately ill patient's care. Here is what happens when that relative tells us to "do everything" to save the life of an ailing loved one...

Technorati Tags: Intensive Care Unit, Medical Intensive Care Unit, Soapbox Series, Medicine

Request for Information on Blogs and Kidney Disease

I've been asked to write an article on blogs and kidney disease. If you're a patient or health care professional and would like your blog mentioned in the article, please email me at kidneynotes at gmail.com. Thank you.

Technorati Tags: Blogs, Kidney Disease, Nephrology, Medicine

Google Earth

(Apologies if the formatting is off. Blogger is working on the problem.)



Google Earth is now free. The map update is impressive: I just returned form Thailand and was able to identify many of the places I visited. From the web site:

Google Earth combines satellite imagery, maps and the power of Google Search to put the world’s geographic information at your fingertips.

Technorati Tags: Google Earth, Maps, Thailand

Brief Intermission

I'm away for two weeks. KidneyNotes will resume when I return.

Keraunopathology: The Study of People Struck by Lightning

Slate has an article on keraunopathology and the culture of people who have been struck by lightning.

Jerry LeDoux is a guy you don't really want to interview, because interviewing him means having to be near him, and that's like planting yourself by a dartboard. The stone claw hanging from his neck attests to his grisly encounter with a bear's jaw at a roadside park in August 1990. (His wife, Bee, brandishes a photo album that documents the mauling before he's done telling the story.) The Purple Heart on his Navy Seals sniper hat testifies to the three bullets he took in Vietnam. The ugly black mark on his finger is evidence that he once air-nailed it to a floorboard. The scar on his left arm is proof that he accidentally screwed his flesh to the wall. The long knife wound on his hand? "Things happen," he says. The most improbable of his many accidents is the one that left the least visible evidence—just a few white splotches on his arms and a discoloration near his hairline. But that doesn't mean it's easily forgotten. LeDoux rolls up his sleeve to show off a tattoo of a man getting struck by lightning engraved on his left bicep.

All LeDoux remembers about the moment he was struck in August 1999 is that he was standing ankle-deep in a puddle when he was overcome by an intensely bright light. He woke up a half-hour later, 20 feet away, with a vague taste of battery acid in his mouth, he said. The soles of his shoes had melted, his two-way radio had exploded, and several of his teeth had shattered. The medical ID tag he wore around his neck was melted into his chest. He drove home from work that afternoon and was back on the job the next day. "I didn't even know I was hurt. I didn't realize anything was wrong," says LeDoux, a 62-year-old master mechanic from Sulphur, La. It took several weeks before he realized just how fried his circuits were—and almost six months to find a doctor who believed he'd been struck...

Technorati Tags: Keraunopathology, Lightning, Slate, Medicine

Grand Rounds XXXVII

Grand Rounds XXXVII, this week's best posts of the medical blogosphere, is up at Medgadget.com.

House, MD: Diagnosis & Treatment

I've seen only a few episodes of House, MD, and I'm impressed that the show -- intentionally or not -- captures the best and worst of internal medicine. Greg House is boarded in both nephrology and infectious disease, two specialties which exemplify the crazy variety of differential diagnoses and treatments in medicine. Fittingly, you sometimes see House as Holmes, using deduction to logically hunt down disease, one of the best parts of the field. Other times, he bumbles around, orders every invasive test he can think of, doesn't have a coherent plan, and fires shotgun blasts of treatments at shadowy problems (such as during a recent episode, when he treated a patient with plasmapheresis, intravenous immunoglobulin, and cytoxan). The haphazard ordering of multiple tests and treatments without much thought is a bad habit shared by House and many other internists, even those who are otherwise brilliant. I like the show because it captures the best and worst of internal medicine.

The Soapbox Series: Normalizing Patients.

Technorati Tags: Soapbox Series, House, Television, Medicine

What Happens When Monkeys Are Taught To Use Currency?

...that is the premise of this article in the New York Times Magazine (written by the authors of Freakonomics).

It includes the immortal line: "Chen has taken steps to ensure that future monkey sex at Yale occurs as nature intended it."

Technorati Tags: Freakonomics, Economics, Psychology, Monkeys

Hilarious Journal Articles Part 8

An Acute Hypertensive Episode Triggered by an Ambulatory Blood-Pressure-Monitoring Device

N Engl J Med 2004 350: 2315-2316

A 46-year-old man was referred to the hypertension clinic in Ashkelon, Israel, for ambulatory blood-pressure monitoring to rule out white-coat hypertension, because his blood pressure was high when measured in the office but normal when measured at home. His medical history was unremarkable. Shortly after the monitoring device was attached to the patient, he was arrested by the police. The wires penetrating through his shirt had caused bystanders to suspect that he was a terrorist wired to a bomb (the blood-pressure-monitoring device had a separate battery pack, partly obscured by his jacket). Police officers immediately handcuffed him, as is standard procedure for handling an armed terrorist, and released him after a brief interrogation.

While the man was being arrested, the peak blood pressure (at 9:12 a.m.) rose to 161/101 mm Hg (Figure 1). The elevated systolic blood pressure persisted for more than 90 minutes, and the elevated diastolic blood pressure for more than 45 minutes. Tachycardia, with rates up to 122 beats per minute, persisted for more than four hours. A second hypertensive episode was triggered by another police interview approximately four hours after the initial arrest...

During the subsequent nine months, the patient's blood pressure -- as measured with an ambulatory monitor and at home -- has been normal, with a mean daily blood pressure of 122/81 mm Hg and a mean heart rate of 81 beats per minute. The patient has remained asymptomatic...

"Hilarious Journal Articles" is an occasional series. Submissions are welcome and will be acknowledged.

• Hilarious Journal Articles, Part 7
• Hilarious Journal Articles, Part 6
• Hilarious Journal Articles, Part 5
• Hilarious Journal Articles, Part 4
• Hilarious Journal Articles, Part 3
• Hilarious Journal Articles, Part 2
• Hilarious Journal Articles, Part 1

Technorati Tags: Hilarious Journal Articles, Humor, Medicine

Son Dies from Heart Attack While Trying to Revive Father (Who Dies of Heart Attack)

Via Fark:

SENECA, S.C. - A son trying to save his father from a heart attack died when his heart failed after he couldn't resuscitate his dad...

Also see Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress (N Engl J Med 2005 352: 539-548).

Technorati Tags: Medicine, Cardiac Arrest

New England Journal of Medicine Interviews

In my search for medical podcasts, I've been listening to the free interviews offered on the New England Journal of Medicine Web Site. (See the lower right sidebar on the main page. These are not podcasts, because they aren't part of the NEJM feed, though I wish they were.) The audio files are excellent and have included topics such as the Terri Schiavo case, the risk of a new flu pandemic, and compassion in medical education.

Technorati Tags: Medicine, Interviews, New England Journal of Medicine

Hilarious Journal Articles Part 7

Breast Fat and Fallacies: More Than 100 Years of Anatomical Fantasy

J Hum Lact. 2005; 21: 126-130.

The authors studied the anatomy of 136 patients who underwent breast reduction surgery from 1998 to 2003 to determine the relationship of breast fat to the glandular tissue of the breast. Histological sections of freshly preserved breast tissue taken from representative patients were examined and compared to depictions of normal breast anatomy as portrayed in standard anatomical texts from the classic work of Sir Astley Cooper in 1845 to current publications such as Auberbach and Riordan's Breastfeeding and Human Lactation. Most texts portray little intermix of fat with the glandular tissue of the breast. Our studies confirm the texts that demonstrate the fat and glandular tissue to be inseparable and present in continuity with each other except in the subcutaneous plane where only fat is present. The implications of this anatomical fact as it relates to breast surgery and human lactation are discussed.

"Hilarious Journal Articles" is an occasional series. Submissions are welcome and will be acknowledged.

• Hilarious Journal Articles, Part 6
• Hilarious Journal Articles, Part 5
• Hilarious Journal Articles, Part 4
• Hilarious Journal Articles, Part 3
• Hilarious Journal Articles, Part 2
• Hilarious Journal Articles, Part 1

Technorati Tags: Hilarious Journal Articles, Humor, Anatomy, Medicine

Please Note: We Are Recalling Every Drug On This Huge List

"FDA Advises Consumers about Recalled Drugs from Able Laboratories"

The Food and Drug Administration notified consumers and healthcare professionals of a nationwide recall of all manufactured drugs (mostly generic prescription drugs, including drugs containing acetaminophen) from Able Laboratories of Cranbury, NJ, because of serious concerns that they were not produced according to quality assurance standards. Able Laboratories has ceased all current production...

And there is an impressively long list here which includes acetaminophen/codeine, atenolol, hydrocodone, indomethacin, lithium, naproxen, nitroglycerin, tramadol, among many others... What a headache.

Technorati Tags: FDA, Drug Recall

What are the Odds of Dying of X?

Thanks to Engadget. From the National Safety Council:

The table below was prepared in response to frequent inquiries, especially from the media, asking questions such as, "What are the odds of being killed by lightning?" or "What are the chances of dying in a plane crash?"

The table has four columns. The first column gives the manner of injury such as motor-vehicle crash, fall, fire, etc. The second column gives the total number of deaths nationwide due to the manner of injury in 2002 (the latest year for which data are available). The third column gives the odds of dying in one year due to the manner of injury. The fourth column gives the lifetime odds of dying from the manner of injury...

Technorati Tags: Odds, Probability, Dying

Profit Making in Virtual Worlds

The New York Times has a story titled, "The Game Is Virtual. The Profit Is Real." (For a fictional account, see Cory Doctorow's story Anda's Game.)

Technorati Tags: Virtual Worlds, Profit