My husband and I were married on a beautiful day in early October 19 years ago. Like many others our vows included the phrase “til death do you part.” This quilt is my “tongue in cheek” homage to that promise.
Friday, October 30, 2009
Thursday, October 29, 2009
The bullet point summary:
- As widely reported, the "Robust" public option is dead; long live the "Weak" public option! Enough House moderates - citing fiscal conservatism - rejected the cheaper option which would have paid providers at Medicare + 5%, and the bill as released would require the public option to negotiate fee schedules with providers like any other insurance company. IMHO, this is better policy even though it costs more, but hypocritical Blue Dogs get under my skin.
- 96% of legal American residents covered.
- The bill is Deficit Neutral and actually reduces the deficit by $100 Billion over ten years.
- Total expenditures are in the region of $900 Billion.
- Slows the rate of growth of Medicare from 6.6% to 5.3% annually.
- Expands Medicaid to 150% of federal poverty level (and I didn't find the citation but I read the Feds were going to pay 75% of the costs of the expansion).
- Financed though savings in Medicare Advantage, taxes on families earning >$1 million, individuals earning more than $500,000, taxes on the insurance industry and medical device makers.
- The Insurance industry's anti-trust exemption is revoked.
- Curiously, it allows states to make "insurance compacts" which will allow insurers to market policies across state lines -- a long-time conservative goal.
- Closes Medicare Part D donut hole
- All the typical insurance regulations, Insurance Exchanges, etc, with a strong employer mandate (8% of payroll for large companies).
The changes would provide more health care help for Nevadans without dipping into the state's budget at least temporarily.Under changes made by the Senate Finance Committee, Nevada would be one of four states to be reimbursed 100 percent by the federal government over five years for the cost of increasing the number of people eligible for Medicaid.After five years, the federal government would pay 82.3 percent of the cost to provide care to the newly eligible people. Nevada would pay 17.7 percent, said sources who worked on the legislation."I promised the people of Nevada that I wouldn't support any health insurance reform proposal that wasn't good for our state, and I meant it," Reid said in a statement.
A hernial sac is a protrusion of a part of the peritoneum through an opening in the abdominal wall. In this sac there may or may not be found portions of the abdominal organs. If they can be “replaced” in the abdominal cavity the hernia is called “reducible.” Otherwise it is an “irreducible” hernia. Such reduction may be impossible on account of altered shape of the organs in the sac, its “contents,” so-called, or on account of adhesions which have formed around the sac and its contents. The hernia may become inflamed as a result of traumatism, etc. This rarely leads to suppuration. It may produce so much swelling of the hernial contents that the blood-vessels which supply them are occluded, and strangulation results.A hernia may exist at birth or develop soon afterward in an abnormally weak spot in the abdominal wall. It may also appear in later life, either suddenly, following some crush or severe strain, or gradually, as the result of oft repeated lesser strains.The subject of hernia, and especially its operative treatment, is exhaustively discussed in works upon major surgery. Still, the general means of correct diagnosis and the ambulant treatment of patients who, for one reason or another, cannot be operated upon, are here in place.
A patient suspected to have a hernia should be examined in both standing and recumbent postures.Inspection may show variation in size at different times if the hernia is reducible. Peristaltic movements are often visible in large intestinal hernias.Palpation may reveal the presence of intestinal coils, of gurgling gas and fluid, of lumpy omentum, or of pasty fecal masses capable of being indented.Compression, when the patient is recumbent, may affect the reduction of the hernia.Percussion will bring out the resonance of intestinal coils containing gas. It will also give a thrill in case the swelling is due to a hydrocele or a cold abscess.Auscultation may reveal an intestinal gurgle or, in rare cases, an aneurysmal thrill.An impulse on coughing is obtained in case of most herniae. It may also be obtained, though less marked, in case of a large varicocele or in case of a hydrocele which extends well up into the inguinal canal.Reduction of the swelling upon compression or spontaneously when the patient lie down is very significant of hernia, but may also occur with an imperfectly descended testis or a cold abscess.
Operation of hernia, wherever situated, to be successful must accomplish these three steps:1. The reduction of the hernial contents, either before or after the sac has been opened.2. The closure of the peritoneal cavity at the normal level. The sac is usually tied at this point, its neck, and the surplus removed.3. The approximation by firm sutures of the damaged wall of the abdomen, or at the least of its strongest part, namely, the deep fascia.The various methods of accomplishing these three steps vary in different situations and in the hands of different operators. They are fully described in all surgical text-books.
If the condition of the patient and the character of the hernia make it probable that the three steps above described can be carried out by operation, and primary union attained, operation should be advised. It is, of course, absolutely indicated in case of strangulated hernia as a relief of acute symptoms, even under circumstances in which a permanent cure of the hernia is not to be expected.A truss is to be recommended in all other cases of reducible hernia. A patient having an irreducible, inoperable hernia is indeed in a bad state. Some of them gain relief by an operation which changes the hernia from an irreducible to a reducible one, so that a truss can be worn. An unusual type of partly reducible hernia is shown in Figure 111.
Hernia of the umbilicus in the new-born is extremely common. The sac is usually small and contains intestine or is empty. This hernia has a strong tendency toward recovery, but to facilitate this end it should be constantly kept pressed back by means of a cloth-covered, wooden button-mold and a short strip of adhesive plaster. This should be changed every day or every second day after the infant’s bath, but before the old one is removed the new one should be prepared, and in the interval the hernia should be pressed back by the nurse’s finger until the new button is put in place. The plaster should extend in a different direction every day so that the skin may not become irritated. If treated in this manner the great majority of infantile umbilical herniae can be cured in a few months.Umbilical hernia in the adult is especially common in stout persons of middle age. It first appears as a flabby tumor as large as the terminal joint of the finger, covered with normal skin. It is usually irreducible. Its contents are omentum. As it grows the sac becomes more distended; small intestine will often be added to the omental contents. This part of the hernia is usually reducible, at least for a considerable period. Such a hernia frequently becomes strangulated.A truss is an unsatisfactory appliance for umbilical hernia of the adult. An operation should be performed early, if possible before intestine is involved.
Inguinal hernia is more common than femoral hernia both in the male (39 to 1) and female (3 to 2); or, to put it differently, for every 84 inguinal hernias in the male there are 8 inguinal hernias in the female, 6 femoral hernias in the female, and 2 femoral hernias in the male. It is usually indirect, that is to say, the omentum, intestine, etc., which fills its sac leaves the abdomen by the normal route of the inguinal canal, and does not burst through the posterior wall of the inguinal canal to the median side to the epigastric artery (direct inguinal hernia).Inguinal hernia may be congenital or acquired, and if acquired it may develop suddenly as the result of a crush or strain, or slowly.Symptoms – These symptoms are usually present: normal moveable skin; underlying tumor giving impulse on coughing, growing smaller or disappearing entirely under pressure or on lying down; enlarged ring and inguinal canal evident on reduction of tumor; reduced tumor does not reappear when patient stands and coughs if the canal is blocked by the surgeon’s finger; no true fluctuation; opacity to transmitted light.Possible additional symptoms of intestinal hernia are: resonance on percussion, gurgling on manipulation, indentation of doughy fecal masses in large intestine.Treatment – Treatment by operation entails only a slight risk, and is generally successful. It should therefore be advised in the case of all healthy children and active adults. Treatment by truss is advisable for feeble and aged persons and for those whose tissues in the inguinal region are so thinned by previous unsuccessful operation that they cannot be made to withstand the intra-abdominal pressure.A truss is a pad held firmly against the lower part of the inguinal canal to prevent the exit of the omentum, etc., from the abdominal cavity. It has been well compared to the stopper of a bottle. Opinions differ as to the best form of truss. A satisfactory truss is one which, with a minimum of pressure and without causing the patient any pain, prevents the hernial contents from entering the hernial sac.The hernia must be fully reduced before a truss is applied. This is best done when the patient lies on his back. A truss should never be applied to a hernia which is only partially reducible. It will rarely succeed in keeping back the rest of the hernial contents, and by its pressure on the part already in the sac it will cause pain and possibly serious inflammation, or even gangrene.A truss is rarely needed in case of a very young infant; but before the child is old enough to walk it should be fitted with a truss or should be operated upon. Operation is advisable for large congenital herniae, as cure is improbable when the neck of the sac is so wide. If the tunica vaginalis communicates with the peritoneal cavity by a rather narrow passage, and the contents of the hernial sac can be reduced into the abdomen without dragging the testicle upward, a truss may cure the patient in the course of a few years. For this purpose it should be worn constantly day and night, as crying no less than walking will force the abdominal organs into the hernial sac. As the child grows older the truss may be left off at night, and if the neck of the sac becomes obliterated the truss need only be worn during exercise, and finally not at all. A cure is sometimes obtained from a truss in adult life, but is far less likely after the patient has attained his growth.
In femoral hernia the protrusion of abdominal contents is under Poupart’s ligament and through the femoral ring. Such a hernia is usually small, and this fact, added to the tortuous course of the canal, sometimes obscures the impulse on coughing and renders diagnosis difficult. An enlarged lymphatic gland, with which femoral hernia is often confounded, if unilateral has almost always an evident cause in some scratch or cut of the foot or leg.Femoral hernia should always be treated by operation.
always requires treatment in bed or immediate operation, but most of the patients are seen by a physician while they are still walking about, so that the symptoms should be fixed clearly in mind, ready for instant service. They vary according to the character of the compressed organ. Omentum may become strangulated and give only moderate pain and disability for days. Large intestine, and even small intestine if only a part of the circumference of the bowel is constricted, give the same symptoms in a more marked degree, plus vomiting and more or less distention. If the lumen of the small intestine is completely obstructed there is repeated vomiting, becoming brown and foul-smelling (“fecal”), and absolute stoppage of the bowels even for gas.The various hernial orifices should be examined in all cases of intestinal obstruction.Treatment – Dorsal decubitus, the steady pressure of a pad of unbleached cotton and a spica bandage, and the cold of a big ice-bag will cause the reduction of many strangulated hernias. This treatment should be tried only in the early hours of strangulation, lest one succeed in reducing a loop of intestine already gangrenous. In most cases immediate operation is indicated.
Wednesday, October 28, 2009
Harriet Hunt was the first woman to apply to Harvard Medical School. The year was 1847, and Harvard rejected her – as it would all women for the next century. It was 1945 before the school would finally
admit women medical students.Today, Hunt’s experiences seem like ancient history to students like UAMS senior medical student Sarabeth
Bailey, who decided at a young age to enter the medical field. Bailey, a small town girl from DeQueen, Arkansas, was the first in her family to pursue a higher education, and found the doors of UAMS wide open to her when she entered in 2006………….
Tuesday, October 27, 2009
Codeblog is this week's host of Grand Rounds. You can read this week’s “Trick or Treating” edition here.
Welcome to Grand Rounds! This is volume 6, number 6…. and the 6th time I am hosting… during the week of Halloween. Does anyone else find that creepy coincidentally satanic fascinating?!For this edition, I thought we could go out Trick or Treating on Medblogger Lane. I’m sure we will find some colorful stories along the way…
………….In response, a friend of mine challenged me: if the system is too complicated, how should we simplify it?I wish more policy-makers were asking this question.For me, the answer is clear: Primary care. Time was, your primary care doctor was able to serve as the hub of your medical activity. He or she could spend all the time needed to figure out what was wrong and to coordinate with your specialists. It’s not true anymore. Patients are left on their own trying to navigate the system. In many ways they end up acting almost as their own primary care doctors. Patients try to pick their specialists, find out what to do about their condition, decide on good treatment choices……………….
Interested in smallpox vaccination history as mentioned by @badastronomer? Jenner Museum in on Twitter @JennerMuseum
I called her at home to give her this news. While I informed her ……., she heard only “Multiple Sclerosis”. “What does this mean?” she asked, but she didn’t wait for my answer. She began to cry. “I am so young. There was so much I wanted to do. I wanted to have a family.”“I have the same disease,” I told her. I had decided to reach across the space between us and to share a bit of myself. I went on to say that I have four kids, that I still ski, run, play lacrosse and work as a doctor, that I am healthy and energetic. “There is tremendous variability in how people do,” I offered, “and some people do very well. It is the unknown that is scary.”
- Suzanne Somers carpet bombs the media with napalm-grade stupid about cancer – Orac at Respectful Insolence
- Suzanne Somers’ Knockout: Dangerous misinformation about cancer (part 1) -- David Gorski at Science-Based Medicine
- Suzie's At it Again – Margaret Polaneczky,MD (aka TBTAM)
- Suzanne Somers, Larry King and Cancer - Enough is Enough (TBTAM)
So what do you think about the idea of videochatting with your shrink on the computer? Patrick Barta is a psychiatrist in Maryland who has started having some of his sessions (5 percent or so) on Skype. He's blogging about his experiences and talking about the good and the bad aspects. Do visit his blog: Adventures in Telepsychiatry and let him know what you think about Skype-Therapy!
The National Museum of Health and Medicine and Family Magazine will host family-friendly Halloween activities for ages 5 and up. Children will be able to participate in a costume contest (with prizes!) and make skeleton crafts (a dancing macaroni skeleton, a medieval plague mask, and a skeleton wall hanging) as well as join in a Halloween-themed family yoga demonstration by Shakti Yoga.
A brief review: Light can be modeled as photons, which are characterized by a wavelength λ and a frequency f. …………..…The camera obscura, a system of lenses used to project images, was known in the 1000's CE, but it was an aid for drawing – there was no way to save the images. Daguerre developed a process in 1839 that employed copper plates and mercury vapor;…………..Before film, photographs were taken on glass plates, which produce much more durable images, but are very difficult to carry in your wallet or purse………..Eastman Kodak is credited with the first flexible (although not transparent) film in 1885…………..
Monday, October 26, 2009
I talked with a man recently about my cancer. He had trouble finding words. He didn't know what to say and looked to the ground. The "breast" part of it all made him noticeably uncomfortable.When I first felt pain, and later a lump, below my left nipple, it didn't sink in that I, a man, could actually have breast cancer. Years from now I may very well be able to count myself as a cancer survivor simply because the tumor in my breast caused pain. (Something very rare, in fact, for both men and women.) The pain, like a pin being driven into my nipple, drove me back to the doctor for a second, then a third time over a four-month period. My unwillingness to accept my physician's assurances that no further tests were warranted may have saved my life. As devastating as it was . . . [Full Text of this Article]
Breast cancer: The pink disease; a woman's problem; a girlie, nonmasculine thing.
Sunday, October 25, 2009
Friday, October 23, 2009
This near shot show the quilting which is circles. Most of the fabrics have geometric patterns: circles, dots, squares, strips, stars, etc.
Thursday, October 22, 2009
This is a condition in which the edge of the nail, usually of the great toe, by its too close contact with the flesh beneath causes irritation, ulceration, or suppuration. There has been much discussion as to whether the nail or the flesh is the more at fault. This discussion is without profit. It is much better to study the normal conditions, and see what can be done to restore them. Figure 292, A and B, shows the normal toenail in longitudinal and transverse section. The drawings are from the toe of a young male adult. It is important to note the relations of the matrix of the nail to the first phalanx and to the joint; since the bone and joint are landmarks in the performance of the operation for the cure of the ingrown nail.
If the nail is allowed to grow out to the end of a normal toe, the ordinary pressure of the shoe brings the edge of the nail against the underlying skin at the end of the toe where the skin is tough, so that no damage results. If an ill-fitting shoe constantly rubs the toe, or if some one steps on it, the trauma may break the underlying skin. The edge of the nail will then be in constant contact with the sore, and will act like a foreign body, and prevent the ulcer from healing.
This is especially true if the corners of the nail have been cut away, so that the pressure of the nail’s edge comes on the more delicate skin by the side of the nail, rather than on the tougher skin at the end of the toe. The resulting inflammation, ulceration, and granulation may go on until the toe presents the appearance shown in Figure 293.
Such a toe is very painful, and the pain is only partly relieved by cutting away the upper of the shoe, etc. As there is an easy exit for the discharge, infection rarely extends upward into the foot and leg. On the other hand, the conditions for repair are not good, so that a patient may go hobbling about for months with a small ulcer under the nail’s edge, marked by an exuberant growth of granulations and a slight discharge.
Treatment – There are three ways to cure the exiting ulcer of an ingrown nail: (a) One is to interpose some protecting material between the edge of the nail and the ulcer; (b) another is to remove the edge of the nail from the ulcer; and (c) the third is to remove the flesh from the edge of the nail.In mild cases the ulcer due to an ingrown nail may be cured by depressing the flesh along its edge and pushing a small wisp of absorbent cotton under it. This should be wet with some astringent solution, for example, silver nitrate, 1:50. The upper of the shoe should be cut from the sole far enough to relieve the great toe from pressure. The dressing should be changed every day or two. Cotton should be kept under the edge of the nail until the corner of the latter has grown out to the end of the toe. Otherwise the ulcer is likely to reform.The nail can be pushed upward away from the ulcer by means of a littler silver hook. A thin strip of spring silver is so bent that it will hook under the edge of the nail, and then half encircle the toe, on its plantar surface. As the patient steps on the toe the buried edge of the nail is lifted upward. The hook is kept in place by adhesive plaster or a bandage. This method, like that of cotton and astringents, finds its best use in mild cases occurring in people of some intelligence.
- Soak the foot in warm water three or four times each day.
- When not soaking, make sure the foot is clean and dry.
- Carefully wedge a small piece of clean cotton or waxed dental floss between the skin and the toenail. Be sure to change this packing daily.
- Wear open-toed sandals or similar while the condition heals. Otherwise, opt for comfortable shoes that don't squeeze the toes.
The edge of the nail may be pared away, and so separated from the ulcer. This is the treatment of many patients as well as chiropodists. It often gives temporary relief if the ulcer does not extend too near the matrix, but it can cure only mild cases of ingrown nail, for as the nail grows out its corner digs again into the flesh. For the same reason, “tearing out by the roots” the whole or a part of the nail is doomed to failure. The matrix cannot be torn out, and will grow another nail at least as distorted as its predecessor.
A satisfactory radical operation must remove, with the edge of the nail, that portion of the matrix from which it grows. The details of this operation are as follows: Cleanse the toe as thoroughly as possible with soap and water and an antiseptic solution; shut off the blood-supply of the toe by a bandage tied about its narrowest part. Inject a local anesthetic along the edge of the nail and beneath it as far back as the base of the second phalanx. Cut through the nail and overlying skin in a line parallel to the axis of the toe. This cut should separate from the nail a strip about one-fourth of an inch wide, and should extend clear through the matrix of the nail – a dense white layer easily differentiated from the subcutaneous fat. The overlying skin at this side should be dissected free from this separated marginal strip of nail and from its matrix.
This strip of nail and matrix should be dissected out by cuts made above and below it, and meeting well beyond it under the skin at the side of the toe. The surgeon should remember that the nail grows from the thick layer of epithelial cells placed both above and below the plane of the nail, the former extending nearly to the reflection of skin, and the latter extending to the white semilunar line. The skin flaps are retracted and the wound is inspected for any possible bit of matrix which may have been left. It is then well wiped out with an antiseptic solution, such as a solution of bichlorid, 1:2,00, and closed by the pressure of a wet dressing wrapped around the toe; ligation of blood vessels is rarely necessary, especially if the dressing is partly applied before the constricting bandage around the toe is removed. Too great pressure must not be applied to the lateral flap, however, lest sloughing or infection follow. The shape of the wound facilitates drainage if a wet dressing is put on and frequently moistened. The dressing should be changed daily for four days; then if all is well, a dry dressing may be substituted and changed again every three or four days. If the wound heals as it should, it will be quite closed in ten days. The proximal half usually closes by “first intention.” Sutures may be inserted, but are not necessary.
The disfigurement after this operation is slight, and the functional result is perfect.
In performing the above described operation, one should bear in mind that every bit of the nail has its corresponding portion of the matrix from which it springs and that growth of the nail, except in cases of distortion, is parallel to the long axis of the toe. One should not, therefore, remove a broader portion of the matrix than will correspond to the buried portion of the nail. When this rule is followed, the visible portion of the nail will continue to be formed and normal appearance of the toe will be preserved.If a portion of the matrix is left in the operative field, it may grow up by the side of the nail in harmless stubs of nail, or, if larger, it may grow a long spike of nail which pierces the skin at the side of the toe and renders a second operation necessary, or it may be unable to pierce the skin and will then curl up, forming a subcutaneous mass of half hardened epithelial debris.The operation above described has been developed in the hands of the author from several cruder ones, based on the same principle, of removing the matrix of the offending portion of the nail. Some of them were less certain in accomplishment, and some more painful in execution, and some more mutilating. Some operators, in addition to the removal of the matrix of the involved part of the nail, tear out the whole formed nail. This has no advantage, and renders the toe more or less sensitive for some weeks.The third method of separating the edge of an ingrown nail and the ulcer it causes, is by removal of the ulcer. This is accomplished by cutting away the skin and subcutaneous tissue of the side of the toe. As there is then nothing for the nail’s edge to press against, the soreness quickly disappears. The wound left to granulate is from half an inch to an inch in diameter; so that healing takes a month to six weeks. The ultimate result is good, but the shape of the toe is somewhat altered in appearance. This operation bears the name of Cotting.
Wednesday, October 21, 2009
Halter announces free clinic details
We brought you this news yesterday, but Lt. Gov. Bill Halter has issued a news release today with more details on the Nov. 21 free medical clinic to be held at Little Rock's Statehouse Convention Center……HALTER NEWS RELEASELITTLE ROCK (October 16, 2009) -- The Statehouse Convention Center in Little Rock will be the site of a free medical clinic for people seeking care from a health professional on Saturday, November 21, Lieutenant Governor Bill Halter said today. The National Association of Free Clinics (NAFC), a national nonprofit organization, will operate the clinic.“This is a fantastic opportunity for Arkansans who need health care to get the medical attention they sorely need, at least for a day. We are profoundly grateful to the National Association of Free Clinics and to Keith Olbermann, without whom this would not be happening,” Halter said.The NAFC will set up a registration process for patients and volunteers leading up to the November 21 clinic. The Alexandria, Va.-based non-profit organization operates as an advocate for more than 1,200 free medical clinics and the people they serve nationwide. The non-profit organization engages a volunteer workforce of doctors, dentists, nurses, therapists, pharmacists, nurse practitioners, technicians and other health care professionals to help meet the medical needs of patients served by free clinics.The NAFC has received donations from people responding to a call from Olbermann, an MSNBC news anchor, for free medical clinics in six states, including Arkansas. Olbermann issued the call last week during his hour-long “Countdown with Keith Olbermann” program, which airs at 7 p.m. CST Monday through Friday on MSNBC. He announced the date and location of the Little Rock clinic on Thursday night’s program and also reported that 13,600 people had donated more than $1 million to the NAFC………….U.S. Census Bureau statistics show that, on average, 492,000 Arkansans (17.6 percent of the state’s population) were without health insurance coverage during the three-year period of 2006 through 2008.
Harmony Health Clinic is a free medical and dental clinic located in Little Rock, Arkansas. The Clinic, which is an affiliate of Volunteers in Medicine, provides routine health care to local residents whose income does not exceed 200% of the Federal Poverty Level and are currently medically uninsured and over the age of 13. The Clinic has commenced providing limited services, but will gradually expand its services as soon as the physical facilities and operating funds to accomplish this goal are available.
Tuesday, October 20, 2009
Pressly’s mother suing 3, hospital: Daughter’s privacy violated, she says By John Lynch; October 21, 2009; ArkansasOnline.com (subscription required)The lawsuit by Patricia Cannady claims they violated Pressly's privacy by illegally looking at her medical records….Cannady's lawsuit says the actions of the three were extreme and outrageous. It also accuses the hospital of failing to have a system that keeps employees and doctors from illegally accessing medical records.St. Vincent's issued a statement saying it stands by its safeguards and how the situation was handled.
The hospital has acknowledged firing at least six employees for violating Pressly’s privacy but won’t say exactly how many, and officials on Monday would release only a three-sentence statement defending the hospital.“We take every patient’s privacy seriously,” the statement from spokesman Margaret Preston reads. “We stand by our commitment to patient privacy, our safeguards and how we handled this situation.”Jay Holland, a doctor who worked at the hospital; Candida Griffin, a former emergency-room coordinator; and Sara Elizabeth Miller, a former account representative, are targets of Cannady’s lawsuit. The three have each pleaded guilty in federal court to a single misdemeanor count of violating federal health privacy laws, known as the Health Insurance Portability and Accountability Act of 1996. They each face a maximum of year in jail and a $50,000 fine when they are sentenced next Monday.Griffin and Miller were fired, acknowledging in their June court appearance that they looked at Pressly’s records out of curiosity during the first two days of her stay in the emergency room before she was moved to intensive care.
Previous related post:
Don’t Forget HIPAA Privacy Rules (July 2, 2009)
Addendum (October 25, 2009)
Sentences were handed out today to the three convicted of HIPAA violations as follows:
A federal judge has sentenced a doctor and two former hospital employees to a year of probation after they admitted breaking federal privacy laws by peeking at the medical records of KATV's Anne Pressly.Dr. Jay Holland was also fined $5,000 and ordered to perform 50 hours of community service by speaking to medical workers about the importance of patient privacy.Candida Griffin, a former emergency room unit coordinator at St. Vincent Health System, was fined $1,500, while Sarah Elizabeth Miller, a former account representative at St. Vincent Medical Center in Sherwood, received a $2,500 fine.
Sharp Brains is this week's host of Grand Rounds. You can read this week’s “brain and cognition” edition here.
Encephalon (brain & mind blog carnival, edition ) finally meets Grand Rounds (health & medicine blog carnival).
What a nice surprise. Hello. Nice to meet you!
Greetings from Las Vegas!
It’s the BlogWorld Expo edition of Change of Shift!
Well, at least it’s being compiled in the same city.
We have a new blogger again this edition, and an unintended ER theme seems to have arisen from the nursing blogosphere this week!
Such a “spirit jump” is exactly what Meaghan Edelstein had in mind when she created Spirit Jump (www.spiritjump.org) as a way to connect patients with people who want to brighten the day of someone with cancer. Indeed, it was personal experience that gave Edelstein the idea. “I was given a 20 percent chance of survival,” says Edelstein, who was diagnosed at 28 with stage 3 cervical cancer in 2007.
Medbloggers at #bwe09 good summary of types of legal pittfalls of twitter, including defamation http://bit.ly/3E5w9x (thanks @kevinokeefe)
Many of the more dangerous substances, such as opioids, should be disposed of by flushing down a sink or toilet, the agency said.Included on the flush list are a number of fentanyl, morphine, and oxycodone-based drugs. The full list is available on the FDA's Web site.But the agency said most medications are not recommended for flushing and should instead be mixed with an unpalatable substance, such as coffee grounds or kitty litter, placed in a sealed plastic bag, and thrown in the trash.The FDA also recommended the use of drug take-back programs -- available through municipal trash disposal agencies in many area -- as an alternative to disposal by trash or drain.
RT @precordialthump: Clozapine-Induced Acute Megacolon (TPR) http://bit.ly/c1hmm6:58 PM Oct 11th
10/22: Dr. A Show: Post BlogWorld Expo
Monday, October 19, 2009
Sunday, October 18, 2009
Without further ado, let’s check out the best in surgical blogging!
A trip to Las Vegas to meet fellow medical bloggers in person.
Good panel presentations and discussions.
Great food, laughing, more discussions, karaoke.
Returning home with great memories to loving family
In Case You Were Wondering (Dr Wes)
Blogworld 09 HIPAA and Blogging (Dr Anonymous)
Medbloggers at Blogworld (Dr Anonymous)
How Nurses Want Marketers To Talk To Them (Fresh Influence)
Scenes from Blog World Expo (Kevin, MD)
BlogWorldExpo: Medical Bloggers Make Their Debut (SixUntoMe)
MedBlogWorld In A Nutshell (Dr Anonymous)
The Rise Of The Medical Blogosphere (Dr Bryan Vartabedian)
Blog World Expo 2009 (Gina, CodeBlog)
Vegas Meets MedBlogging — What’s Next? (Marc at JNJ BTW)
ABC News Covers Medblogger Track At Blog World Expo (Dr Val)
More on that Medical Blogging Track at BlogWorld (Marc at JNJ BTW)
Paul Levy Phones It In - Literally! (Dr Anonymous)
Via BlogWorld Expo 09 in Las Vegas (Mother Jones)
Fabulous Las Vegas (Bongi)
BWE 09: Why Bongi Blogs (Dr Anonymous)
Several Videos from Nursing Show TV, Jamie Davis – PodMedic
- Blogworld Expo – Jamie Interviews Dr A
- Blogworld Expo -Dr A Interviews Mother Jones RN
- Blogworld Expo – Dr A Interviews Bongi
- Blogworld Expo – Dr Wes and Dr Rob
And this one shows Dr Val's artwork on the back of Bongi's T-shirt. Check out the Hippo.
Friday, October 16, 2009
I had this small “Rosie the Riveter” scrap of fabric which reminded me of Kim, Emergiblog. She did so much to get the medical bloggers together at the Blog World Expo that I decided to make her a small quilt of thanks. Here it is:
Thursday, October 15, 2009
The report, "Fewer Emitters, Lower Emissions, Less Cost," (PDF) determined that if contraception was made widely available between 2010 and 2050 to women and men around the world who wished to use it, the reduction in unwanted births could result in saving 34 gigatonnes (one billion tonnes) of carbon emissions. That's roughly 60 years worth of U.K. emissions or 6 years worth of U.S. emissions.
- Fewer Emitters, Lower Emissions, Less Cost, a Cost/Benefit Analysis; Thomas Wire; August 2009 (pdf)
- Sexual and reproductive health and climate change; The Lancet, Volume 374, Issue 9694, Page 949, 19 September 2009 doi:10.1016/S0140-6736(09)61643-3
- Managing the health effects of climate change; The Lancet, Volume 373, Issue 9676, Pages 1693 - 1733, 16 May 2009 doi:10.1016/S0140-6736(09)60935-1
- Should contraception qualify for climate funds? by Candace Lombardi; September 17, 2009
Wednesday, October 14, 2009
Hematoma of Ear (Boxer’s Ear)
Blows upon the ear may give rise to hemorrhage beneath the perichondrium. The effused blood causes a rounded fluctuating tumor which may stretch the ear far beyond its normal size and completely change its appearance, or it may be confined to a small portion of the pinna. It is more often anterior than posterior. Absorption of the effused blood is extremely slow, and the tumor should therefore be promptly incised, the blood clots thoroughly removed, and the wound sutured. The skin of the ear has a good blood supply, and wounds in it heal promptly if the edges are accurately approximated by sutures.
Cauliflower Ear (September 21, 2007)
Mangled Ear--a badge of honor? (August 4, 2008)
Tuesday, October 13, 2009
Robin, Survive the Journey, is this week's host of Grand Rounds. Her theme is “Participatory Medicine”. You can read this week’s edition here.
When I chose the theme for this week's Grand Rounds, I chose it because it is near and dear to my heart. Before I knew what it was called, I was looking for a "participatory medicine" model. Long before I heard the term "ePatient", I was one.
Welcome to Palliative Care Grand Rounds! This monthly blog carnival highlights some of the best and most interesting blog posts related to palliative care. Grand Rounds are published on the first Wednesday of every month. As this month's host of Palliative Care Grand Rounds, we will give our own "GeriPal spin," incorporating posts that feature the intersection between geriatrics and palliative care. Topics are sorted by heading. Thanks to our readers for suggesting posts. Have fun reading!
I got some very exciting news this week; our book is now available for pre-order on Amazon!I anticipate it will be released 1 NOV, and after that it should also be available at our publisher, NTI Upstream.
This trouble-shooting guide below will help determine the cause(s) of instrument staining problems.
- Brown/Orange Stains: Most brown/orange stains are not rust. This stain color is the result of high use of chlorhexidine, improper soaps and detergents, baked-on blood or soaking in saline.
- Dark Brown/Black Stains: Low pH (less than 6) acid stain. May be caused by improper detergents and soaps and /or dried on blood.
- Bluish-Black Stains: Reverse plating may occur when two different types of metals are ultrasonically processed together. For example, stainless steel instruments processed with chrome instruments may cause a stain color reaction. Exposure to saline, blood or potassium chloride can also cause this bluish-black stain to occur.
- Multi-Color Stains: Excessive heat caused by a localized “hot spot” in the autoclave.
- Light and Dark Spots: Water spots from allowing instruments to air-dry. With slow evaporation, minerals from water are left on the instrument’s surface.
- Black Stains: Possible exposure to ammonia.
The above article is part of the Make Your Giving Count! Join America's Giving Challenge 2009. Every little bit counts, like Intueri’s raising money for the MS Society or my small part in helping her or Dr Rob & Zippy raising money to “Stamp out Children’s Brain Cancer!”When I was a boy, my mom had a magnet on the refrigerator with a little picture of Gandhi along with a quote from him. It said: “No matter how insignificant what you do may seem, it is important that you do it.” As a child, I was raised to believe that, and to this day I do my best to live it.
What does it mean to be commanded to be joyful?…….It seems to me that joy is something different. Joy can be cultivated. And joy can coexist with sorrow……..Joy is deeper than happiness.
Smart mama--she knew just what to do! RT @dreamingspires: WOW video footage of Elephant giving birth http://bit.ly/46smpU
10/16: Live from BlogWorldExpo (5 pm ET)
10/17: Dr. A Show: Sat Nite (9 pm ET)
10/22: Dr. A Show: Post BlogWorld Expo
Monday, October 12, 2009
Solid Tumors of the Breast
AdenomaSometimes during adolescence one of the breasts will become abnormally firm and larger than its fellow and rather more sensitive to pressure, but without acute pain. The enlargement is diffuse and uniform, and there is no adhesion of the breast to the structures either beneath or superficial to it. Such a condition has a tendency to resolve in the course of time. This return to the normal state may be hastened by an application of ichthyol ointment.
An adenoma or an adenofibroma of the breast is a tumor which is composed of a localized increased growth of glandular and fibrous tissue. There are several types of such tumors distinguishable microscopically, but as no adenoma is composed only of glandular tissue and no fibroma is without a certain increase in glandular tissue, and as both of these often contain cysts, an exact differential diagnosis between them is not always possible, nor has it more than a pathological significance. The tumor is generally painless and is first noticed by the patient during a bath or by accident. In other cases there is a little pain in the tumor.
Treatment – Such tumors are essentially benign, but they may also change their type of growth into one which has a tendency to spread into the surrounding tissues. Hence they should be removed, or at least carefully watched from month to month in order to be sure that they are not growing. Puncture with a hypodermic needle, and aspiration, will differentiate between a cystic and a solid tumor if fluid is obtained. A negative aspiration is not conclusive. If the tumor is small and freely moveable, a local anesthetic will often suffice; but otherwise, and especially if the patient is more than thirty years of age, she should be told beforehand of the possibility of a major operation and should be given a general anesthetic. If the growth is found to be malignant, the operation should be continued until it includes the removal of the breast and dissection of the axillary and clavicular regions, and the excision of one or both pectoral muscles, according to the judgment of the surgeon. It is of great assistance at such times to have a pathologist present, who, by making frozen sections of even a small, freely movable tumor which has been growing but a few months and is painful. This is especially the case if the patient is a woman more than thirty years of age.
The treatment of malignant tumors of the breast is quite out of the range of minor surgery, but the importance of a correct diagnosis in the early stages is so great and these tumors are so often first seen in ambulatory practice, that the diagnostic points should be emphasized.
In examining a patient’s breast these points should be observed:Palpation – The patient should lie flat on the back with both breast exposed for the sake of comparison. Some examiners prefer to have the patient sit upright, but the recumbent position is better for a thorough examination. Each breast should then be thoroughly examined by rolling its substance between the palmar surface of the fingers and the wall of the thorax. The aim of the examination is to determine the presence of any nodules or other irregularities. If there are multiple nodules in both breasts, the case is probably one of chronic mastitis. The same is probably true of multiple nodules in one breast, for if these are cancerous, the disease will of necessity be far advanced, and some of the other symptoms will be present. A single nodule in one breast, or in each breast, may or may not be cancer. It should be further examined.
Retraction of the Skin – This is best shown by pushing the breast, but not the tumor, toward the suspected part of the skin. Retraction of the skin, under these circumstances, is one of the most reliable signs of cancer.
A Flattening of the Normal Curve of the Breast Over the Tumor -- This is determined by sighting across it with the eye on the same level. If present it is an indication of malignancy.
The Presence of One or More Enlarged Glands in the Axilla or Between the Breast and Axilla – This is not one of the earliest signs. Both Axillae should be palpated. If the glands in each are equally enlarged, and only one breast contains a nodule, the axillary glands are presumably non-cancerous.
Retraction of the Nipple – This is an early sign of cancer only when the disease begins under or near the nipple. In other cases the growth may be well advanced before retracting the nipple.
Hemorrhage from the nipple, either spontaneous or occurring when the nipple is gently squeezed, is a symptom of value if there is no inflammation or other obvious explanation of its occurrence.
Failure to Withdraw Fluid through a Fine Aspirating Needle -- A long hypodermic needle is sufficiently large. Fluid indicates cystadenoma in most cases, though some cancers contain fluid.
The importance of carcinoma of the breast is so great that, unless the examiner can be sure that the tumor is of a benign character, he had better assume it to be malignant. In doubtful cases a section should be removed for microscopical examination. This may be successfully done with cocaine, unless the patient is of a nervous disposition. If the tumor is malignant, an extensive removal of breast and axillary gland and pectoral muscles and fascia is indicated.
Carcinoma beginning in the nipple, so-called Paget’s disease may be mistaken for eczema. There is redness and scaliness, followed by a shallow ulceration with a slightly indurated base and narrow indurated margin. It is inexcusable to neglect such a condition, since the microscopic examination of a small section of the affected skin will reveal the true nature of the disease.
Sarcoma – Sarcoma of the breast differs somewhat from carcinoma in its gross characteristics inasmuch as it usually develops at a greater distance from the nipple and forms a diffuse swelling deeply situated beneath the skin, and often extending beyond the margin of the breast in one or more broad lobules before the surgeons’ advice is sought in regard to it. It grows rapidly, without pain, and forms new nodules by continuity rather than through the lymphatic system; hence the axilla may be entirely free although the tumor has grown to a diameter of two inches or more. Such a freedom of the axilla is never seen in carcinoma of the breast of a similar size. Sarcoma grows more rapidly than carcinoma, and a thorough and early removal is, therefore, not less important.
Tuberculosis of the Mammary Gland – One of the less common situations for tuberculosis is the mammary gland. Because of its rarity, and because of the similarity of the lesion in its general outline to carcinoma of the breast, this mistaken diagnosis is often made. There will generally be a history of tuberculosis in the patient, or examination of the corresponding lung may show that the primary trouble was located within the chest and has worked outward. If an ulcer or sinus exists its appearance will keep an observant man from making a wrong diagnosis. There will be in the edges of the tubercular ulcer none of the active growth which is always seen in the edges of a carcinomatous ulcer. The axillary glands are usually enlarged if an ulcer exists.
Treatment – In tuberculosis of the breast it is quite unnecessary to remove more than the affected part. Usually the whole gland is diseased at the time of operation, but unless the axillary glands are plainly diseased it is wrong to subject the patient to the extra shock of an axillary dissection. On account of the possible involvement of an underlying rib, a general anesthetic is preferable. If the disease is plainly limited to the freely moveable breast=gland, a complete removal can be satisfactorily effected under local anesthesia if the patient’s temperament warrants it.
October – Breast Cancer Awareness Month (October 2, 2008)
Mammograms (October 13, 2008)
ARM Technique (October 15, 2008)
Breast Reconstruction—Part I (October 2007)
Breast Reconstruction – Part II (October 2007)
Sunday, October 11, 2009
Friday, October 9, 2009
As promised last week, here’s the autograph quilt for BWE. The quilt is going to be used as a door prize. It has 64 white spaces for attendee’s autograph (name and blog title). I used batiks in blue, green, and brown shades. The quilt is machine pieced and quilted. It is 43 in square.
See you all in Las Vegas next week! Looking forward to meeting you all as well as gathering autographs.
Thursday, October 8, 2009
The Five Steps of a Breast Self Exam:
- Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips. Look for any changes in the size, shape, and color. Look for any dimpling, puckering, or bulging of the skin. Has the nipple changed position or become inverted? Is there redness, soreness, a rash, or swelling?
- Now, raise your arms and look for the same changes.
- While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).
- Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together. Cover the entire breast from top to bottom, side to side—from your collarbone to the top of your abdomen, and from your armpit to your cleavage. Follow a regular grid pattern, so that no areas are missed.Begin examining each area with a very soft touch, and then increase pressure so that you can feel the deeper tissue, down to your ribcage.
- Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower. Cover your entire breast, using the same hand movements described in Step 4.
Breast Reconstruction – Part II (October 2007)
Breast Cancer Reconstruction Webcast (April 2008)
Silicone Implants and Health Issues (March 2008)
Wednesday, October 7, 2009
- Carve in a clean, dry, well-lit area.
If your tools, hands or cutting table are wet, this can cause slippage and lead to injuries.
- Always have adult supervision (without alcohol use)
Children under age five should never carve. Instead, allow kids to draw a pattern or face on the pumpkin and have an adult carve. Allow the child to be responsible for cleaning out the inside pulp and seeds. They can use their hands or a spoon for this. Children, ages five to ten, can carve but only with adult supervision.
- The right way to cut.
You should always cut away from yourself in small, controlled strokes. A sharp knife is not necessarily the best tool because it often becomes wedged in the thicker part of the pumpkin, requiring force to remove it. An injury can occur if your hand is placed incorrectly when the knife dislodges from the thicker part or slips.
- Use a pumpkin carving kit.
Special pumpkin carving kits are available for purchase and include small serrated saws that are less likely to get stuck in the thick pumpkin. If the saw does get stuck and then becomes free, it is not sharp enough to cause a major cut. Fewer injuries occur with use of carving kits. (photo credit)