Friday, October 30, 2009

Til Death Do Us Part Quilt

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. 

The quilt is machine pieced and quilted.  It is 13 in X 14 in.
The back is a lovely navy batik with astrological symbols of the heavens.  There is a 4 inch sleeve for hanging this small wall hanging.

Thursday, October 29, 2009

John Stossel Speaks at Healthcare Town Hall

I am not as well educated in healthcare policy or politics as Dr Wes, Dr Val, KevinMD, Movin’ Meat, or Dr Sid Schwab.  I keep reading and listening, trying to understand and decide where I stand.  I seem to be more of a centrist (I think).

I was not able to attend any of the previous town hall meetings held in Little Rock on healthcare, but was able to attend the one today.  It was sponsored by the Americans for Prosperity.   The headline speaker was John Stossel.  I am happy to note it was a civil discourse though that may be due to most of them leaning the same way.

I didn’t come away any clearer than before. 

I do tend to agree with Stossel that “when insurance is paying” (and not the individual) “it changes behavior.”  We aren’t as engaged in the decision making when someone else is paying.  However, it is very difficult to get straight answers or even estimates when it comes to healthcare.  It’s easy to say what an x-ray might cost.  It is difficult to estimate all the drugs, surgeries, care someone might need who has been involved in a major accident.  WSJ Health Blog provides links to sites that can help with cost questions.

I don’t tend to agree with Americans for Prosperity when it comes to pre-existing conditions.  I know it messes with “free market” values that I and others feel insurance companies should NOT be allowed to deny coverage due to pre-existing conditions.  A couple of extreme examples were in the news recently regarding babies – one denied because of overweight, the other due to underweight.  It’s one thing to argue that I as an adult can control my weight, exercise, and not smoke, but it’s another to deny someone like Kerry insurance coverage as an adult due to being diagnosed with Type I diabetes as a 6 yr.

There are too many regulations in medicine for a true free market.  I do worry about adding more. 

There were a few good questions asked, but not so good answers.  Here’s one which many of us have been asking – What in the healthcare reform is addressing the projected shortage of doctors?   Will there be access to care even if there is insurance coverage?  No good answers given.  None.

Movin’ Meat has a good post up today, House Health Care Reform Bill released.  Here’s a portion of it.  Be sure you read the entire post.

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).

Something mentioned at the town hall which troubles me:  “Nevada is the only state which will not have to match Medicaid funds.”  In my humble opinion, no state should gain at the detriment of another. 

Benjamin Spillman of the  Las Vegas Review-Journal writes this

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.

Dr Wes tweeted this link earlier today.  Read it.

doctorwes

Politico: Must-read supporting documents for new House #hc bill http://tinyurl.com/ygqog89 #healthcare

1908 View of Hernias – Dx and Tx

The section of the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD on hernias is very interesting.

Hernia --

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.

General Principles of Diagnosis --

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.

General Principles of Treatment --

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.

The symptoms of hernia in different situations vary greatly. A brief description is therefore given of each.

Umbilical Hernia --

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 --

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.

Femoral Hernia --

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.

Strangulated hernia

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.

[Dorsal decubitus in this text means lying flat on ones’ back. I would most likely write an order: “Patient must remain supine and flat.”]

Kraske’s Operation (mentioned in the text description of photo) –involve the removal of the coccyx and excision of the left wing of the sacrum to afford approach for resection of the rectum in cases of cancer or stenosis.

Wednesday, October 28, 2009

“Female Physicians Fill Halls of Medicine”

Interesting article in the November issue of the Journal of the Arkansas Medical Society regarding women in medicine -- Healing the Gap: Female Physicians Fill Halls of Medicine by Casey L Penn (pdf, pp 104-106)

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………….

Related post

Women in Medicine (April 24, 2008)

Women in Surgery (August 21, 2008)

Tuesday, October 27, 2009

Shout Outs

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…

………………………….

Better Health highlights’ Evan Falchuk JD  post:  If I Could Fix One Thing About US Healthcare.

………….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……………….

………………………………………

H/T to @EvidenceMatters  for the link via twitter to the Jenner Museum.  What a wonderful website filled with history of Dr Edward Jenner and the story of the smallpox vaccination!

Interested in smallpox vaccination history as mentioned by @badastronomer? Jenner Museum in on Twitter @JennerMuseum

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When is it important for physician’s to tell patient’s about their own illnesses (the physician’s)?  Dr. Anne Brewster has multiple sclerosis.  She writes about revealing this to a patient with the same disease in her essay:  Boundary Issues: A Doctor with MS Confides in Her Patient

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.”

……………………………..

Good for fellow bloggers for taking on Suzanne Somers!  (photo credit)

………………………………..

I just recently signed up for Skype (haven’t used it) but have wondered about using it as Shrink Rap suggests:  Skype Therapy.   I think HIPAA may prevent us from making the most of Skype, texting, etc.  Too many privacy/legal  issues for now and that’s a shameful waste of good technology.

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!

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If you live in or near Washington DC, you may want to Bring your kids! Halloween at the Medical Museum, Sat. 10/31, 10am-1pm.  It’s a free event, but photo ID’s are required.

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.

……………………………………..

H/T to Dr Isis for this video on Polaroid.  I am a Polaroid fan and was saddened when they quit making the film.

Also, check out this post at Cocktail Party Physicsimages from supernovae to supermodels by Diandra Leslie-Pelecky

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…………..

…………..…………………

 

There has not been an announced guest or topic for this Thursday night  Dr Anonymous’ show.   The show starts at 10 pm EST.   Dr. A has a couple of nice videos up of his appearance on local TV news giving his take on H1N1.

You may also want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

 

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Monday, October 26, 2009

Male Breast Cancer

October is Breast Cancer Awareness Month.  Most of the focus is on women.  There was a wonderful essay from a male breast cancer patient/survivor.  Here’s the beginning of the essay.  Unfortunately, you need a “subscription” for full access.

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]

Mr. Wright laments the “pink” color attached to breast cancer:

Breast cancer: The pink disease; a woman's problem; a girlie, nonmasculine thing.

Most of the general public thinks of breast cancer as only a woman’s disease.  This misconception delays diagnosis for the too many.  Men need to be educated that they do in fact have breasts.  They can in fact get breast cancer.  There will be ~2000 men diagnosed with breast cancer this year in the United States. In the U.S., the ratio of female to male breast cancer is approximately 100:1 in whites, but lower (70:1) in blacks. 

The essay brought to my attention the John W. Nick Foundation.  Their website has some great information, resources, and personal stories.  I hope you will check it out and spread the word.

 

REFERENCES

Oh, to Live in an Age When Men Had Breasts . . .; JAMA. 2009;302(14):1511-1512; Scott W. Wright

Sunday, October 25, 2009

SurgeXperiences 309 – Call for Submissions

I will be hosting SurgeXperiences 309 (November 6th) so please submit your surgery related posts by midnight on Friday, November 4th.    There is no theme other than surgery.  Submit your post via this form

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.   If you would like to be the host  in the future, please contact Jeffrey who runs the show here.

Here is the catalog of past SurgeXperiences editions for your reading pleasure.

Friday, October 23, 2009

Kite Tails Baby Quilt

This baby quilt uses 3 in squares of scrap fabric in 4-patch blocks put together in a pattern known as “kite tails.”  The finished quilt is 42 in square.  It is machine pieced and quilted.

This near shot show the quilting which is circles.  Most of the fabrics have geometric patterns:  circles, dots, squares, strips, stars, etc.

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Thursday, October 22, 2009

Ingrown Toenail Care in 1908 and Now

Flipping through the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD I found at an antique store last month, I came across the section on ingrown toenails. The causes of ingrown toenails were much the same as one hundred years.

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.

Note: Today the common causes of ingrown toenails are still listed as wearing shoes that crowd your toenails, cutting your toenails too short or not straight across, injury to your toenail, and unusually curved toenails.

Prevention begins with those causes. To prevent ingrown toenails, it is important to wear shoe that fit properly and don’t pinch. It is important to trim your toenails straight across. It is important to protect your toes from injury, so wear steel-toed shoes if needed.

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.

The first one mentioned is actually considered part of the current day’s “home care” suggestions:

  • 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.

Moving along to the second and third treatments for more severe cases.

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.

Anyone with diabetes or circulation problems are at greater risk of complications from an ingrown toenail. Do not hesitate to be seen by your physician if you have diabetes or a foot circulation problem and develop an ingrown toenail.

It is important to began care of an ingrown toenail as soon as it's recognized. You should start to see improvement within two or three days. If you don't, contact your doctor.

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Wednesday, October 21, 2009

“Free” Medical Clinics

I’ve been catching up on news that happened while I was in Las Vegas at BlogWorld Expo. The news (via Arkansas Blog) on the “free medical clinics” caught my eye. First, because “free medical clinics” aren’t free. There are many costs associated with them, including the building, utilities (electricity, water, heat, etc), medical supplies, paper supplies, etc. It’s only “free” to the person who receives it. I wish the “free” clinics would be called “charity” medical clinics, but I don’t think that will ever happen. It’s too honest. Not that the persons on the receiving end don’t need or deserve it, but who wants to think about the actual cost involved.

That said, I think it is a wonderful thing for my community to do. I will have to look into it and see how I can “donate” my time. Maybe I can do wound care for them.

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 RELEASE

LITTLE 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.

I’d like to applaud a current and permanent Charity Clinic in Little Rock: Harmony Clinic

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

HIPAA Violations Lead to Lawsuit

It’s been a year since Anne Pressly, 26, was found beaten bloody and unconscious in her bed by her mother, Patricia Cannady.   Pressly was a well respected, well loved news reporter who worked for KATV, Channel 7.  She never recovered from her injuries and died on Oct. 25.

Cannady is has filed a lawsuit claiming her daughters privacy (under HIPAA) was violated.  The suit names St. Vincent Infirmary Medical Center, Dr. Jay Holland, Candida Griffin, and Sara Elizabeth Miller.

Anne Pressly's Mom Sues Hospital, Dr., Others by Monika Rued; October 21, 2009; KTHV.com

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.

Pressly’s mother suing 3, hospital:  Daughter’s privacy violated, she says By John Lynch; October 21, 2009; ArkansasOnline.com (subscription required)

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.

 

Shout Outs

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!

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Kim, Emergiblog, is the host of the latest edition of Change of Shift (Vol 4, No 8) ! You can find the schedule and the COS archives at Emergiblog. (photo credit)

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!

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I meet the founder, Meaghan Edelstein, of  this charity organization, Spirit Jump, at the BlogWorld Expo.  They send cards of encouragement to children, women, and men battling cancer.  I hope you will check out their website and perhaps send a few cards.  Check out this nice article on Spirit Jump:

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.

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H/T to @bobcoffield for this reminder to be careful what you say.  Read the whole article, “Twitter can be a legal minefield: Watch what you say: It's amazing the trouble 140 characters can get you into By Gillian Shaw, Vancouver SunOctober 15, 2009”

Medbloggers at #bwe09 good summary of types of legal pittfalls of twitter, including defamation http://bit.ly/3E5w9x (thanks @kevinokeefe)

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FDA Issues New Drug Disposal Guide by Cole Petrochko, Staff Writer, MedPage Today,  Published: October 15, 2009

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.

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This shows just how amazing the brain can be!

Embedded video from CNN Video

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H/T to @ BiteTheDust for the link to this nice article:

RT @precordialthump: Clozapine-Induced Acute Megacolon (TPR) http://bit.ly/c1hmm6:58 PM Oct 11th

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This Thursday night  Dr Anonymous will have a post-BlogWorld Expo Show. Come join us. The show starts at 10 pm EST.

Upcoming Dr. A Shows

10/22: Dr. A Show: Post BlogWorld Expo

You may also want to listen to the shows in his Archives. Here are some to get you started:

GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

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For any of you doing research on Alzheimer’s – did you know you can apply for research grants from the Alzheimer's Art Quilt Initiative (AAQI)?  You can!  The grants are $10,000 to $30,000.  The money is raised by quilters with activities such as this one:  World Quilt Federation Smackdown to raise money to fight Alzheimer's using these four quilts from some well respected quilt artists!

 

 

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Monday, October 19, 2009

Xiaflex for Dupuytren’s

The U.S. Food and Drug Administration Advisory Panel met Wednesday, September 16, to review the data on Xiaflex and its use for Dupytren’s Disease. A company rep came by the office a couple of weeks ago to update me. I find the possibility of treating Dupuytren’s with an injection absolutely, wonderfully, fascinating!!!

Dupuytren's contracture is an abnormal thickening of tough tissue (fibrous layer) underneath the skin of the palm and fingers. It is the thickening of this tissue that can cause the fingers to curl. It can be disabling. (photo credit)

Until now there has been no treatment other than surgery. Xiaflex is an injection which will be done in the office.

A recent study published in the New England Journal of Medicine which looked at 308 patients with joint contractures of 20 degrees or more in a prospective, randomized, double-blind, placebo-controlled, multicenter trial showed significant improvement. More cords that were injected with collagenase than cords injected with placebo met the primary end point (64.0% vs. 6.8%). Overall, the range of motion in the joints was significantly improved after injection with collagenase as compared with placebo (from 43.9 to 80.7 degrees vs. from 45.3 to 49.5 degrees).

The most commonly reported adverse events were localized swelling, pain, bruising, pruritus, and transient regional lymph-node enlargement and tenderness. Three treatment-related serious adverse events were reported: two tendon ruptures and one case of complex regional pain syndrome.

Auxilium, a specialty biotech company, is seeking FDA approval of Xiaflex (collagenase clostridium histolyticum) to treat the early forms of Dupuytren’s using an injection of Xiaflex. , an office-based, nonsurgical option, may reduce joint contractures caused by Dupuytren's disease.

Auxilium intends to market the drug for use not only by hand, orthopedic and other surgeons but also to rheumatologists, nonsurgeons who specialize in arthritis and other joint issues. Physicians would be trained with a video and a training manual, Auxilium said.

Source

FDA News Release

American Academy of Orthopedic Surgeons

Injectable collagenase clostridium histolyticum for Dupuytren's contracture. ; N Engl J Med 361:968 (2009); Lawrence C Hurst et al.

Sunday, October 18, 2009

SurgeXperience 308 is Up!

Jeffrey, Vagus Surgicalis, is the host of this edition of SurgeXperiences. You can read this edition here.

Without further ado, let’s check out the best in surgical blogging!

The host of the next edition (309), November 1st, has not been announced. The deadline for submissions is midnight on Friday, October 30th. Be sure to submit your post via this form.

SurgeXperiences is a blog carnival about surgical blogs. It is open to all (surgeon, nurse, anesthesia, patient, etc) who have a surgical blog or article to submit.

Here is the catalog of past SurgeXperiences editions for your reading pleasure. If you wish to host a future edition, please contact Jeffrey who runs the show here.

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BlogWorld Expo 2009

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

Priceless!

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Check out these great posts (have added more as I found them):

One for the Medical History Books (Emergiblog)

Going Virtual @ BlogWorld (Running a Hospital)

Dr. A Show 123: Live at BlogWorld Expo (Dr Anonymous)

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

Here is a photo of the comment section of Dr Rob’s T-shirt showing Dr Val’s artwork (notice Zippy)


And this one shows Dr Val's artwork on the back of Bongi's T-shirt. Check out the Hippo.

    Friday, October 16, 2009

    One for Emergiblog

    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:

    The quilt is machine pieced and quilted.  It is 25 in square.

    Thursday, October 15, 2009

    Blog Action Day

    This year the topic of Blog Action Day is climate change, so I have decided to briefly mention the link between population control/contraception and climate.  This connection is finally getting attention again.  It was discussed when I was in college in the 70’s but became a political hot potato when China limited the number of children their citizens could legally have.

    My roommate in college, KB, was an environmental science major.  She and I had many discussions (arguments) over how many children a family should have.  My mother had 8 children.  I also had two half-siblings from my father’s first marriage and 5 step-siblings.  She came from a family of 2 children.

    At the time, I voiced the desire to have 4 children.  She thought I was being irresponsible in not limiting the number of children I had to 2 children --  one to replace myself, one to replace my husband (as yet not meet). 

    As it turned out, she had 3 children and I had none.  I’m not sure if hers was by choice (if she changed her mind) or not.  Mine was not, it just wasn’t meant to be, but maybe we ended up balancing each other out.

     

    Last month, world leaders meeting at the United Nations and later in Pittsburgh included world population in their discussions on climate control.  I don’t think it would be necessary to mandate population control.  We could do more to help prevent the unwanted pregnancies by making contraception more available.

    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.

    Population growth is linked to changes in food and water supply and housing. Rapid increases in population growth is most likely to have negative effects – increasing food and water scarcity, environmental degradation, and human displacement.

    There are more than 200 million women throughout the world who want, but lack access to modern contraceptives. This lack of contraceptive availability results in an estimated 76 million unintended pregnancies each year. This increase puts strain on regional environmental resources (water, food, housing) with increased disease if those resources aren’t sufficient.

    The Lancet editorial discusses the need for better contraception available to women around the world. “It is disappointing to see that there are still tensions between the population and some of the sexual and reproductive health and rights community.”

    The editorial points out a case study from Ethiopia that trained people in sustainable land management practices, while increasing availability of family planning. The area saw an immediate improvement to the environment with better agricultural practices, which in the long term will be sustained and not eroded by a rapidly increasing population.

    Contraception is important to population control which is important to the health of our planet and global warming. It’s all linked.

     

     

    REFERENCES

    • 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

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    Wednesday, October 14, 2009

    Hematoma of Ear (Boxer's Ear) – 1908 TX

    I have previously discussed Boxer’s Ear or Cauliflower Ear.  Now I’d like to share the section on the topic from the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD.

    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.


     

    Related posts:

    Cauliflower Ear (September 21, 2007)

    Mangled Ear--a badge of honor? (August 4, 2008)

     

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    Tuesday, October 13, 2009

    Shout Outs

    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.

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    Geripal is the host of the  October's edition of Palliative Care Grand Rounds, the monthly best of the Palliative Care blogs.

    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!

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    Congratulations to pediatric surgeon Dr Chris Coppola, Made a Difference, who made the following announcement this past week (photo credit):

    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.

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    There is a very nice article on proper care of surgical instruments in the “throw-away” publication Surgical Products, September 2009 issue, p 8-10: “In For the Long Haul by Derek Lashua.” This is just an example of the information in the article:

    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.

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    I very much enjoyed this inspirational article by Matt Damon in this past Sunday’s Parade Magazine:  “We Can Move Mountains” (photo credit)

    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.

    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!”

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    H/T to @murzee for the link (via twitter) to this absolutely wonderful essay on Joy! I hope you’ll read the entire essay.

    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.

    ………………………

    Thanks to @Geek2Nurse

    Smart mama--she knew just what to do! RT @dreamingspires: WOW video footage of Elephant giving birth http://bit.ly/46smpU

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    Tonight Dr Anonymous will have a pre-BlogWorld Expo Show. Come join us. The show starts at 10 pm EST.

    Upcoming Dr. A Shows

    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

    You may also want to listen to the shows in his Archives. Here are some to get you started:

    GruntDoc, Sid Schwab, Dr. Val, Kevin MD, Rural Doctoring, Emergiblog, Crzegrl, Dr. Wes, TBTAM, Gwenn O'Keeffe, Bongi, Paul Levy, John Halamka, and ScanMan

    ……………………

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