Grand Rounds Volume 7 Number 52

Updated 3/2017-- photos and all links removed (except to my own posts) removed as many no longer active. 

Welcome to  Grand Rounds 7:52, the weekly collection of the some of the best in online medical writing from all (doctors, nurses, patients, healthcare professionals).  Next week’s host will be ZDoggMD. His theme is Funny Medical Stuff but he will accept good submissions on almost any medical topic.  He set a deadline of September 20 (today), so don’t delay.  You can email submissions to him at zdoggmd (AT) gmail (DOT) com 

Dr. Charles, The Examining Room, ask me to remind you of the Charles Poetry Contest.  It seems the “science hordes” have actively submitted poems while the medical folk have not.  You have until September 31st to get your poems in. 

Dr. Charles submitted this particularly moving poem to Grand Rounds for your enjoyment:  A Four Minute Heaven (by Kevin Nusser)

Heaven lasts four minutes
the duration of hyperactivity
from the oxygen-deprived brain
this is my four-minute stroll
It opens with me beside the bathtub
washing Sarah’s hair, she is 6 years old
I’ve used too much shampoo to get extra bubbles
and they are running down the wall above Sarah’s hand ………….

Go read the rest of this poem and check out the other ones.

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Paul Levy, Not Running a Hospital, asks a seeming simple question “What would you do?" which garnered many thoughtful comments.  If you haven’t read it, please, do and the comments too.

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The post painfully aware  from PalMD, White Coat Underground, is aptly titled from so many angles.  I hope you will go read it all (photo credit):

She didn’t look well.  No one “looks well” sitting in an crowded ER, but she really didn’t look good.  At first glance from across the room I assumed her to be fairly old, how old I wasn’t sure.  Scrawled atop her clipboard in red Sharpie was ADMIT TO MEDICINE. I pulled the board and walked over to her. ……….

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Bongi, other things amanzi, tells us about how medicine and culture can collide in his post tangled tassels

in quite a few of the cultures in south africa people tie ribbons, strings and tassels around their own and their children's wrists and waists. these tassels are imbibed with power to keep evil spirits at bay, i am told. if these tassels come off then the patient is completely unprotected from any and all marauding evil spirits that may be lurking around. of course, not wanting to be responsible for the unopposed assault by multiple evil spirits, most people are fairly reticent to remove these things. i saw it slightly differently. …..

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Henry Stern, InsureBlog, introduces a patient on the lookout for a "Competitive Oncology."

……….So what is she looking for?

Well, obviously that they "connect" on a personal level, but then she said "I want a doctor who's competitive." When I asked what that meant, her answer stunned and delighted me: ………….

Go read Henry’s post to find out the answer.  I loved it!

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Movin’ Meat tells us “what health care rationing looks like”:

………….. OK, I can get behind those as non-emergency ER conditions. I'd quite like to see those folks re-routed to clinics or PCPs. But wait, there's more! Other "Non-emergent conditions" for which the state will not pay include:
Chest Pain
Abdominal Pain
………. There are many others -- these are just the most ridiculous "non-emergency" conditions that jumped out at me. It's also manifestly arbitrary and haphazard what made it onto the list and what did not. The HCA considers "Cholelithiasis with acute Cholecystitis" an emergency condition worth paying for, but "Acute Cholecystitis" is not. The state will pay for hand cellulitis, but not for the more dangerous foot cellulitis……...

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Jordan, In My Humble Opinion, writes a lovely piece on a time when he had A Moment Of Clarity

Although the name on the chart was oddly familiar I couldn't place her. I was covering for a partner who was on vacation. It felt like my day would never end.

When she bopped into the office I knew immediately. We went to school together. Years ago. She sat down quietly on the exam table typing away on her mobile phone. I approached cautiously my mind musing on occupational hazards. I wondered if she would recognize me. ……….

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d.o.ctor writes about an observed pericardial window procedure and the irony that a big heart can mean a medical abnormality and a generous spirit:   A Window into the Heart

It's quite curious really, the expressions we use to describe a person's generous spirit can have a completely different meaning in medicine. Let me explain...

I was assigned a patient one very early Monday morning. He had arrived at the hospital with increasing shortness of breath, and upon further investigation it turned out that he had pericardial effusion. In the time leading up to the surgery, pericardial window with drainage of the effusion, …..

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Dr John M has been in a small rut this week. During a “rut-busting” indoor training ride (complete with some good tunes), he was inspired by the framed Hippocratic Oath hanging on the basement wall--“the one they gave me as I walked across the stage in 1989”:   The basics…

………I read it, again. There was a churn, from within. Sometimes it helps to remember the basics—the bottom line, the real meaning, the forest, not the trees or the CPT codes, or the…(many) negative things that draw our hearts, our minds, and our souls from the basics.  ………….

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Richard Winters, MD, Beyond the Clinical, is a first time grand rounds submitter (thank you very much).  He gives us 5 ways to Fight Bitterness and Be A Content Physician Leader (photo credit)

I was crabby.
But I didn’t know it.
Relaxing into the evening. Sitting on the couch. Reading news and checking email. Surrounded by family.
My 6yo daughter excitedly asks me something about smurfs and mermaids. I snap.
“It’s time for bed. Go brush your teeth. I need time alone. And this place is a mess.”
Then I feel guilty………….

None of us want to take the stresses and anxiety from the work place home.  Go check out his tips.

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The Boerewors Emergency Medicine Chronicles wrote a remembrance post sparked by 9-11.  He lost two friends that day when the towers fell, but this post is from his days in a South Africa emergency room:  Triage

Saturday 2 July 1988.
About 17H20.

I was at work as a Charge Nurse in the Department of Emergency and Ambulatory Paediatrics aka 'Children's Casualty' , (Area 161) in the Johannesburg Hospital .

We were having a very pleasant afternoon …. reasonably quiet,a few interesting cases to keep us on our toes but mostly we were relaxed and chatting.  ……

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Kim, Emergiblog, tells us how making a mistake as a teenager these days is not like it used to be; it can follow you forever: 
Somebody's Baby.

The car drifted by the ambulance entrance. The glow of the brake lights lit the corner of my eye.

Incoming.

I closed my textbook. Sigh. I was hoping for downtime.

There was activity in the parking lot. A group emerged, formed a circle and scooted rapidly through the pneumatic doors, right up to the nurses station.

They all spoke at once.

Not breathing…won’t wake up…vomited…alcohol poisoning…can’t wake her up…drinking….not breathing…oh my god…poured water on her…throwing up…called parents…voicemail…

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Dr. Val, Better Health, interviewed actress Meaghan Martin ( @ettejnahgaem ) who shared how she overcame "poke-a-phobia" on the #HealthyVision show:  Actress Meaghan Martin: Teenagers, Self-Esteem, And Contact Lenses  (photo credit)

…….. I was a typical nerd as a kid. I had glasses, braces, and an asthma inhaler. ……….

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Steven, SteveSeay.com, discusses using prank phone calls and "intentional mistakes" as a cognitive behavioral strategy for reducing social anxiety in his post Social Anxiety Treatment:   CBT & Intentional Mistake Practice (an example)

When I was a kid, one form of mischief that was briefly popular in my neighborhood was crank calling strangers. Usually, the bravest kid in the group would pick up the phone, and with the encouragement of all the other kids in the room, would dial a random telephone number. A brief, very Bart Simpson-esque conversation would then ensue. Usually it would go something like this:

Kid: Hello, ma’am. I am conducting a brief survey for the Grocer’s Association. Do you have a minute to answer a quick question?
Stranger: Of course. How can I help you?
Kid: I was wondering if you have Sara Lee in the freezer.
Stranger: Why, yes I do.
Kid: Well then let her out!!!
We would then bust out in laughter and hang up the phone ……………….

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Do you use black humor in your workplace?  Do you keep it there or do you use it in public places, including Facebook and Twitter?  There has been much discussion of this over the past week and Laika, Laika's MedLibLog, writes a post “about the inappropriate use of black humor by doctors (using terms like "labia-ward") at Facebook & Twitter”:   Medical Black Humor, that is Neither Funny nor Appropriate.  Please, go read it all.

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Elaine Schattner, MD, Medical Lessons, wants us to Keep it in Focus: One in Seventy.  One in 70 is the number of women in the U.S. who develop breast cancer in their forties.  Elaine feels this “astonishingly high number gets lost in the media's mixed messages about breast cancer awareness and screening.”

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Dr Ves, CasesBlog, writes Doctors are natural communicators - social media is extension of what they do every day and gives us some simple guidance for social media use

The suggested guidance for social media use by health professionals is very simple and based on a recent book by a nurse and social media advocate:

1. Remember the basics:
- your professional focus
- the laws around patient privacy (HIPAA in the U.S.)
- the professional standards of regulatory bodies and of your employers
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A guest post by Robert Peinert on The Sterile Eye blog asks “Is the Tide Changing?”  (photo credit)

Over the last several years, as I continue to do research for various projects, I’ve read about a growing number of Medical Photography Departments that are shutting their doors or changing their focus. Private hospitals, public community-based hospitals, and even several university-based hospitals have closed their photography and media departments in recent years. Costs and hospital/departmental needs are among the top reasons, however a more reoccurring reason is the growth of technology…….

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Skeptic Scalpel (@Skepticscalpel) wants us to know “why Joint Commission hospital ratings suck”:  Joint Commission Proves It's as Irrelevant As HealthGrades

The New York Times reports that the Joint Commission has just published a list of its 405 "Top Performing Hospitals." As is typical of these types of evaluations, most of the large, well-known teaching hospitals where knowledgeable folks [like doctors] go for care when they are really sick didn't make the list. ……

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Louise,  Colorado Health Insurance Insider,  tells us that Negotiating Premiums Doesn't Lower the Cost of Healthcare

………….How would it help to have health insurance exchange boards negotiating with health insurance carriers to try to lower premiums – without addressing the root problem, which is the ever-increasing cost of healthcare?  If the carriers were to agree to lower premiums, they would have to cut back on how much they spend in claims, since that’s where most of the premium dollars go (you can only trim admin costs so much).  That would mean either cutting back on benefits or paying providers less money for the work they do.  Neither of those options are just between the carriers and the exchange board.  Cutting back on benefits directly impacts the insureds, and cutting back on reimbursements directly impacts providers.  Either way, it’s not something that can be realistically “negotiated” between health insurance carriers and health insurance exchange boards.  The other major players in the healthcare industry (Pharma, hospitals, doctors, device makers, etc.) have to get involved too. ……….

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Dr Ves, Allergy Notes, tells us that food-specific IgE tests aren't sufficient evidence for eliminating foods from a child’s diet

In a study of more than 100 children on food elimination diets based on positive serum IgE immunoassay results, oral food challenges (OFCs) demonstrated that most of the foods were being unnecessarily eliminated from the diet. …….

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Nora O’Brien-Suric, Health AGEnda blog, provides us an overview of geriatric emergency rooms in her post:  “Building a Better Emergency Department for Older People”

In an earlier post I mentioned my observations of how traumatic a trip to the emergency room can be for older people, and I promised to write about the emergence of geriatric emergency department (ED) models that provide better care for older people and can be a cost savings to the hospital. …….

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Jessie Gruman, Prepared Patient Forum, talks about how Nine out of 10 of Us Like Health-Related Numbers

“My doctor can titrate my chemotherapy to the milligram but can’t tell me when I am going to die,” a friend who was struggling with his treatment for cancer complained to me a couple years ago.  ….

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Thank you for contributing and reading.