Super Bowl Stadium Snack Tray

TOTAL CALORIES: 24,375
TOTAL GRAMS OF FAT: 1,285
TOTAL COST: $86.47

Step by step instructions here.

Four Chord Songs

Pretty cool.

h/t Ace.

The Uselessness of the TIMI Risk Score

Supposedly one of the measures which is evaluated during the process of "Chest Pain Center Accreditation" is the use of the TIMI Risk Score in the Emergency Department:

• Age over 65 years

• More than 3 risk factors for CAD

• Known CAD (stenosis ≥ 50%)

• ASA Use in Past 7 days

• Severe angina (≥ 2 episodes within 24 hrs)

• ST changes ≥ 0.5mm

• Positive Cardiac Marker

Add one point for each factor, total up the points, and you now have an estimate of the likelihood in the next 14 days of all-cause mortality, myocardial infarction, or severe recurrent ischemia requiring urgent revascularization.

In theory this sounds like a neat way to streamline and validate our medical decision-making, but in practice this system is totally worthless to us in the Emergency Department. Consider these examples:

1) The 64 year old with known coronary artery disease status post stenting of his proximal LAD, who has neglected to take his aspirin or plavix for the past week, who presents with a single severe episode of unstable angina that woke him from sleep 2 hours ago, who has significant ST depression, but his first set of cardiac enzymes is negative. He has only a TIMI risk score of 2, so he supposedly has only an 8% risk of death. I guess we should send him home.

2) The 44 year old hypertensive Marlboro man with chest pain and a positive troponin but no ECG changes gets only a TIMI score of 1, so his risk of death is even lower, only 5%. He can follow up next week, I suppose. Be sure to tell him to come back if he gets worse.

In practice, we aren't sending anyone home with ischemic ECG changes or elevated cardiac enzymes, so I find that this scoring system is completely useless to my practice. Protocol-driven medical decision-making is always going to be inferior to expert clinical judgment. This is also one of the reasons you should be suspicious of the current fad of the various "accreditation" merit badges hospitals proudly display. They are equally worthless.

Thank You President Bush

You can leave a thank you message to President Bush here.

UPDATE: And you can read the letter from the Bush twins to the Obama girls here.

Rationing AICDs in Canada

Dr. Wes on rationing of electrophysiology services in Canada:

I asked how many defibrillators (they) performed a year and asked who paid for them, and she said the government. "But we got authorization to do five more devices next year," she said.

"Only five?" I asked in disbelief.

"Yep, and we were lucky. Other centers got fewer. They're expensive, you know. We have to be very careful about who we select to get one of those. It's not like America - people here are used to waiting."

And then I wondered: would America ever be capable of overt rationing, as in Canada?

I hope not.

Jack Johnson

On this day of remembrance for Martin Luther King Jr. and the eve of the historic inauguration of Barack Obama, I suggest to those of you who are unfamiliar with the story of the "Galveston Giant" that his life is worth remembering today as well.

It was just over 100 years ago on December 26, 1908 when Jack Johnson became the first black heavyweight champion of the world.

If you have Netflix, the Ken Burns biography Unforgivable Blackness is available to watch instantly. It's amazing to consider how much things have changed in a century.

"Johnson in many ways is an embodiment of the African-American struggle to be truly free in this country — economically, socially and politically," said Burns. "He absolutely refused to play by the rules set by the white establishment, or even those of the black community. In that sense, he fought for freedom not just as a black man, but as an individual."

Shot Time

At every ER where I've ever worked, there is a rule that must have been passed down through generations of nurses, a requirement with such authority that its justification is rarely questioned, a guideline that is so ingrained in nursing practice that only a fool would speak out against it, and then only in passing, because everyone knows that this policy is as important to nurses as their midshift break. I'm referring to the dogma that patients must remain in the ER for 20-30 minutes after receiving a tetanus shot before they are allowed to leave the premises.

Nurses will occasionally bend the "only 2 visitors in a room" rule, they might fudge on putting both of the siderails up on your stretcher, they aren't always precise about how quickly they push certain drugs through an IV, and they definitely don't reach 100% compliance when it comes to making you change into a gown prior to my evaluation, but if you try to leave too soon after receiving your tetanus shot, you'd better be prepared for a struggle, or at least a tongue-lashing. By the nurse, that is. I don't really care.

I've ordered literally thousands of tetanus shots, and not once have I needed to re-assess a patient afterwards. But most of those patients have complained at least a little bit about the wait, and many of them have become quite upset. Is it really worth it? Call me a heretic, but I say let them go. The evidence seems to support my anecdotal experience: "The risk of death from anaphylaxis following DT, Td, or tetanus toxoid (is) extraordinarily low (page 110). No cases of death...were reported through MSAEFI (the CDC's Monitoring System for Adverse Events Following Immunization) between 1979 and 1990. During that time, approximately 1.3 million doses of DT and 29 million doses of Td were distributed (page 109)."

Coo-Coo or Contra Coup

I recently treated a very old and pleasantly demented gentleman who had slipped and fallen at home, sustaining a laceration to the back of the scalp. It was a witnessed fall, his second in less than a month, and there was no report of syncope or loss of consciousness. Other than the laceration, the patient was without complaint and neurologically intact, at his baseline mental status. He just wanted me to hurry up and close his wound so he could go home.

I briefly considered not ordering a CT scan; after all, his recent head scan (reflexively ordered by one of my risk-averse colleagues) was normal, he wasn't on any blood thinners, and he seemed to be OK. Apparently there are some ivory tower physicians who think we ER docs order too many imaging studies, and I heard them murmuring like a chorus in the back of my mind. Fortunately, I ignored them.

I'm certain that if I had NOT ordered a CT scan on this patient with a seemingly benign injury, the Multidisciplinary CT Scan Rationing Committee would have had a meeting with the Quality of Care Committee and they would have jointly supported my decision...even after his subdural hematoma and hemorrhagic cerebral contusions had become clinically apparent and possibly devastating. Maybe they would have even given me an award for my outstanding clinical judgment or my superior rationing of resources.

In the real world outside of academic conference rooms, nobody ever gives you a pat on the back for ordering fewer tests or practicing more cost-effective medicine. But one thing that academia and private practice have in common is that administrators in both arenas have a very low tolerance for missed or delayed diagnoses, particularly when the outcome is bad.

So we'll continue to order as many damn CT scans as we want. Personally, I'd rather order 1,000 "unnecessary" CT scans than face the question of why I didn't order the one that might have mattered.

My Beach Office

Ask about our lunch specials.

Grand Rounds

Grand Rounds is up, hosted this week by Dr. Edwin Leap. I hadn't contributed lately, but I happened to have a post this week which fit his topic: profit in medicine. Well done, Dr. Leap.

Four Fifty

This really happened:

A young lady presented to the ER with a superficial laceration to the finger that required sutures. Maybe she also got an X-ray to rule out glass in the wound, I can't remember. When the treatment of uninsured patients is completed, our billing clerks request payment of the emergency department facility fee at the time of service. Of course we can't make them pay (unlike any other business), but we still ask for payment. The physician's fee is billed later through our billing company.

"That will be four fifty," said the billing clerk.

The young lady fished out a five dollar bill from her purse.

"No...four HUNDRED and fifty dollars."

It might as well have been $450,000,000.00.

Global Warming (or not)

"(Climate change) is the biggest whopper ever sold to the public in the history of humankind." - the Huffington Post

An inescapable truth.