I had the privilege of being one of the docs who chatted with Sam Soloman about the most useful smartphone medical apps available. Check out the Parkhurst Exchange’s Practice Management article, that’s little snippet makes me sound so much smarter and more concise than I really am!
My iPhone sits in my scrub pocket or in a leather holster on my belt every day. I rely on it for the usual phone and message features, to handle quick e-mails, and listen to music on a daily basis. If I’m at work, ePocrates, Skyscape’s Taber’s Dictionary and the thankfully free MedCalc seem to see regular action. UpToDate is fortunately built into our hospital’s EMRs so I don’t tend to access it via my smartphone’s small-compared-to-a-desktop’s screen. I use a few other apps when I have more time to dig deep. Skyscape’s RxDrugs has a lot more Canadian and over-the-counter medications in its catalogue; Netter’s Atlas helps when straining to remember long forgotten things like muscular insertion points; and Diagnosaurus helps broaden my differential when I feel like I’ve wandered down the garden path.
PDAs are changing the way we practice. Yesterday, we wrote an “open book” pharmacology/prescribing exam, where the test was about choosing appropriate medications and writing clear prescriptions. If we pass this and other measures, we are then recommended to the College as sound prescribers and will be issued the appropriate registration numbers and duplicate (narcotics) prescription pads.
The object of the exam was not to test our recall of doses or to probe the bounds of our prescribing accurately for rare disorders. Rather, it was a test to see that we could come up with a reasonable drug choice given the patient’s context, using the resources regularly available to us. The questions got at things like: What anti-hypertensive medication would you start first-line for a diabetic patient? What would you do if they were still hypertensive after weeks on that drug? What might be a better choice for someone managing their chronic pain with hundreds of T#3s a month?
We were told to bring our PDAs, since those (and the CPS!) are our main prescriber tools. I think the nature of the questions – testing application and synthesis of knowledge rather than rote memory – and the allowance of our Smartphones was a reflection on the fact that medicine has changed. I don’t know about endorsing one brand of software over another, but some medical schools are even integrating smartphones into their education model.
We are trained to be critical thinkers, and there’s too much medicine to remember; offloading some of the raw data from our brains, there’s now more space to think carefully about why we do what we do, and about how it should be done.
Now the hype is being hyped.
I have to say that it’s hard not to chuckle at the big media outlets, making news out of their own desperate need to make news. After encouraging the panic, and seeing it die down, big media is looking for another story besides the deadliness of H1N1. The new story: media coverage (and public attitude) regarding the current flu pandemic is overblown.
Tragedies have occurred, but it’s time for a reality check, according to most MDs. I recall a recent CBC broadcast indicating that the chances of dying from H1N1 are equivalent to the chances of dying in a car crash. The CBC asks its audience, do you think H1N1 has been over-hyped?
People are looking to unusual sources for their information. The National Post asked some Canadian celebrities about their viewpoints on the vaccine. I’m no expert, but I do get the official government bulletins and live and breath medicalese.
Whenever I spoke to my patients about H1N1, especially when expressly asked “so, why is this a big deal? should I be concerned?” my ’short’ answer was as follows:
Lots of people are sick right now with sore throat, cough, fever, and sore muscles. These people probably have the flu. And if they have the flu, it’s probably H1N1. Most people are miserable for a while, but are able to recover in less than 2 weeks from this flu, which really is just that – a flu. There’s no point swabbing and testing since it doesn’t change our management. If we catch you in the first 48 hrs of having symptoms, we can start Tamiflu.
The reason that we are a bit scared about this H1N1 thing is that people who are generally healthy – and who often do well with the seasonal flu – can (but won’t necessarily!) get very sick. Being young, female, pregnant, and aboriginal are just some of the risk factors. Really, anyone can get it. And if you get it, chances are you’ll be A-OK after a crappy time in bed.
There is some data out there about rates of admission and deaths, but because we are treating most people presumptively and NOT testing them, the numbers are probably way off.
From UpToDate: “2 to 5 percent of confirmed cases in the United States and Canada have required hospitalization . . . however, since the number of cases of mild illness is almost certainly under-reported, [the actual rate is much lower]. . . Of 272 patients requiring hospitalization in the United States for pandemic H1N1 influenza A between April and mid-June 2009, 25 percent were admitted to the intensive care unit (ICU) and 7 percent died”
I hate giving patients prognostic numbers, statistics, etc. because they really aren’t meaningful or accurate, but if I do, I try and frame things so that it makes real sense. When talking about statins, I love to mention “Number Needed to Treat” for my low-risk patients because it makes a huge difference in how they see the cholesterol-lowering therapies risk/benefits balance.
(NB: I’m making up the following numbers for illustrative purposes) For example, if a person has a 0.005% overall risk of being in the ICU as a result of H1N1, I can tell them as such. But I’ll say, when it’s you - it’s 100%. So, protect yourself and others. Wash your hands, get your vaccine, stay home if you are sick and cough into your sleeve. Your risk of dying of this is very very very low, but why not do everything you can to minimize it?
Alan Cassels, a drug-policy critic, has an important viewpoint. While I recommend the vaccine to most of my patients, it is not necessary for everyone. He does have a point in that a large body of data is lacking with respect to vaccine efficacy and safety. Also, drug-companies do stand to benefit from fear-mongering and mass-immunization campaigns so we must be careful. Still, the vaccine has passed the standards set by Health Canada and preliminary data is reassuring and points to efficacy. When you work on the front lines, and see people dead or dying from this, it’s hard to say “ehhhh, let’s wait for more data before we do something.”
Special circumstances require special treatment. In aggressive cancers and AIDS, experimental medications are often tried. These are radical situations demanding radical therapy. Does a pandemic flu count? We’ll never know what would happen if we didn’t vaccinate.
The ideal study would be to vaccinate one population and not vaccinate another population and to introduce the H1N1 strain into all of the subject’s mucous membranes. Then when more people in the non-vaccine group died, we could say “oh look, the vaccine is beneficial.” The design and composition of the vaccine have enough parallels to the available seasonal flu vaccines that we can reasonably assume that the H1N1 vaccine may have a similar safety and efficacy profile.
In One Flu Over the Cuckoo’s Nest, John Mazerolle concludes that the epidemic of stupidity is worse that the pandemic flu; “So, in short, get your flu shot, but don’t panic about it, and remember the government is not out to get you. They just do it by accident sometimes.”
So, I’m about to roll up my sleeve, since I’m working the perinatal unit and it’s a given that I don’t want to be passing my viral passengers to any lovely, glowing preggers ladies.
Just because I was probably one of the last people to see this cartoon:
You’ve probably noticed that my blog has stalled temporarily.
I’ve been on a little break to Vancouver for some Halloween fun, and I’ll be back in action on Thursday Nov 5th when I start my Obstetrics rotation. Yay, babies! I’m sure I’ll have lots of fun things to write about as soon as I start. My favourite part of deliveries is seeing the look on the dad’s face. Sometimes it’s joyful tears, sometimes bewilderment, and other times, their face goes white and they promptly collapse onto the floor. We usually try and put a chair under them before this happens though!
For now though, it’s catching up with old friends and big-city culture on the agenda. Maybe the only insight you get from this post is that doctors like to have fun too. In my case, fun came in the form of dressing up as Boba Fett and dancing like an idiot with my nearest and dearest. The toughest part was trying to see out of the foggy, dark-visored helmet. Also, my jetpack was fairly heavy as the night wore on, and now I sympathize with all the patients I’ve met with macular degeneration and trapezius strains!
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In the meantime, hang in there eager Canadians! I know the H1N1 vaccine lineups are a major deterrent to getting the shot but I’m so glad you are keen on protecting yourself and those around you.
Houston Neal over at Software Advice has asked that I share with you his survey, regarding what affect the Stimulus Bill has had on the use of Electronic Medical Records (EMRs) by physicians.
“What effect has the Stimulus Bill had on EMR adoption rates?”
As a Canadian, I don’t have grounds to answer, but you might! The survey ends tomorrow night (Thursday) and takes about 4 seconds to do. The text refers to ‘tire kickers,’ and I’ll admit, I had to look this up on urban dictionary; basically, it refers to those ‘buyers’ who appraise their options but don’t commit to buy anything. They come and kick the tires of the car (or EMR!) that they are interested in, but never purchase.
On Friday, the official first reports regarding Recovery Act funds will be released.
Makin' vaccine
So, today is the day we’ve all been anticipating. The heavily hyped, steeped-in-controversy, roll-up-your-sleeve-and-say-’ouch’ H1N1 vaccination is available (CBC)!
Through bulletins from the Canadian Medical Association, the British Columbia Medical association, and the Public Health Agency of Canada, we docs have some sort of idea about this vaccine.
** CTV has an Excellent “FAQ” for the Swine Flu Vaccine.**
(I could rehash it, but you should just read the darn thing.)
Even though that FAQ is comprehensive, I just wanted to share a few other links. If you are a real keener, see this brief summary of British Columbia’s H1N1 Pandemic vaccination plan, a document prepared for physicians.
Who is susceptible to influenza?
Everyone. Pregnancy, aboriginal heritage, being young, living in a remote community, and being female seem to be risk factors for developing more severe illness. Those 65 and older may have been exposed to this viral strain long ago, and as such, may have some residual immunity.
Who should get the vaccine?
Everyone (almost). See The Public Health Agency of Canada’s list for the full recommendations.
Should I still get the seasonal flu vaccine?
This part is still somewhat controversial. Current recommendations are that those older than 65 should have the seasonal flu vaccine, and that those getting the H1N1 vaccine have the seasonal shot simultaneously, or if they chose to opt out of one, the H1N1 vaccine should take priority. See the aforementioned FAQ for a more thorough answer.
Some people are opting to get both for various reasons; the main one being that the H1N1 vaccine won’t protect you against other strains of the flu, which can also be deadly, and those strains will probably still be floating around this year (ScienceBlogs). Those not wanting both may have a contraindication to one or the other, may be leery of the vaccine components, may feel they are not at risk, or worry about the vaccines interacting/rendering each other ineffective. Though there was a little blip of data that suggested the last point may be worth considering, and Quebec jumped all over this, now the recommendation is that it is safe and effective to have both immunizations.
National review and examination of both the sequential and the simultaneous administration of the pandemic H1N1 vaccine and the seasonal flu vaccine have determined that administering the seasonal and H1N1 vaccines at the same time is unlikely to impair the immune response to either one. (BC CDC).
I don’t want the shot because something bad will happen to me/my child if we get vaccinated.
See my previous post about safety of seasonal flu vaccines and their components; if you really want to dig deep, all vaccine monographs are catalogued by Johns Hopkins Institute for Vaccine Safety. Again, there is much more in the FAQ about vaccine safety. I defer to that. If you’ve heard something about Guillian-Barre Syndrome (GBS), this NeuroLogica Blog is a good read.
If you make the decision not to get vaccinated, you are not only putting yourself at risk, but you are putting everyone around you at risk (Wired).
I have been working too much and not sleeping enough. Specialist residents have it far harder than I, so I shouldn’t complain, but I’m going to anyway. Just a little, since I’m too tired to think of anything else to write, and I haven’t posted in a few days.
The ER is a fun but demanding environment, and now I’ve definitely bollocks’d up my Circadian rhythm; I inadvertently tested my body’s ability to “phase advance” and attend an early morning Rounds and then completed a day shift, after having worked last night. This is certainly not the most I’ve worked, nor the most tired I’ve been. But it is not the most comfortable way to persist.
I’m glad I did it because the talk (about a Palliative care twinning project in Nepal) was well worth it. That, and I had a great shift in the ER, getting to do a thoracentesis for the first time (following my last night’s first-time Heimlich valve chest tube insertion). Fluid and air in potential spaces, watch out! I’ve got a needle and I (kind of ) know how to use it! I also recently was part of a code, in which I got to tube someone and finally learned how to do a Subclavian Line (whoopie!) after reviewing some software about Subclavian Line insertion and feeling rather an idiot for not having learned one clinically.
Lucky me, I’m on house call all weekend, and will be doing ER shifts Friday and Saturday during the days. It’s going to be quite rough, but somehow it always works out.
So, I would sleep more, but between some genius’ idea of a location for on-call sleep rooms (right at the entrance to the OR, a high-traffic area at most hours, with several *beep-latch click* security door access panels directly on the opposite side of the thin walls) and the vibrating (stuff falling off the shelves, windows rattling) construction during the daytime at my apartment, I’ve had a HARD time this month.
Incidentally, our Resident Physician union is currently offering a survey in which one of the questions asks about a hard-cap on weekly hours. Does more sleep make for better doctors? (NY Times article). I don’t know about that because sometimes there are learning opportunities that far outweigh sleep, but a lot of the time sleep is sacrificed for less important reasons. But right now? It’s totally nap time.
Oh. And I should probably eat.
* Disclosure: I was provided a free copy of the iPhone software for the purposes of review.
Over at PalmDoc, software is the name of the game. Recently, Meister Med’s Lumbar Puncture software was reviewed. I was asked to do the same for their Subclavian Line software. (Thanks to Alan for the opportunity.)
Software: Procedures- Subclavian Line
Manufacturer: Meister Med
Cost: $2.99
Availability: iTunes App Store
I come at this software as a first year resident, one who has just gotten a handle on central lines in the form of intravenous jugular (IJ) catheterization during my month’s rotation in the ICU. The next step? Subclavian lines. Now, how better do I feel to have a virtual cheat-sheet in my pocket? Much!
In addition to their iSilo catalog, Meister Med offers four iPhone applications: PediDoser, ICD-Meister, the recently reviewed Procedures – Lumbar Puncture, and now, a very simple and straightforward app for mastering these technically challenging central lines. Procedures – Subclavian Line is a standalone multimedia application containing almost everything you need in order to perform a subclavian venous catheter insertion.
First, I explored the Procedure Details section, in which there were Indications, Contraindications (absolute and relative), Complications, Step-by-Step Technique, Landmarks, and (ICD-9) Coding.
I have worked with many different Intensivist attendings, and each has their own reasons for preferring jugular or subclavian lines; though the reality is that different circumstances require different approaches,when there are no other deciding factors, the nature of complications is often considered. Generally, those who prefer to stay away from subclavian lines often site the fear of a pneumothorax as the reason, and those who prefer the subclavian argue that the low infection rate makes it a better choice.
So, the utility of the Complications section of this software is particularly evident. It quotes rates of infection, pneumothorax, hemothorax, catheter malposition, and other complications that may result during insertion of this type of line.
While academic discussions and choosing to employ the subclavian line correctly in the clinical setting are important, your money’s worth is really in the Step-by-Step and video section. Reviewing the text and then opening the standalone video, I feel confident that anyone could skip the “see one” stage of learning. I’m not going to undertake a subclavian line without clinical supervision, but this is a good start and will surely save me from major faux pas. If I could add anything, it would be more in depth landmarking discussion, perhaps including ultrasound-guided techniques.
My apprehension with subclavian lines is related to finding the vessel; I want to be able to get it in as few tries as possible, and not cause a pneumothorax or go arterial in the process. This software hasn’t completely relieved my fears, but it does offer a good starting place.
For less that $3, you can develop a solid approach or hone your technique to this important clinical procedure. It’s well worth it.
I’ve accidentally collected some odd links over the past few weeks, and what else to do but share them?
If you are looking for things to put in your curio, check out “Radio Guy’s” virtual museum of weird medical devices.
Rather than a collecter, are you more of a diagnostician and into House’s brand of rare and strange conditions? You might like reading about the Top 10 Strange Medical Anomalies. From Proteus Syndrome to Progeria, they sure have picked some odd ones.
Maybe you’ve never heard of it, but part of “medical student (or resident) syndrome” is that we diagnose ourselves at some point with many of the diseases we read about. I am proud to say, I have not once considered that I have Jumping Frenchmen of Maine Syndrome. This disorder – consisting mainly of an increased startle response – was first discovered in Quebecois lumberjacks in the 1800s. If that tickles your dopamine receptors, The Science Channel actually maintains a list of the top 10 little-known mental disorders.
It’s hard to tell whether some of the medical conditions listed by Oddee are a blessing or a curse; Permanent Sexual Arousal Syndrome, hyperthymestic syndrome, and not feeling cold (like the Iceman) have got to have their perks! Okay, probably not for long. Cancer sucks (a gross litotes, I know) but one cancer survivor could be a superspy, thanks to having their fingerprints erased by chemotherapy.
More of a miracle-lover? Take the baby that gestated in the capsule of the liver, a guy who survived a survival knife being rammed into his brain, and the person whose , for starters. Oddee helps us out again with their 10 Most Fascinating Medical Miracles.
Are any of these things true? I don’t know. But not a week goes by in our hospital without something remarkably odd happening. Whether it’s ducking doughnuts lobbed at me by a certain 1st floor patient with dementia, brushing off sexual advances from a psychotic admit, or hearing about a patient shooting at security guards with a pellet gun, life at the Regional is never normal. Thank goodness for laughter.
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We Canucks have our Thanksgiving a bit earlier than our friends south of the border. Tonight, there was the standard turkey, potatoes, gravy, etc. and our bellies are full of warmth and wine.
Why are we so sleepy after we eat this bountiful meal? *yawn* There are lots of causes of fatigue, but some very specific to turkey day. Some say it is that a large amount of blood diverted to the gut for digestion, relatively reducing the oxygen that reaches our brain, that causes this fatigue. Better explored is this theory:
Turkey contains high amounts of tryptophan (* I’ll address this ‘fact’ later). Tryptophan is an amino acid, and a precursor for serotonin, a neurotransmitter thought to be involved in mood, sleep, appetite, and learning. An increase in tryptophan means an increase in serotonin (1); this and the subsequent production of melatonin – a hormone that helps regulate our body’s clock – is the going explanation for why eating turkey makes us want to head to bed.
A placebo-control study explored objective and subjective measures of fatigue following ingestion of tryptophan; the study, published in Nature, found that both perception and objective measures of fatigue were significantly altered in the test group. The study only had 6 participants, drawing into question its validity and generalizability. However, other data, like rat studies, support the increased tryptophan –> elevated serotonin & melatonin –> central fatigue theory.
In MIT’s Technology Review, they looked at data showing that tryptophan helps sustain trust and cooperation. They also touched on the idea that the turkey isn’t actually the cause of our post-prandial (after meal) fatigue. And this seems to be true. Turkey doesn’t contain much higher levels of tryptophan than do other kinds of meat, and per gram of protein, milk is actually one of the foods that is most rich in this substance (wiki helped me). The large amount of alcohol and carbohydrates that we imbibe along with our turkey dinners is probably the more likely culprit for our fatigue.
Alcohol is a central-nervous system depressant and can be a contributor to dangerous degrees of fatigue. Even if we are sober, we still pack our bellies with lots of starchy goodness over the holidays. Ingestion of carbohydrates triggers the release of insulin, a hormone involved in metabolism. The surge of insulin stimulates our muscles to uptake certain kinds of amino acids with the exclusion of tryptophan, creating a relatively elevated amount of tryptophan in the blood. More tryptophan is then taken up by an amino-acid transporter into the central nervous system, converted into serotonin, melatonin, and voila, zzzzzzzzzzzz! If you are a biochemistry keener, read the Introductory section of this paper.
On that note, I’m off to bed. Enjoy your holiday and please be safe on the roads. Gobble gobble!
From Tryptophan to Serotonin to Melatonin
I trimmed down and emotionalized my previous Letter to the Editor about the lack of extended care facilities for the elderly on Vancouver Island. I added some new information: one of the hospital social workers learned at the hospital-wide bed meeting that 80 of our beds were occupied by these medically-stable folks awaiting placement*. 80! That’s a huge issue, and the reasons are obvious. So I thought I’d share it in a letter.
Fortunately, it’ll get some air as the Times Colonist did publish it. You can read that version here.
Just a quick note on Letters to the Editor. Even if you write to the smallest, piddliest, lowest-circulation paper, anything that mentions a Minister or Premier tends to wind up on their desk. Easiest way to get to the top! (according to Dr. Schumacher, former CMA president). Even if that’s not true, at least someone will read it! I hope.
* yes, I used second hand information. I think the source is good, but I’m a journalist. My goal was to get the issue some attention, and I think this might be a fair start.
