28 August 2011

Chiropractic medicine, in comic form

Darryl Cunningham has a lovely detailed explication of the state of chiropractic "medicine," in a multipanel cartoon format!


Worth clicking through to see the whole thing.

26 August 2011

Bruce Lee vs Chuck Norris

A martial arts classic, though perhaps a bit campy 40 years later:

And no, I have no idea what's up with the kitten.

25 August 2011

Thank God for Japanese Pop Culture

It's like a cotton candy-themed acid trip.

I can't look away. It's a weird fascination.

18 August 2011

Time waste central

Well, it's not exactly time wasted, because it's educational. But I just came across a fun and kind of addictive web site called One Night in the ED. It's not new -- looks like it's at least 6 years old, but I never saw it before.

It's just a collection of about 70 CT scans (and a few plain films) which you can view as unknown and try to guess the diagnosis. The CTs are fully represented and you can scroll up and down as you would on your PACS system. Then you click through to the diagnosis and an explanation.

It's great fun -- I just wasted half an hour there and I suspect I'll be back later.

Reversing the trend

Well, this is satisfying. Over the years, in our ER we have mirrored the nationwide trend and have significantly increased the utilization of CT scans across the board. The reasons are manifold. Some cite malpractice risks, and indeed in our large group we have had one lawsuit for a pediatric head injury and another for a missed appendicitis which probably did contribute. But, in my opinion, there have been many other drivers of the increased use. For one, CTs have gotten way, way better over the last 15 years, which quite simply has made them a better diagnostic tool. They've also gotten way faster. As the facilities have invested in CT scanners, they have increased their capacity and increased their staffing, so the barriers to their use have rapidly diminished. I am so old that I remember when ordering a CT involved calling a radiologist and getting their approval! No more of that, I can tell you.

But a couple of years ago, we really started paying attention (perhaps belatedly) to the risks of increased exposure to radiation, especially for kids. And at that point, we began a concerted effort to reduce the use of CT scans in children. I pulled the numbers today, and here are the results:

(patients <14 y/o, all types of CT scans)

A 40% reduction from the peak utilization. Not too shabby. We were at about the national average at our peak -- studies show that CT scans were ordered about 6% of the time for pediatric ED visits. How did we make the change? Mostly by paying attention to it and talking about it a lot to our medical staff. We made it a journal club, we presented it multiple times at our department meetings. This is, by the way, a pretty significant commitment of limited resources, since we typically have only about 2 hours of clinical education time with our docs per month, and every time we brought it up, it was at the expense of some other topic. We also developed pediatric abdominal pain algorithms which utilized ultrasound and surgical consultation above CT scanning, and we emphasized the CT-sparing clinical decision-making rules for head injury.

Are we still "too high"? I don't know, because I don't know where it optimum rate of CT is. It's not zero, not at a trauma center, and sometimes there are belly pain cases that really do need imaging beyond ultrasound. I'm content with the relative reduction we have achieved so far, and hope we can improve on it as all the docs gain comfort with the radiation-minimizing technique. Some docs are always slow to change their ways, or persistently risk-averse (and test-happy). Maybe more data will come out to guide us in further reducing unnecessary scans.

Or, American medicine being what it is, maybe we'll just wind up ordering more MRIs.

Mad Skillz

Just amazing

17 August 2011

Breaking it in

Well, our new ER has officially been "christened." Somehow a drunk guy got out of his room, came right up to the nursing station, took a poo on the floor right in front of the main nursing desk, and went back into his room -- all without being noticed.

Yup, it's a great night in the ER when there's human feces on the floor in the main hallway.

09 August 2011


Stands for "Damn You Autocorrect!"

I'm sure half of these are fake, but even so they're fricking hilarious. Be sure to check out the "Best of DYAC" -- it's totally worth it.

Spot the Lesion

Yesterday, I presented the case of a woman with double vision and ptosis and challenged you all to a game of "spot the lesion." To be honest, I found this stuff impenetrable as a medical student and it was only by sheer force of will that I was able to commit it to memory for exactly long enough to pass a test on it before immediately purging it from my memory. I did this several times for various board exams and such, but it never really "stuck." Hated neuro beyond words, I did.

As mind-numbing as I found it all in the abstract, I get excited about these cases in application. I may not remember where exactly the internal capsule is or what it does, but when I see someone with an interesting neuro deficit due to a lesion there, all of a sudden it makes so much more sense, and is, dare I say it, cool. I know, kinda sad.

This case is as classic (and cool) as you will ever see. It's a complete palsy of the Oculomotor Nerve (CN 3 for those keeping score at home).

So how do you approach figuring that out?

First of all, it's unilateral. Note the movements of the left eye are all normal. Some other things, systemic diseases, can cause ptosis (the droopy eyelid) or diplopia (double vision) -- think neuromuscular stuff like myasthenia gravis, botulism, etc. But those are usually bilateral. As an isolated right-sided finding, however, that should prompt you to think about either a central cause or a direct neuropathy. But central causes of this sort of thing are not likely, because the oculomotor nuclei are located deep in the midbrain, and are crossed, so a stroke or something bad there is not likely to give unilateral or isolated neurological findings. Therefore, we know it's a peripheral neuropathy. Yay! But which one?

The ptosis -- especially a complete paralysis of the levator palpebrae -- should be a huge red flag that the third nerve is involved. Even I remember this mnemonic from medical school:

The III is the pillar that holds the eye open; the 7 is the hook that closes it. Then you look at the pattern of movements that the eye has lost and note that it matches the oculomotor muscles which are innervated by the third nerve:

extraocular muscles

She can abduct it, so CN6 is intact, But up, down and adduction are shot, which are all CN3. The fact that with straight gaze and lateral gaze the right eye is a bit down compared to the left is due to the preserved function of CN4. Thus, the classic pattern of CN3 palsy -- "down and out."

Then you look at the pupil. It's big -- so you know this isn't a Horner's syndrome, though that wouldn't cause ophthalmoparesis either. And it's not reactive, either. The most common cause of acquired CN3 palsies is diabetic microvascular ischemia -- one of the many peripheral neuropathies that the sugar causes. But those are usually pupil-sparing. This involves the pupil, so something is compressing or otherwise pissing off the nerve directly.

The solution (as for just about everything in neurology, it seems) is to order your MRI, but in this case, you definitely want an MRA as well. Because the next most common cause of CN3 palsy is compression by an aneurysm (notoriously the PCA - posterior communicating artery). The deficit can apparently be intermittent with an aneurysm. But all sorts of things can do it, and the treatment will depend on the cause. It could be direct compression from a pituitary tumor, or a cavernous sinus thrombosis. If the patient presents with stiff neck and meningismus, either subarachnoid hemorrhage or meningitis should be considered, as they can do this. Demyelinating diseases can also do this, so if all else fails and if the demographic makes sense, consider MS. In older patients, consider arteritis, too. Herpes zoster can also rarely do this, though it's more classically the seventh nerve. These can occur post-traumatic, but be sure that the pattern of the deficit matches the nerve and that you're not going to miss an orbital wall fracture! I recently saw a patient with a port-traumatic transient internuclear ophthalmoplegia, which was also pretty cool. Sadly, I didn't have the presence of mind to get pics of that one.

In the incident case, the MR showed a suprasellar mass invading the cavernous sinus, most likely a pituitary macroadenoma:


Not something you can see commonly, but very classic, and a nice opportunity to review and relearn all the neuroanatomy we learned in medical school, but in the context of a real case.

08 August 2011

xkcd again!

Damn, this one hit close to home, since Liza's going through radiation right now:

xkcd: Tattoo

But it makes it sound so BADASS.

Make sure to click through to see the rest of the comic. It's worth it. Make sure to mouse over the image to read the alt-text.

Randall Munroe is a genius.

Case of the day

A 72-year old woman presents with a complaint of headache and that her right eye "just isn't working right." She is generally healthy, with only an idiopathic anemia, and no associated symptoms other than some fatigue and poor appetite. She characterizes the headache as being a sinus headache, and notes that it has been occurring on and off for a month or so, though she has never had any fever or nasal congestion/drainage. She has had "eye problems" related to this headache in the past, but today it is more severe than before.

When the patient looks at you, this is what you see:


She cannot voluntarily retract the right eyelid. It is nontender, and when you retract it for her, she complains of diplopia. You see this:

straight gaze

The right pupil is dilated and fixed; the left is 3 mm and reactive. Note that with level gaze the eyes do not seem quite conjugate. The right eye is deviated mildly down and out. When you ask the patient to look to her left:

Left Gaze

There is no movement of the right eye at all. And when you ask her to look up:

Upwards gaze

Again the right eye does not move. Same with downwards gaze. On attempted right gaze you see this:

Right gaze
Uploaded with Skitch!

But on right gaze the patient still complains of diplopia. Vision in the right eye is grossly intact to confrontation. The right pupil reacts neither to light or attempted accommodation (on a very limited exam). Neurological exam is otherwise entirely normal, including as many cranial nerves as an ER doctor remembers how to test.

So -- what is the clinical finding here, and where is the lesion most likely to be based on the information you have?

Answer and discussion tomorrow.

(Photographs taken/published with patient permission.)

01 August 2011

We are now the hostage

News today is all over the debt ceiling deal which is brewing in Congress. I'm less interested in the horse-race element of who won, who lost than I am in the policy implications of the deal as it is currently taking shape. And there's one thing there that I really don't like, and anybody in healthcare should be pretty apprehensive about.

Here's the broad outline:

  • The debt ceiling gets raised and economic Armageddon is averted. Good enough.
  • A panel of mutually agreed spending cuts of about $900 Billion is enacted.
  • A commission is formed to negotiate another $1.5 trillion in deficit reduction over the next year or so.
  • A trigger is placed: if the commission fails to agree on the $1.5T in deficit reduction, certain deep cuts automatically go into effect.

The land mine here is the trigger. It's supposed to be a package of unacceptably painful spending cuts, so heinous that neither party would be willing to let them go into effect. It includes deep defense cuts which probably will be blocked, deal or no deal. But it also includes deep cuts into medicare and medicaid. To avoid any accusation that either party is willing to reduce benefits, though, there is no reduction in eligibility or benefits. All the reductions are in provider compensation.

I find this pretty scary. Details are not out there, so I don't know whether these cuts would be from hospitals, physicians or some combination. But I recall the ten-year cost of the SGR fix is supposed to be about $300 billion and sources indicate that is about the amount that is supposed to come out of medicare if the trigger goes into effect. I kind of doubt that the whole amount would come onto the shoulders of physicians, but it's a concerning possibility.

I'll be very interested to see the detail of the deal when they become available -- probably after passage. It seems to me that this is a terrible deal for health care providers -- the nation's economy was held hostage to the debt ceiling and deficit hawks. Now that has been defused, but the health care sector has replaced the overall economy as the hostage, and one I fear policymakers will be more willing to sacrifice in the name of expediency.