Wednesday, April 25, 2007

I’ve been away and computerless for the last few days

So today I surveyed some of the medical blogs for recent interesting posts and these (in no particular order) caught my eye:

Retired Doc comments about Joint Commission’s recent decision to change the four hour antibiotic rule for pneumonia treatment to six hours. They just don’t get it. (The updated and recently published guidelines promulgated jointly by the ATS and the IDSA have eliminated all specific timing recommendations for the administration of initial antibiotic doses, citing the potential for abuse of antibiotics and flaws in the evidence upon which the original four hour rule was based. “Guideline concordant therapy” for community acquired pneumonia should include the administration of antibiotics as soon as possible, and in most cases in the ER, but no longer incorporates rigid time rules).

DB cites a clinical vignette from the New York Times presented by columnist and Yale internist Lisa Sanders, M.D. The patient, who presented to the ER with abdominal pain, hypotension and profound bradycardia was ultimately “cured” by the urology resident. The sequence of events was that this patient, despite a lack of prior urinary symptoms, was in acute urinary retention which led to renal failure, hyperkalemia and, consequently, depression of cardiac function. The case is instructional and interesting on several levels. Could application of the Prostate Symptom Score have averted the crisis? Although it’s an intriguiging question, Dr. Sanders’s self flagellation seems unwarranted.

The Patient’s Doctor has a couple of items concerning Wal-Mart, headquartered just down the street from where I sit. The Washington Post reports Wal-Mart’s plan to open 400 in-store clinics. IHealthBeat reports on remarks by Wal-Mart’s CEO on the role of business in transforming U.S. healthcare.

The Dinosaur presented a case puzzler here, and the solution here. One commenter was partially correct and everyone else missed it a mile. The patient had an uncommon presentation of a common disease (peptic ulcer). The lesson? Perhaps it’s the old saw (that I think I remember once reading in Cliff Meador’s Little Book of Doctors’ Rules) that you can not diagnose that which is not in your differential diagnosis, assuming you generated one in the first place. Or maybe that it’s occasionally appropriate to order an imaging study without a focused clinical question, other than just to “see what’s going on.”

For a little gallows humor here are some politically incorrect mnemonics being kicked around at the Student Doctor Forum (via Kevin).

The blogosphere was screaming after the U.S. Supreme Court decision to uphold the Partial-Birth Abortion Ban Act of 2003, even calling it shameful and incomprehensible, apparently so incomprehensible that no medical blogs I could find provided a link to the original document. For those interested and who think they can comprehend the nuances, it’s here.

4 comments:

ema said...

First, ACOG called the decisions "shameful and incomprehensible".

Second, so incomprehensible that no medical blogs I could find provided a link to the original document is a huge, and utterly incorrect, assumption.

Third, you were being sarcastic with the remark about comprehending the nuances, right? But just in case:

1) Overall, SCOTUS ruled that politicians can dictate clinical practice with no regard to medical evidence.

2) In particular, SCOTUS ruled that politicians can proclaim dismemberment the standard of care and outlaw intact removal, because, apparently, they find fetal skull reduction to be teh icky.

Of course, since the size of the skull is reduce in order to effect delivery whether the fetus is intact or dismembered is irrelevant. But why should lawyers and politicians pay attention to reality...um, I mean nuances.

R. W. Donnell said...

Ema.

Allow me to clarify.

First, I am pro-life. That's merely a disclosure, as I don't want to debate it here.

Second, I incorrectly attributed "shameful and incomprehensible" to you, having missed it in the ACOG press release. Indeed it's the president of ACOG who says he can't comprehend the ruling. That lack of comprehension is well illustrated by his statement that the ruling "leaves no doubt that women's health in America is perceived as being of little consequence."

Third, although I'll give you credit for considerable prior research and thought on the background of the decision, when I surveyed the medical blogs neither your post nor others I saw had a link to the original transcript of the April 18 decision.

That brings me to my point about "nuances", which is to say that I would expect the medical blogosphere to find better ways to respond to the decision than by screaming. Now I would never try to write the rules of blogging, and you can say whatever you want to however you want to, but name calling ("vermin, lower-than-cockroach-droppings politicians and lawyers") seems a little shrill to me for people of science. And the ACOG reaction was just that---*reactionary*.

If you have a good grasp of the issues and want to criticize the decision effectively why not just link to the decision, cite those statements by Justice Kennedy you disagree with and hammer away?

ema said...

Dr. RW,

Thank you for your response.

First, I am pro-life.

I appreciate the disclosure, but your personal support of women's lives (or mine, for that matter) is irrelevant apropos the SCOTUS ruling. The issue at hand is having to practice medicine based on political diktat.

That lack of comprehension is well illustrated by his statement that the ruling "leaves no doubt that women's health in America is perceived as being of little consequence."

The ruling eliminates the health exception, making reproductive age women the "select" group of patients who cannot, legally, receive care, until and unless their life is in danger. This action, in your view, shows that women's health in America is perceived as being of paramount importance. How so?

...when I surveyed the medical blogs neither your post nor others I saw had a link to the original transcript....I would expect the medical blogosphere to find better ways to respond to the decision than by screaming.

I don't speak for other medbloggers, but I have yet to respond to the decision. The post you linked to, and mistakenly assumed to be an analysis, was just a reaction roundup.

Now I would never try to write the rules of blogging, and you can say whatever you want to however you want to....

Heh, good!

...name calling ("vermin, lower-than-cockroach-droppings politicians and lawyers") seems a little shrill to me for people of science....If you have a good grasp of the issues and want to criticize the decision effectively why not just link to the decision, cite those statements by Justice Kennedy you disagree with and hammer away?

First, you need to pay attention. I wasn't criticizing the decision. I was criticizing ACOG's response.

Second, it's not name calling if, as I've done repeatedly on my blog, you support your derogatory characterization of politicians/lawyers who interfere in patient care and actively harm your patients with facts.

R. W. Donnell said...

Ema,
I can see that this exchange has the potential for an endless back-and-forth. I think we understand each other's positions as well as could be expected. Thanks for your thoughts.