Monday, April 30, 2018

Family of late pop singer Prince sues everyone for malpractice

According to the New York Times, “The suit claims that Prince’s death was a “direct and proximate cause” of the hospital failing to appropriately diagnose and treat the overdose, as well as its failure to investigate the cause and provide proper counseling.”

The suit names a hospital and an emergency department physician in Moline, Illinois where Prince’s private jet made an emergency landing when he became unresponsive during a 2016 flight home to Minnesota from a concert in Atlanta.

An employee of his told paramedics who met the plane that he “may have taken a Percocet.” After Prince regained consciousness, he supposedly told the ED doc he had taken two Percocets, but she did not believe him because it had taken two doses of Narcan, an opioid antidote, to revive him.

Friends said he refused all testing including blood and urine toxicology because he was trying to keep his addiction a secret.

Monday, April 23, 2018

2018 Residency Match Update

The National Resident Matching Program Advance Data Tables for the 2018 Main Residency Match again show an increase in the number of first-year positions offered, going from 28,849 in 2017 to 30,232 this year.

Of the 18,818 seniors graduating from US allopathic medical schools, 17,740 (94.3%) matched, 1078 (5.7%) did not match, and 474 withdrew or did not submit a rank list. The 5.7% who went unmatched was identical to last year’s figure.

The 1511 graduates of US allopathic medical schools from previous years did not fare as well with 43.8% matching and 56.2% going unmatched—slightly worse than the 2017 percentages.

Wednesday, April 18, 2018

What is the worst way to combat school shootings?


Please read carefully because there might be a test.

A school district in Pennsylvania placed a 5 gallon bucket of rocks in each classroom two years ago. If locking and barricading the classroom door does not work, the students have been instructed to throw rocks at the would-be shooter instead of hiding under their desks.

According to a Buzzfeed story, the school superintendent for Schuylkill County believes the rocks serve as a powerful deterrent. He said, “If an armed intruder attempts to gain entrance to any of our classrooms, they will face a classroom full of students armed with rocks. And they will be stoned.”

Maybe it’s working. Since the arrival of the rocks, there have been no shooter incidents in any Schuylkill County school.

Wednesday, April 4, 2018

The decline and fall of the rectal exam



For almost 20 years, the value of the digital rectal exam (DRE), a long time staple of the complete examination of the trauma patient, has been questioned. Performing a rectal examination on all trauma patients is no longer advocated except for a few specific indications.

As recently as two months ago, trauma surgeon Michael McGonigal blogging at The Trauma Pro reinforced the message. Because a rectal examination is so uncomfortable for patients already traumatized and its yield is so minimal, he advocates doing it in only patients with spinal cord injury, pelvic fracture, and penetrating abdominal trauma. For a more extensive discussion of the topic, see Life in the Fastlane, an emergency medicine blog.

Monday, March 12, 2018

Can data in electronic medical records be trusted?

If the subject is respiratory rates, the answer is “No” according to a recent study. The authors reviewed the records of 28,500 patients over 220,000 hospital days and found recorded maximum respiratory rates “were not normally distributed but were right skewed with values clustered at 18 to 20 breaths per minute.”

The figure below shows maximum respiratory rates compared to heart rates which were normally distributed.
Reminder: Most sources say the normal respiratory rate of an adult ranges from 12 to 20 breaths per minute.

Thursday, March 8, 2018

More negative data about the nonoperative management of simple appendicitis

If you think I am the only one urging restraint in the adoption of nonoperative management of patients with uncomplicated appendicitis, you are wrong. A pediatric surgeon and a research fellow from Harvard and Massachusetts General Hospital have recently published their thoughts on the matter online in Annals of Surgery.

They call their opinion piece “Ulysses Syndrome” because they liken the fate of those undergoing nonoperative management to the “10-year ordeal filled with unexpected peril and ample misfortune” that befell Ulysses while attempting to go home.

Here are a few highlights.

Monday, March 5, 2018

How the public is misinformed about the outcomes of CPR

A survey of 1000 volunteer adults found 71% regularly watched medical television dramas, but only 12% said the shows “were a reliable source of health information.”

The participants were given some brief vignettes describing scenarios where CPR was administered—a 54-year-old who suffered a heart attack at home and received CPR by paramedics, an 80-year-old with a postoperative cardiac arrest in the hospital after surgery, and a post-traumatic arrest in an 8-year-old.

Those surveyed estimated CPR success rates at 57% to 72% and rates of long-term survival with neurologic recovery at 53% to 64%.

Monday, February 19, 2018

Perforated appendix not seen on CT scan

From an email received two days ago. Posted with permission and edited for length and clarity.

I came across your blog while looking for information on something puzzling that happened to my sister. I read the blog on CT scans and appendicitis* and went through all of the comments section. I couldn't find a case like my sister’s.

She has been sick off and on for the last two months. It began with what seemed like a bad stomach virus, fever, throwing up, diarrhea, gas pain, bloating, and stomach cramps. She brushed it off as a 24 hour type thing, stayed home from work a few days, and felt better but never returned to normal. She would have intermittent stomach upset and began to have weight loss. About 3 weeks ago, she went to see her GP who ran some tests (antibody tests, no CBC, chem 7 or normal work up) and diagnosed her with gluten intolerance.

Monday, January 22, 2018

"The Resident"

A new medical drama with the same old characters.

The show opened with the chief of surgery in the middle of a rather bloody open, not laparoscopic, appendectomy.

The circulating nurse started taking selfies with her phone; the anesthesiologist was distracted; the patient started moving; blood spurted all over the surgeon.


According to a nurse, the patient lost 2 liters of blood in 20 seconds.

What artery, other than the aorta, could he possibly have cut that would bleed so much? The chief of surgery just stood there. I yelled at the TV, “Put pressure on it for God’s sake.“

Finally, they started CPR and the surgeon seemed to be packing the wound.

Monday, January 15, 2018

Facial exercises to make you look younger? I don't think so.

One would think a study covered by the New York Times would be both scientifically valid and important. Apparently, that is not always the case.

Under the headline “Facial Exercises May Make You Look 3 Years Younger” is a story about a research letter published in JAMA Dermatology. The Times article concludes with a quote from the lead author, “But for now, it is reasonable to consider contorting and pinching up your face if you wish to try to look younger.”

Is it reasonable? Let’s see if this 1½ page research letter proved its point.

Monday, January 8, 2018

Is chronic pain after inguinal hernia repair a big problem?

Yesterday one of my twitter followers posted this:
He was referring to a paper in the British Journal of Surgery that said 15.2% of patients who had inguinal herniorrhaphies complained of severe chronic pain one year after the surgery. Open hernia repairs caused significantly more chronic pain than did endoscopic total extraperitoneal [TEP] repairs, but the reoperation rate was significantly higher for TEP procedures.

The study included almost 23,000 patients and was based on data from the Swedish Hernia Registry and a questionnaire sent to the patients one year after their initial hernia operation. Pain was rated on a scale of 1 to 7 and was considered chronic if it was present for more than 3 months and interfered with daily activities.

The recurrence rate for the 18,000 patients who had open anterior mesh repair was 3.4% compared to 23.3% for the 2688 who had TEP repairs.

The authors concluded that the trade-off for less pain was an increased recurrence rate. Only 232 [1.39%] of the 1666 patients with recurrent hernias had undergone repeat herniorrhaphy.

Some of the comments on Twitter were as follows:


When I was in private practice in the early 1980s, I invited all of my post-op hernia patients to return to my office for yearly follow-up at no charge.

One day, a nice elderly gentleman was sitting in the exam room when I walked in. After an exchange of pleasantries, I asked him how his hernia repair was doing. He said he had no problems and was quite happy.

I had him stand up and when he lifted his gown, I saw a softball-sized recurrent hernia. Ever since then, I have not trusted any studies in which follow-up was not done in person.

Based on my experience, the recurrence rate after groin hernia repairs could even be higher than the Swedish study reported.

The incidence of chronic pain after inguinal herniorrhaphy may depend on how surgeons follow their patients.