Should a consultant pass through the ED to see what's up?

A couple of weeks ago, this tweet appeared.

I could relate to it for two reasons. One, I lived in New York City in 1975, and here is the other.

Early in my career, I thought it was a good idea when leaving the hospital at night to exit via the emergency department to see if there were any potential surgery cases brewing. I was hoping to avoid going all the way home, getting paged to the ED, and having to go right back to the hospital. I soon learned to stop that practice because it was similar to poking a skunk.

It wasn't like this in my med school

When I was a medical student, we had to practice drawing blood on our lab partners. I remember the first day we did it. One guy fainted as he was having his blood drawn, and another fainted while he was drawing someone else's blood.

We've made a lot of progress in medical education since then. In 2015, teaching blood drawing, which is going to eventually be taken over by robots anyway, is passé.

Students are suing a Florida sonography school because they were forced to perform transvaginal ultrasounds on each other almost every week. Those who complained were allegedly told to “find another school if they did not wish to be probed” said an article in the Washington Post.

While that seems out of line, it pales in comparison to allegations lodged against a former US Army doctor who ran a company that taught battlefield medicine to soldiers and made more than $10.5 million in the process.

According to Reuters, he gave students alcohol and drugs, including ketamine, a powerful hypnotic used as an anesthetic. Sometimes alcohol and ketamine were given at the same time.

Trainees were told to insert urinary catheters into each other, and two students underwent penile nerve blocks. On another occasion, when students balked at receiving penile blocks, the doctor had the students perform a penile nerve block on him. It's not clear what a penile nerve block has to do with treating wartime casualties.

If that's not troubling enough, he supposedly ran what he called "shock labs," during which he drew blood from trainees, observed them, and gave their blood back to them.

But wait, there's more. The doctor is alleged to have had a few beers with a student and examined, manipulated, and photographed the student's uncircumcised penis.

The doctor's claim that his methods are standard in Virginia medical schools was refuted by experts quoted in the Reuters piece.

The Virginia Medical Board has suspended the doctor's license and will hold a hearing on June 19.

And we thought sticking each other with needles was traumatic.

Ultrasound selfies? How surveys can mislead

Do you believe that traditional hospitals will be obsolete in the future? A recent survey found that 57% of those polled believed that would happen.

The survey, sponsored by the Intel Corporation, involved 12,000 subjects from the United States and seven other countries around the world.

Here are some other revelations from that survey:

• 84% said they would be willing to share their personal health information to advance and lower costs in the health care system.
• 70% said they were receptive to using toilet sensors, prescription bottle sensors, and swallowed health monitors.
• 53% said they would trust a test they personally administered as much or more than if that same test was performed by a doctor
• 30% of people would trust themselves to perform their own ultrasound. 

That made me laugh. Ultrasonography is one of the most operator-dependent tests in use today. It is not easy to perform, nor is it easy to interpret.
I then began to wonder about the credibility of this survey. Before I retired, I practiced in a typical small town in the northeastern United States. Some patients googled me, and a few searched the Internet for information about their illnesses. But for the most part, it was a technologically unsophisticated population.

I just can't envision most of my patients wanting to share their personal health information, use toilet sensors, or trust tests they did at home. Do their own ultrasounds? Not likely. Many of them did not even know what medications they were on.

After rereading the article about the survey, it occurred to me that the sample may have been flawed.

This sentence stood out. "[The] Intel Health Innovation Barometer was conducted online by Penn Schoen Berland in Brazil, China, France, India, Indonesia, Italy, Japan and the United States." The key word is "online."

This reminded me of a famous survey conducted by a magazine called The Literary Digest, which polled 10 million people and had a response of 2.4 million just before the 1936 presidential election. The magazine had correctly called the previous four presidential winners.

The names of the 10 million people queried were drawn from lists of the magazine's subscribers, owners of automobiles, and those with telephones. The survey predicted a crushing defeat for President Franklin D. Roosevelt at the hands of the Republican nominee, Alf Landon.

Of course, the opposite occurred. Roosevelt won all but 8 electoral vote, a huge landslide. What went wrong? Unlike the prior years, 1936 was the middle of the Great Depression, and this time those who had enough money to subscribe to The Literary Digest, own cars, and have telephones were not a representative sample of those who voted.

Do you think maybe the 12,000 people polled online might not be a representative sample of the general population of the world?

I'm not expecting patients to do their own ultrasounds anytime soon. I think hospitals will be around for a while too.

Is ultrasonography overrated? A radiologist thinks so

In response to an article in the New England Journal of Medicine that discussed whether bedside ultrasonography (US) should be taught to medical students, radiologist Dr. Saurabh Jha recommended that clinicians do a proper history and physical instead of point-of-care ultrasound.

His post appeared on the KevinMD website.

As if a radiologist advising doctors to do an H&P wasn't shocking enough, Dr. Jha then confessed that he thinks "ultrasound images look like a satellite picture of a snow blizzard."

He worried that rather than finding hidden pathology, indiscriminate use of US by inexperienced physicians will simply lead to more and more testing.

Even seasoned radiologists tend to overcall abnormalities on US said Dr. Jha. This leads to increased use of other imaging studies, most of which turn out to be normal. Using US to avoid the risks of ionizing radiation often results in patients having CT scans anyway.

In the comments section of the post, Dr. Jha emphasized that he was talking about situations where the pretest probability of finding something wrong is very low. Directed US based on clinical indications is obviously of value.

Emergency medicine physicians who

Photo via Dr. Ryan Radecki (@emlitofnote)

commented listed several instances which bedside US can be useful such as in identifying pericardial effusions and fluid or blood in the abdomen of trauma patients.

Ultrasound is clearly the test of choice for right upper quadrant abdominal pain. There is nothing better for identifying gallstones, but thickening of the gallbladder wall and fluid surrounding the gallbladder are best seen with US done in the radiology department.

Probing all body cavities with a transducer for no specific indications is another matter.

Is there still a role for a good history and physical examination in modern medicine? Yes.

Is US a useful test? Yes, in the proper context, it can be very helpful.

Should every medical student be taught how to do bedside US? I don't think so. A course is just the beginning. Learning how to perform US requires a lot of repetitions. Many medical specialists will never use it.

I agree with Dr. Jha that the time should be used to "Teach them to organize their thoughts coherently."

What's your opinion?

Note: These folks also tweeted the photo.@EM_Educator @MDaware @EBMGoneWild @choo_ek

A lawyer tries (unsuccessfully) to take down Skeptical Scalpel

A trial lawyer named Max Kennerly has taken issue with a piece I wrote called "Can defensive medicine ever be stopped?" It appeared last week on KevinMD.

On his blog, he he says defensive medicine is a "myth" and accuses me of many wrongs, too numerous to detail here.

I will address a few of them.

He read my post but apparently did so selectively. He failed to note that I agreed with him that tort reform did not reduce the cost of medical care in states that have enacted it. This was documented by a paper from the National Center for Policy Analysis which I cited.

He went on to criticize three brief examples of defensive medicine that I mentioned in my post—about abdominal pain, a wound infection after colon surgery, and chest pain.

Mr. Kennerly writes, "a young girl with lower abdominal pain gets an ultrasound for appendicitis (among the least invasive, least expensive, and most helpful tests in history — remember this funny GE ad for their portable ultrasound?)."

What was surgery like in the 1970s?

When I first started my residency in the early 1970s, things were remarkably primitive by today's standards.

There were no ultrasound machines. Believe it or not, we would diagnose acute cholecystitis by history and physical examination alone. The only diagnostic tests we had were oral cholecystogram (OCG) and intravenous cholangiogram (IVC). For OCG, pills were taken the night before the test. If the cystic duct was patent, iodinated contrast would appear in the gallbladder and stones could be seen. Non-visualization of the gallbladder meant either the cystic duct was blocked or the pills were not absorbed (presumably due to inflammation, not necessarily of the GB) or the patient forgot to take the pills. The test was useless in acutely presenting patients. IVC was similar except the contrast was given intravenously. The common bile duct could be seen faintly unless the patient was jaundiced. It rarely showed stones in the GB.

There were no CT scans. We had to make the diagnosis of appendicitis by, you guessed it, history and physical examination alone. And since laparoscopic general surgery did not become common in the US until 1990, all appendectomies and cholecystectomies were done as open procedures.

There were no computers in any clinical departments or nursing units. Everything was on paper. The good news? There was no way to "copy and paste" progress notes. We had different colored paper for different sections of the chart, which made things easy to find. The bad news? Charts often went missing. Handwriting analysis rivaled that of archeologists deciphering hieroglyphics in Egypt. But paper charting was faster to do and easier to "leaf" through.

When submitting a research paper, drafts had to be prepared on a typewriter (an ancient kind of word processor that put the words directly on paper). If you needed to change a paragraph on page 1, the entire manuscript had to be retyped from the beginning. And making slides for presentations involved cameras with 35 mm film, taking the film to be developed and hoping the slides came out OK. Find a typo? Take the picture over and have the film processed again.

Now we use PowerPoint. It's easier, but I'm not totally convinced that it's real progress.

Maybe the biggest change has been the advent of the Internet. In the palm of my hand, I can instantly access huge amounts of information formerly available only in print books and journals. To look up a paper, we had to use Index Medicus, an encyclopedic series of books listing every article by subject in most journals.

There were far fewer journals back then. You had to know the correct heading or keyword to search or you could miss something important. Cross-referencing was not easy because it was in print and there was a different set of volumes for every year. And libraries kept many years' worth of volumes of journals.

Of course, many more changes have occurred. Can any of my older colleagues comment?

Ultrasound-Guided Central Venous Catheter Insertion

Despite the large amount of published evidence (here, here, and here) that ultrasound guidance reduces the failure rate of central venous catheterization, especially for cannulation of the internal jugular vein, some physicians still claim that there is no difference between the success rate of ultrasound guidance and the landmark method. This was the subject of a brief discussion regarding the safety of central venous catheter insertion in coagulopathic patients on Twitter. 

I have a couple of anecdotes to share. I was called to insert a line in an obese patient with idiopathic thrombocytopenic purpura (also called immune/autoimmune thrombocytopenic purpura or ITP). The patient’s platelet count was 2,000. Despite the short, bulky neck, a physician assistant (PA) who had done only 20 previous internal jugular sticks, accessed the vein on the first attempt using ultrasound guidance and there were no complications.

We were called to insert a central line in a morbidly obese man (see photos) who was hypotensive. A PA who had done fewer than 10 previous central line insertions successfully cannulated his right internal jugular vein on the first try using ultrasound.

I would not have attempted to cannulate the first patient without ultrasound guidance. The second patient would have probably had a subclavian approach which would have been difficult.

I was skeptical regarding ultrasound for vascular access for years. Now I would not insert a central venous catheter without using it.