Three times a charm from the M$ folks:

As from my last post, these ads have been entertaining so far. This time they buy a Sony Vaio.

computing tech

OMT, manipulation, counterstrain, and circulatory stasis are a few terms that were never incorporated into my medical school curriculum. They are all associated with osteopathic medicine, or D.O.’s. I never considered osteopathic medicine when I was applying for medical school, partly due to my ignorance of the specialty, and mostly due to the stigmata that D.O.’s aren’t real doctors. To clarify, the M.D. and D.O. educational curriculum are theoretially identical except that D.O. curriculum includes more training in musculoskeletal systems.

I’ve gotten the occasion to discuss medical cases with some osteopathic folks, and the experience was eye opening. The following is an excerpt from one of my first presentations. I was presenting a gentleman who had a hemidiaphragm weakness later found to due to demyelination disease:

Me: “Mr J is a 64 guy with Class III heart failure and emphysema who presented with SOB over the last week after experiencing some viral URI-like symptoms. He also has a-fib, liver di…”

OMT attending: “Yeah, yeah, what did the ribs look like?”

Me: <confused> “Well, he did had some asymmetrical inspirations. The right side was more sluggish. Lungs were crackly…”

OMT attending: “Which ribs were preferred? Inspiration? You think it’s pump, bucket, or caliper?”

At that point, one of the other residents, an osteopath, bailed me out by saying, “He’ll benefit from some treatment”.

Over the next hour, we performed some rib raising, muscle energy techniques, and diaphragm release/facilitations. The patient told us he felt symptomatically improved afterward. Several days later after I switched services, I believe the next team transferred him to UPenn.

Nuts. I guess OMT didn’t work in this case.

medicine medicine

Several entries ago, I wrote about my experiences with Google Voice.  It is by far one of the best forwarding services available today; one of its features include transcription of voicemail to text.  The transription has been shockingly accurate for me…that is, until I started using my number to discuss medical-related issues. Take the follow excerpt a urogynecologist left for me:

Hi...I last changed her catheter on Feburary eighteenth. Uh, I placed a sixteen
French foley catheter over her suprapubic site...if you think it looks cruddy
you can exchange it out...

Here is the transcription from Google voice:

Hi...if I west change her catherine said you were eighteen i placed a sixteen
french pollack after for super P B X site...if you think it works cruddy
always replace it out...

The message was actually enunciated clearly in the voicemail, and the doctor did not have any weird accents (Egyptian or Bostonian).  Overall, the transcription was accurate, and I assume that these shortcomings will be promptly corrected after the Google bots scour this entry and flag the development team. (Yeah, I know you Google spider bots are lurking around.)

Hilariously, I initially thought the transcription was a spam solicitation. I was about to file a complaint to Google that they were selling my number to spammers, but then listened to the actual voicemail. An admirable first attempt, it was. But then again, how often do you use words like, “suprapubic”, “catheter”, and “foley” anyway?

computing medicine, tech

Yea, fanboys are duking out the second episode of the M$ ad campaign on the message boards over the past few days.  Giampaolo is indeed a cool name. What I can assess from this ad is that it’s been too long since I’ve purchased a computer–I had no idea laptops came in cool ergonomic boxes these days…

computing tech

In medicine, patients who have been admitted to the hospital have an option to leave despite being deemed too ill to be discharged. We refer to these patients as leaving “against medical advice”, or AMA.  Many times patients sign out AMA whenever they feel a desire to leave the hospital when work-up is still pending. I once had a patient who presented with symptoms suspicious for myocardial infarction, but had a flight to India several days later. He felt symptomatically better a day after presentation, and decided to leave to pack his bags even though we had not completed all of this cardiac tests.  I had another patient who was admitted for a gastrointestinal bleed from ruptured esophageal varices. No sooner had I finished transfusing him 6 units of red cells did he demand to leave. This guy was a cocaine addict who needed another fix. These are the cases which disobeying medical advice could result in death.

Other cases are not as obvious. I had a young diabetic teenage patient who was admitted for drainage and antibiotic treatment of an infection neck abscess. He left AMA before bacterial cultures could be speciated. While he was unlikely to die from premature cessation of his antibiotics, he did not complete his treatment and risked developing a superinfection or worse, a superbug.

Interestingly enough, the one universal bond that I have noticed about AMA patients is that they were all cared for by a medical team. Not a surgical team. Not a gynecological team. You can argue that fewer surgical patients leave AMA simply because there are fewer surgical patients in the hospital, but I believe the explanation is simpler: surgery has more tangible results.

The argument that surgeons “do more” for their patients is not only stated by surgeons, but also perceived by patients. When I was a medical student, the surgical attendings considered themselves the “Physician +” because they are expected to manage their patients medically and surgically. Those students choosing to specialize in surgery crave the satisfaction of intervening in order to make the patient better. Patients admitted to the surgical service expect a tangible intervention, like removal of an organ or excision of a tumor. They are not likely to leave against the advice of the doctor. Even those surgical patients who are managed medically, such as the small bowel obstructions, almost never leave the hospital without a doctor’s blessing. They are in pain, they cannot eat, and they also know that there is still a possibility that they may be cut open.

Sadly, the same cannot be said about patients managed by internists. The diabetic in ketoacidosis will start feeling better when their anion gap is near closure, but we cannot send them home if their white count is sky high from an unidentified infection. The patient doesn’t see this. He feels better, and wants to go home. The HIV patient with cryptococcal meningitis feels great after I hit him with some narcotics and a dose of amphotericin. He thinks that all he needs are some painkillers. Think again. If he goes home after this, he will be as good as dead–the amphotericin will have just enough time to frag up some fungi in his system to trigger whatever is left of his immune system to go berserk and maybe put him into sepsis.

It is unfortunate that medicine is perceived in this manner, by doctors, patients, and even insurance companies. It is at times frustrating to practice medicine in the context of this disconnect; it feels as if doctors are broadcasting on a different frequency as everyone else. Policy needs to be revised. Policy is being revised. But in the meantime, we will have to wait it out.

medicine medicine, work