You go first

Meaghan Mercer’s article in Medscape today, Shock — Administered Uninterrupted Chest Compressions, is probably registration-protected, so I’m sorry if you aren’t a member and can’t read the whole thing. Here’s the nut graph, though:

When clearing the patient for defibrillation, this causes an interruption in chest compressions causing the central perfusion pressure (CPP) to drop, and it can take more than one minute of good-quality chest compressions to restore them to pre-pause levels. CPP has been found to be the best single predictor of ROSC, with values less than 15mmHg predicting a failure. Therefore, we are greatly increasing the morbidity and mortality of our patients with each second off the chest. Circulation published the article “Hands-On Defibrillation, An Analysis of Electrical Current Flow Through Rescuers in Direct Contact with Patients During Biphasic External Defibrillation,” in which they investigate the amount of leakage voltage and current to a rescuer receives during defibrillation. They found that the current measured in the rescuer’s body ranged from 19 to 907µA. In most cases, the leakage current measured below recommended safety standards and none of the rescuers felt a shock.

I’ll translate that for you: you know that scene in every TV show and movie where someone yells “clear!” and then everyone else moves back? Yeah, maybe not so much anymore. We’ve been kicking this around at work for the past year or so, and we’re all kind of curious about whether or not it actually changes anything, but speaking as someone who has caught a piece of 360J once upon a time and didn’t feel right for about an hour afterwards, I think I’m going to wait for someone else to try this first…

Paging Dr. Google

People like to say that Google has replaced knowledge. OK. Let’s see how Google does when you give it a chief complaint!

“I have a headache”:

“My head hurts”:

“My back hurts”:

“My chest hurts”:

“I can’t breathe”:

“I’m constipated” (world’s worst presenting complaint, by the way; don’t ever do this):

“I can’t pee”:

Do you still trust Google with medical problems? Maybe you should trust Yahoo Answers…

A thought about privilege

“Privilege” is one of those concepts that’s hard for people to understand the first time they run into it. Though it really means something along the lines of “advantages you have that you think are normal,” it’s often interpreted as “things that you have that make you a bad person.” And that’s rough, because privilege affects an awful lot of stuff in our lives, and our interactions as humans are improved when we acknowledge and try to cope with our own levels of privilege. Part of the problem, I think, is that most writing on the subject of privilege has to do with things like ethnicity, race, gender/gender identification, and class — not things that most folks are necessarily willing or even able to examine in depth.

There’s another kind of privilege, too, that may make the whole thing easier to grasp: professional, occupational, or skill-based privilege. If you’ve ever wondered why some people struggle with tasks or concepts that come naturally to you, and wondered why it seems so hard for them, you’re bumping up against privilege. This happens a lot in my line of work; a lot of it revolves around dying and end-of-life care. I have colleagues who abruptly demand to know why Mrs. R. doesn’t have an advance directive, or why Mr. F. is still a full code despite being 97 and having full-blown dementia, or why Ms. J. doesn’t quite grasp that her cancer isn’t going to get better. Depending on how energetic I’m feeling on any given day, I like to use these moments as teaching opportunities to introduce the broader concept of privilege.

Conversations about death, dying, end-of-life care, or catastrophic health care decision-making are easy for us. We have a language to talk about this stuff, we understand what happens, we’ve seen it enough times to know what we want (or don’t want, as the case may be); we are comfortable with this material and these topics because we are familiar with them, and that makes the conversation easier. We watch people die — despite (and — very occasionally, I should stress — as a result of) the things we do — and it doesn’t really faze us much. We’re well acquainted with the subject matter, and that makes it a simple thing to discuss. But most people don’t have that familiarity; truth be told, most people don’t want that level of familiarity, although fluency with a particular topic is generally a requirement to be able to discuss a subject intelligently.

It evidently falls to us to facilitate those conversations, with care and empathy and compassion and great patience. Some people will get it right away; others need more help. Some won’t get it at all, and will end up standing in a resus room at three in the morning wondering why it had to end like this. The new-ish focus on this kind of planning, death-panel demagoguery aside, is really all about dealing with an underprivileged population faced with seemingly insurmountable challenges they cannot even begin to grasp without assistance. This is hard work, and yet amazingly most of us do it instinctively, without a lot of effort, and it often goes well despite the sadness of the overall subject.

This is what privilege looks like on an operational basis. This is what it means to own your privilege, understand how it affects other people, and work towards helping the less-privilege cope with that disadvantage. No one would ever suggest that having this level of comfort with such a horrific body of knowledge is bad, or wrong, or somehow inappropriate — because it clearly isn’t. And it’s much the same thing with the other kinds of privilege, too: none of it, whether gendered or ethnic or moneyed or what have you, is inherently bad, but behaving as though other people don’t matter because they don’t have those advantages is.

Viewed through this lens, privilege becomes a lot easier to understand. Are your parents struggling with their new computer, even though it’s really simple to you? Privilege. Are you a pilot and unfazed by turbulence while your passenger screams and holds on for dear life? Privilege. As the privileged person, you don’t get to set the terms of the discussion, and you don’t get to be the one who defines what the issues are for the unprivileged. Your passenger tells you when the turbulence is too much. Your mom tells you when you’ve helped enough with her new PC. The family will tell you when they’re ready and able to make end-of-life decisions for their loved ones.

I offer this out to the community at large when confronted with the challenge of explaining privilege to people who, for whatever reason, do not or cannot understand what it really means. Find something you have in common that makes you different from most other people, that gives you an advantage over others, and use that as the lever to bring the conversation around to other, more entrenched notions of privilege. It works.

(Inspired by this, which also does a good job, and helped me get my head around some of my own privilege issues.)

Could be worse

Japan Times: Hosptals turn away patients at record rates

A record 16,381 people in serious condition were refused admission by hospitals three times or more while being transported by ambulance in 2010, up 3,217 from the previous year, the Fire and Disaster Management Agency said.

The agency said Friday the rise came because hospitals still aren’t prepared to receive an increasing number of elderly patients amid the graying population.

Among the reported cases, 727 people were rejected 10 times or more, with a 60-year-old man in Tokyo rejected the most, 41 times.

I need to keep this in the back of my head the next time I hear someone complaining — or I am tempted to complain — about hospital delays and wait times here.

Everybody dance now!


Hold on a second, clamhead! You think you can just roll in here and tell us it’s not on when it very clearly is on?! You’re just trying to make us not practice, aren’t you? Because you know your kids are goin’ down when my kids give them this! Give me some moves out, Girl T! Check this out! Yeah! You like that?!”

Much to my sorrow, embedding on this magnificent YouTube video is disabled, but that will in no way prevent me from using it as a teaching aid, or just as some filler material the next time I have to give a talk even tangentially related to cardiac electrophysiology.

It is absolutely brilliant beyond words. Better, I think, than a cheap knockoff of a Justin Timberlake song (which is, in and of itself, pretty damn good).

Panic! On the ISS!

This is friggin’ awesome: A list of ISS medical procedures, though lacking in some areas. There’s nothing in here that would surprise you if you know anything about medicine, inasmuch as the procedures are basically what they are on earth, but they’re structured so that a random astronaut could do it without much thinking. One glaring part that’s missing is the “now what?” aspect of post-stabilization — ok, you’ve just performed the first zero-g cricothyrotomy. Now what do you do?

It’s actually part of a much larger collection of ISS procedures and guidance that should make for some interesting time killing later. (Inspiration for hunting this information down here; links will be updated if I can find the whole manual somewhere.)

Nexus 6

My eyes suck. They’ve sucked for a long time, and not just in terms of vision, though that is the most serious problem I have with them. Most people who know me casually don’t realize I’m as blind as I am (I very nearly meet the standard for legal blindness in my right eye); I wear contacts most of the time, and rarely go out with my glasses on. The first encounter with me and glasses usually provokes odd looks — even with the ultra-expensive high-index plastic lenses, my glasses still manage to deform my face, and the lenses themselves are 7 or 8 mm thick at the outer edges anyway.

To make matters worse, my right eye is dramatically weaker than my left. Corrected, this isn’t such a big deal, but uncorrected there’s enough difference in input that I get dizzy sometimes if I don’t close one eye or the other. As I say, when I’m wearing glasses or have my contacts in, my vision’s usually OK. My contacts have been problematic for a few years — as a function of my allergies (which are also getting worse as time goes on, which is why I’m starting immunotherapy soon-ish), as a function of the lenses themselves. I managed to develop a truly shocking case of giant papillary conjunctivitis a few years ago — it’s never a positive sign when your optometrist comes along, everts your eyelids, and then calls the other members of his practice group over to look at you. I went through a period where I had a serious problem with floaters around the same time, which continue to bug me under some circumstances to this day.

Two positives in all of this: One is that I don’t have an astigmatism (yet), which frankly to my mind is nothing short of a miracle. The other saving grace was that my prescription had seemingly finally stabilized — I’d had the same pair of glasses for almost four years, which was unheard of up to this point. But in the past month or so I’ve noticed that my right eye has been a little blurry, a little less sharp; I blamed it on my contacts and didn’t think anything else of it. (I’ve been fighting with the right kind of contact for a couple of years now — the ones that don’t induce GPC in me dry my eyes out or sting; the ones that keep my eyes moist induce GPC; the ones that do neither are uncomfortable as hell.) I’d been thinking semi-seriously about refractive surgery, and it’s intriguing as hell (the cost balances within a couple of years by my math), but.. I still can’t shake that nagging feeling that maybe something would go wrong. Sure, I knew a bunch of people who had it done, who swore by it, who said it was the best thing they’ve ever done.. and yet, my data-driven soul says, “The plural of anecdote is not data.” Anyway, now that my prescription has apparently changed — one would hope, anyway, that this does not signal the beginning of the dreaded astigmatism — that option’s off the table for a while again, allowing me to defer the decision once more.

So I’d sort of planned to see my optometrist in the next little while and ask about my right eye when I went and did something much worse on Monday: I tore my corneas off.

Okay, that’s overstating it. I actually tore a couple small patches of my cornea off (think of the top of a salt shaker) and irritated the living fuck out of the other parts. Officially it’s called “punctate keratitis” and it’s officially not a big deal (though I do need topical analgesia and I’m now on opthalmic antibiotics), but holy hopping hell did it ever hurt! It might well have been the most painful thing I’ve ever felt, and I’m including the time I tried to sneeze after my neck surgery. What happened was that somehow, the cornea-contact lens interface had dried out, leading the cornea to become hypoxic and irritated. When I finally pulled the lens out, it took chunks of the cornea with it; what was left of the cornea decided that it was going to just sit there and be pissed.

Monday night was brutal — an addict’s dream combination of anti-inflammatories and high-test systemic analgesics knocked me out but did little to dull the pain. I woke up every hour or so, saw the doc on Tuesday morning, then went home and went back to bed after dumping a load of diclofenac into my eyes. (The man who invented opthalmic diclofenac deserves to be kissed several times over.) I woke up in the afternoon feeling marginally better, but with a new problem: everything was just slightly blurry.

And that’s how things have remained since then. I went to work this morning and managed to function fine, though I had a tough time reading the computer screens and I found myself squinting hard at ECGs and printed paper. My recently slacking right eye decided that now would be an excellent time to be even lazier and my left eye wasn’t doing much better either, so there was a lot of close focusing and turning up the font sizes where I could. It’s a little tricky — I can get around fine and I’m OK to drive, but fine discrimination is elusive. This will, I am told, improve as the swelling and irritation goes down, and frankly I can’t wait for it. Meanwhile, it’s annoying as all fuck because things are just slightly out of focus and it takes me a couple of seconds to find the hyperfocal point where everything sort of snaps into place.

(Another interesting thing I noticed today: I am noticably stupider than I usually am. I tried to do some teaching on Monday night and found myself almost incapable of forming a complete sentence, unfairly punishing my students for my own idiocy. Fortunately my Trusted Lackey helped pick up the slack and so I doubt anyone was in a position to complain. But today I was trying to explain ischemic heart disease to a patient and I couldn’t find the words. Thank god no one died today; I can’t imagine how that conversation would have gone with all the ums and ahs and ers and duhs..)

Anyway, at the moment, I have the font size in Mozilla jacked up by +3. Which is.. interesting. It’s kind of surprising how many Wobsites out there depend on fixed-width layouts so that relatively increasing the size of the text manages to seriously screw up the design. Unsurprisingly, the one site that looks exactly the way it does with a “normal” font size is Joe Clark’s, which leads me to think that perhaps I need to put a little more effort at designing for people who need to bump the text size up a few notches..

Feel the pain! Feel it!

This is way too true. But I can go one better. I had a standardized patient once tell me that he was such a good standardized patient, he could mimic physical signs. Hepatojugular reflex? Yup, no problem. Lateralized lung sounds to simulate pneumothorax? Uh-huh, he could do that. Full control over his heart rate so he could pretend to be tachy or brady? Sure, piece of cake. Except, you know, that he couldn’t. That didn’t stop him from trying and repeating this assertion over and over again, and it certainly didn’t stop us from laughing about it every time he left the room.

The best story, I think, came one day while we were standing around one day on break and he told a bunch of us that he didn’t mind it in ATLS sims where people would try to stick airways into him. “I have a well-controlled gag reflex,” he said.

Um… yeah. I’m not sure that’s something you want to be bragging about there, pal.

crap.

I stared at the hole in my glove in disbelief. Did it really happen? Had I really felt it? I wanted to pretend that it hadn’t happened, that I wasn’t actually going to have to go through the whole thing, but the hole, less than half a millimeter in diameter, put lie to any thoughts of denial. You felt it, bub, my glove told me. You felt the thing go in. You know you did. Calmly, I put the jacket down in a safe place and backed away from it.

“What’s wrong?” M. said to me, looking at my face.

“I just got poked by something,” I said. All activity stopped.

She stared hard. “What?”

“In this guy’s jacket. I just got poked by something sharp — a needle, I’m guessing.” We looked over at the guy on the stretcher, writhing. We all knew what it meant: 22, male, no fixed address, injecting drug user, known hepatitis C carrier.. No one needed to say what was going through all our minds, mine most of all. SHIT.

I tore the glove off and looked at my index finger, where the needle had gone in. No blood visible — that’s good, we’re probably not into the dermis. I wiped it with an alcohol swab, then walked over to the sink and calmly scrubbed for what felt like ten minutes, getting as much water flowing over the poke site as possible. How the hell could you be so stupid? my inside voice wanted to know. How in the name of all merciful fuck could you have been so goddamn stupid? Well, for starters, I wasn’t being stupid. I was lifting the thing up, gingerly, conscious of the risk — something swung over and pricked me. The only way this gets any safer is if I use tools. It wasn’t like I was going through his pockets or anything.

Thus began another odyssey for me in the emergency department as a patient, a process which involved a great deal of trying to calm down, do work, and be assessed at the same time. I watched as the Protective Services guys went through the joker’s jacket just as gingerly as I had lifted it up, only they wore leather gloves lined with Spectra aramid. “Lookit this,” one of them said, holding up an open five inch switchblade with a very sharp-looking point. “Don’t suppose this is what got you, eh?”

“I won’t be that lucky,” I said, eying what could only be insulin syringes by their orange caps and slender barrels. “Please tell me there aren’t any uncapped sharps in there.” It looked good for a minute or two, and then the guy pulled one out, the needle glinting in the harsh light of the trauma room. “Fuck.”

“Yeah.” I took a close look at it. Was there blood on it? I couldn’t tell. How long ago had it been used? I didn’t know. I did know the seroconversion rate for HCV is 1.5-3.8% for all comers, that the conversion is associated with deep sticks from blood-filled hollow needles, and that neither of those things appeared to have happened. I knew that HCV has a tough time living outside the body on metal surfaces, but I also knew that it was the second time in as many weeks that I was facing a personal health concern because of something that had happened at work. Last week it had been the guy who ultimately died of pneumococcus and I was the one who was doing airway stuff and might have caught a facefull of particulate; this week, it was different, and yet it was the same. Known exposure, rather than possible. Guy known to carry bad shit, rather than theorized. And in both cases, someone who had something I didn’t want.

R. did the workup. We sat at the desk and did it, me burying my head in my hands and he clucking about it. I can’t remember whether I was more upset about what had happened, or that it had happened at all. I’d never had a needlestick before, of course, though I had managed to stab myself once when I was young and stupid while trying to draw something up (I aimed wrong and missed the vial, instead plunging a 25g into my thenar eminence up to the hub — now I stab into a bottle on a hard surface). R. wasn’t too worried, and in truth, neither was I: Six months of blood tests for anti-HCV, titre check on my HBV antibodies, boosters for HBV as required (they’re not), update my tetanus. Source test the guy who owned the sharp for HBV, HCV, HIV. I’m not worried about the HIV. It’s the hepatitis that scares me.

Twelve hours later, I was in my doctor’s office, explaining my tale of woe. J. smiled, ordered the requisite tests, and sent me on my way. “I don’t need to counsel you,” he said by way of asking as I left, “on the options if you do end up testing positive for HIV, do I?”

I shook my head. “Oh, god no. Because I’m not going to test positive,” I said. And I’m not. The odds are vanishingly small. Almost non-existent. It’s not gonna happen. No way, no how.

It could have been worse. It could have been a lot worse. That it wasn’t is a testament to luck and the fact that I am so damn paranoid about sharps. I’ll be fine. I believe it. Just pisses me off it’s going to take six months before I know it.