Skills of Laryngoscopy

Excellent vid on what I will call "goal directed laryngoscopy" by Dr Weingart at Elmhurst Crit Care..here

Costs and Efficacy

The cost of iv antibiotics was a question raised recently in conference. Is cost a real consideration in deciding which antibiotic to give a patient? I thought this was interesting since a group of my colleagues was recently invited to a night of drinking at a bar in New York on the basis that we should prescribe levaquin (Ortho McNeil) instead of avelox (Bayer) for community acquired pneumonia.

I ran across some interesting
studies, including one, the European MOTIV study which compared avelox to levaquin head to head, showing outpatient use of avelox to be as effective as combined levaquine (twice daily iv) and ceftriaxone (2 grams iv).

There is some concern about quinolones, particularly in the elderly for risks of QT prolongation and tendon ruptures and muskuloskeletal effects(young, old, athletes), and oder quinolones such as cipro do not cover strep very well, and the risk for quinolone resistance due to widespread use for example in the treatment of UTI.

One of our pediatric attendings suggested that quinolones have been used in the pediatric age group in Europe, however I suggested that on the basis of my European experience these agents were often avoided in the young active or elderly patient due to the risks of Achilles Tendon rupture. http://www.jabfm.org/cgi/content/full/16/5/458

In my quiz last week I asked which antibiotic combination is most expensive, the winner for most expensive is TNT- tobramycin and timentin...narrowly beating out zosyn.. both at around 56$ per day from my cost source, this is somewhat old though, since cipro has since gone generic...

and the cheapest- amp-gent, comes in at less than 10 dollars per day.

Yet a better question, at least for those patients, for example with community acquired pneumonia, is probably who should be admitted, and who should be sent home, and what is the most efficient way of arriving at that decision in the emergency department...use of Pneumonia severity indices is one way of doing that, as shown. The AHRQ has a set of guidelinesfor treating pneumonia on an outpatient basis which are useful, in one estimate, the cost of treating an admitted patient for pneumonia is $3000, vs $300 for an outpatient treatment plan.

as follows- the base cost (drug only, not including IV or nurse) of giving a patient the following drugs for 24 hours, obtained from this site at Wisconsin Medical College. Note this is not what the hospital bills...

ampicillin- $ 8.80 (generic)
azithromycin- $19.19
bactrim-$17.64
unasyn- $36.66
ceftriaxone- $ 23.11
cipro- $ 33.88 not accurate- now generic.
clindamycin- $22.89
flagyl-$3.72
gentamicin $1.05(generic)
timentin $48.72
tobramycin-$7.77 (generic)
vancomycin $10.74 (generic)
Zosyn- $56.00

strange architecture

Two swastikas on public supposedly non sectarian architecture- a US Naval base in Coronado, California and the layout of the Staten Island University Hospital in New York..kinda scary huh? What is it with buildings and terrorism?

Can I get a doctor's note?

So, this is hilarious, recent Family Guy episode, Osama gets a note from his doctor because he does not want to do a suicide bombing.

Handicapped Trucker

Handicapped Trucker, originally uploaded by johnsunseasurf.

The driver of this truck is polishing his bumper parked in a handicapped spot in Clearwater, Florida.

Yosemite

Just back from Yosemite and California, took a few pics which are
here
, had an interesting wilderness adventure, capped off by the flight crew on my flight home
asking, "is there a doctor on board?", to which I did in fact respond in the affirmative.

It's kinda hard to use those crappy stethoscopes in the medical kit they give you on the plane when you are at 20,000 feet...and they give you the entire drug kit for the ACLS protocols, but no cardiac monitoring equipment other than a sphygmomanometer, thank heavens I didn't have to run a code at altitude...

CH CH CH CH Chia.... ....Horse.

Yes, this is in fact a massive chia pet spotted on the stoop of a west village house. How it got there is a mystery. But it certainly one ups the Jones's... or is it someone's twist on stealing lawn gnomes?

Mind the Gap

Elevated Anion Gap Acidoses: A summary of approach

A recent summary of a scheme for the evaluation of anion gap metabolic acidoses that I did while at the NYC Poison Control Center. Available at Google Docs- online here.

Ultimate anyone?

So. just had the annual mandatory fun, resident's retreat at Fire Island and realized it has been so long since I played ultimate frisbee, I am SO sore... the last time I played ultimate was in 1999 when I went to Dublin for the first time, ended up tearing my hamstring and got a massive bruise.. No such luck this time. Now I am resolving to keep myself in better physical fitness, but alas, my frisbee got eaten by Dan Waxman's dog, URSA, or as we like to call her, MRSA. And the last sporting goods store I went to all the frisbees were sold out... but, NO shortage of useless Yankees, Mets, or Jets gear... I mean c'mon, it's not even football season!!!!

So, if anyone reads this and is in New York and knows of an ultimate team for out of shape medical residents, well sign me up. But I will need a frisbee. and lots of ice packs. I found one in Brooklyn... anyone down for that?

Click here to check out
The Bay Ridge Ultimate Frisbee Meetup Group!

EM Procedures - Central Line part 5

This is a series of youtube videos on central lines which are pretty awesome... Thought I would post them here..

EM Procedures - Central Line part 4

EM Procedures - Central Line part 3

EM Procedures - Central Line part 2

EM Procedures - Central Line Part 1

ACED it!

This post is inspired by the fresh rhythm of the posts over at protecttheairway.com...

The patient's chief complaint: ankle pain.

Patient was seen here one week ago and ran out of ACE bandages. Patient walked to the ED in 30 degree weather in the middle of the night in the icy cold, winter, to obtain ACE Bandages, risking slipping on cold icy sidewalks to do so. Patient is WEARING a perfectly good ACE bandage.

When patient is asked if they would like the ACE bandage applied by the doctor, patient states, no thanks, I will just take that and go... It was too expensive up at the pharmacy.

When questioned by the doctor if the patient went to their followup visit at the ortho clinic, patient states, I was never told to go there....

Net cost to taxpayer: 400 plus dollars for ED visit for ACE bandage which was also available free of charge at orthopedic follow up clinic.

Net cost to patient: nothing but a stern lecture in the middle of the night.

Dinosaur Orthopedics: Snow day at AMNH

OK, so it snowed on Friday

here is a picture of the cemetery on my way to work (which reminds me to do a good job each day....) ! I was pretty excited, not because of all the bundling up New Yorkers have to do,


but because of the snow. WOW. It was cold. That's why special ear warmers were invented. Mostly, however, I went around wishing I had a balaclava on. So, the weather was cold enough that indoors activities were more appealing. So, the order of the day was to go up to the American Museum of Natural History and check out the dinosaurs!



Now,these dinosaurs got me thinking about orthopedics, of all things. Just have a look at the size of the head on this one, for example.
I began to wonder why there were so many varieties of neck and head and vertebral structural variation in the dinosaurs.Was variation in bony structure accompanied by variation in underlying neural structure?

Take for example the tortoise, which is a well adapted species, living hundreds of years. For example, one of the tortoises found by Darwin recently died in 2006. The tortoise has as it's main adaptation a bony armor, which forms the shell, basically preventing it from exposure to trauma, which is life threating in humans, for example, who have an expsoed cervical spinal cord and walk upright (making them liable to fall and undergo head trauma). Ironically, however, the cause of death in one 154 year old tortoise kept in a British Fort was an accidental fall! So much for that hypothesis!

So, I began to think, which dinosaur species was least likely to require a head or c spine CT? Is this a possible candidate?

The whole concept of the Ottawa Ankle rules was very intriguing when applied to dinosaurs and vertebrate skeletons. If you are evaluating a dinosaur in your ED, can it hop three steps unassisted before you scan it's massive ankle? How do you put a C collar on a beast of this size?

Take the camel or giraffe. They have the longest skinniest bones, highly vulnerable to long bone fractures, and a C spine which also places it at great risk. Cerebrovascular disease in a camel, therefore, would appear to make a camel fall down and injure many bones... How can this possibly be adaptive other than the whole reaching for high leaves and seeing your prey from far away arguments?

Altogether a very interesting afternoon, for anyone interested in orthopedics, the dinosaur exhibit is well worth your time.

New Year's Retrospective

So, I was just looking through some pics, and thought I would put up some cool pics here that I snapped over the last 6 months in NYC. The first one (above) is of Santa riding the L train. It was a very festive Christmas holiday!


Next we have the shot taken from the roof of one of the hospital buildings, I think it is Fierman, in which John discovers the meaning of the word "ph" in an elevator... It stands for penthouse.

Every city has it's own peculiarities with respect to floors. In Ireland, I was constantly miffed by the fact that the ground floor was not the first floor, and what I thought should be the third was actually the second. Here in New York I have had to grasp a whole new vocabulary... mezzanine, lower level, and Sabbath elevators. I determined that it takes approximately 3 minutes to get to the top of one of the twelve story buildings in my hospital if you get stuck in the Sabbath Elevator.

In any case, one of the perks of New York is the rooftop scenery. New Yorkers love their rooftops! Here is an example of the rooftop at the Met, with art from confiscated sharps at the airline security checks...

I ventured north to Boston and saw some trauma backboards being used for a more relaxing purpose, a parkbench, and quite the ham that I am, had to take a photo op...

While in Boston, there was a competition to carve several thousand pumpkins on the Commons. Apparently there is a competition between towns in Mass. to have the most carved pumpkins. Jack o'Lantern turnout was an estimated 24,000 plus pumpkins! As well as some cool rowing on the Charles!

Thinking back to summer, it feels like just yesterday when I was hanging out on the piers on the Hudson...

And watching the sunset on Fire Island...


I even got to take a trip to California and catch a California sunset! and enjoy good times with the cat, grandmother, and fire...