Dr. Wes: An Open Letter…

Dr. Wes: An Open Letter To Patients Regarding Health Reform.

“Now, in the unfortunate circumstance where you might become sick, you will need to develop symptoms that follow a few simple rules. Do not, under any circumstances, develop symptoms that fall outside federal protocols developed based on comparative effectiveness research data. If you do, your doctors will face pay cuts, litigation, limited resources due to lack of funding for cost-ineffective technologies, and the scourge of discharge planners. Does the term “leper colony” mean anything to you?”

Classic.  With just the right amount of snark.

Sometimes All You Have Isn’t Enough

And yet still, IRS wants more from you.  And your business.

“The IRS believes that some percentage of the costs incurred by employees using company-provided wireless devices should count as a “fringe benefit” and thus be subject to taxation. Since workers inevitably end up taking personal calls or emails, the thinking goes, it’s only fair that they pay for the privilege. What’s next? Maybe a per-cup tax on office coffee, or targeting furtive visits to ESPN or Hulu on the office PC? As one wag put it on the Journal’s Web site, “It’s like charging for the use of the company washroom.”

I understand the need to have taxes to support the myriad programs of our government, but this is ridiculous.  And the thing that stings, is that it is happening from top to bottom.  It’s one thing if your federal taxes get jacked, but now many states, counties and cities are finding new and creative ways to wring every last penny out of you.  Fees for awnings, inspections and permits are all going up in my fine city.  If there is a way to slap a fee on it, our lovely city leaders have figured it out.  Not to mention the colossal waste of money that the new soccer stadium will turn out to be.  How is it that a city who’s roads are so behind in repairs intends to spend millions on a new soccer stadium, that may or may not bring in any new revenue to the city?

And so like our friends in Washington, who think that our use of office resources needs to be classified as a “fringe benefit”, it will not be long until the local folks try to figure out a way to do that as well.  Or in other words, “If it moves, tax it.”

I’m a Doctor

No, not really.

We have  to can choose to call you doctor because you have a PhD in Business Administration, not because you are a medical doctor.  You may have gone through pre-med a hundred years ago, but that does not mean you can come onto the floor, thumb through the patient’s chart and attempt to make suggestions for the patient’s care.  And to do this while feeding the spouse’s delusions that their loved one only needs a “blood transfusion tonight!” or a “gluten-free diet” or “restarting of the antibiotics” when really the spouse is “in the River©*” that their loved one is dying of metastatic cancer, is either at the very least unethical, if not totally illegal.

I can sympathize with your need to lend your advice to a family friend in their time of need, but let the professionals handle the managment of the patient and stop filling the spouse’s head with nonsense.

*in the River: referring to a family member who is in denial, i.e. “in the Nile”, a near-Cockney play on words.

Talent and Dedication

Is what it takes to be massively non-compliant and end up in the ED with a blood glucose of 1038. And even better? Not even a hint of DKA. Yep, VBG looked beautiful, electrolytes were a little off, even the Beta-Hydroxybutyrate wasn’t even off. And had she taken any diabetic meds in the last 5 months? Not a single one.

See what I mean? Talent and dedication.

Being Prepared

A 30-something year old male presented to the ED of an outside hospital complaining of palpitations that had been occuring intermittently for about a month.  When he had awoke that morning they were present and had not abated as they had in previous instances, so he went to the ED.  No prior medical history, no medication, no alcohol, tobacco or illegal drug use was reported.  The ED physician contacted a cardiologist at our institution for transport of the patient and admission to cardiology.  The patient’s heart rate was in the 160’s and above, but he was hemodynamically stable, nonetheless an antiarrhythmic drug was started and his heart rate slowed prior to transport.

After an hour and a half transport from the outside hospital the patient arrived and was placed on telemetry.  He was noted to have a rapid heart rate in excess of 190 beats per minute.  Subsequently the following 12-lead EKG was obtained.

As you can see, the heart rate is actually exceeding 200 BPM in this shot.  No P waves are seen as either they aren’t present or the rate is too fast and they blend into the QRS.  But how could a guy who’s rate had been controlled prior to leaving the oustide hospital suddenly ramp up?  Well, if you run out of the drug, in this case procainamide, halfway through transport, you tend to have problems.  Evidently, the medics misjudged the length of transport and left with less than half a bag, which at the rate of the infusion was no going to last them all the way to our facility.  So they ran dry en route and this gent’s heart rate started to go back up as the procainamide wore off.

Needless to say, it was restarted ASAP.  After a loading dose and about 15 minutes on the infusion, his 12-lead looked like this:

So what’s going on with this guy?

If you guessed WPW, you would be correct.  Notice the delta wave that is present, most notably in leads II and III.  Coupled with the rapid rate it is a near classic presentation of WPW.  But what is it?  Wolf-Parkinson-White Syndrome is classified as a pre-excitation arrhythmia where electrical impulses leaving ther SA node travel through an accessory bundle of nerve fibers called the bundle of Kent and travel directly to the ventricle, usually the left, sparking a depolarization before the regular impulse travels through the AV node, or pre-exciting the ventricles.  Notice the short PR interval that leads into the delta-wave of the QRS, this is the electrical stimulus traveling through the accessory pathway to the ventricles.  Typically, the bundle of Kent is present in the fetus, but then is electrically isolated by furhter development, in individuals with WPW, this didn’t happen.  When patients are ina normal sinus rhythm, the haert rate can remain controlled, but in people in atrial fibrillation or atrial flutter, the rapid, chaotic atrial impulses are conducted directly to the ventricles resulting in heart rates up to 300 bpm and usually subsequent arrest.  As you can see there though, just because you’re in normal sinus rhythm doesn’t mean your rate can’t rapidly rise.  Treatment of individuals with WPW can be complicated especiallywhen they present with AFib, as normal pharmacological treament, calcium channel blockers, beta blockers, tend to reduce the conduction through the AV node allowing the impulses through the accesory bundle to maintain and even accelarte the heart rate.  In cases like this patient, antiarrhythmics, like procainamide and amidarone can be used to control the heart rate.  Typically, and in this case, a trip to the EP lab is in order to have the accessory bundle mapped and ablated thereby blocking the pathway.

Here’s a couple of good links for WPW:

Wolf-Parkinson-White Syndrome – Wikipedia

Wolf-Parkinson-White Syndrome – eMedicine

A Little Cardiology Geekery – A Day in the Life of and Ambulance Driver

Neon Days and Neon Nights- flickr

Neon Days and Neon Nights.

“Dark is not the opposite of light,  it’s the abscence of light” the Beastie Boys

Neon pushes back the darkness, hides it from us while drawing us in like proverbial moths to the flame.  While unnerving, there is something magical about streets ablaze in light at 2am when all shoul dbe dark.  But in the harsh glare of daylight, so often these glass masterpieces lose their magic.

This is one cool photoset.  All neon, all the time.

via Digg