Archive for June, 2009
Monday, June 29th, 2009
Two months came and went rather quickly.
Once again I took off two weeks of work to attend this second trial. It better not get postponed again.
I caught an early train into the city. While riding the train, I didn’t feel as nervous as I did last time around. I really felt good about the care I provided and about the case in general. Of course, if you asked me that same question a week earlier, I would have told you just the opposite. This whole thing has been a crazy emotional rollercoaster ride and I’m just glad this trial is starting on a “up” note.
I got to court a little earlier than scheduled and was the first one there. Two attorneys were in front of the judge on a different case and the judge was yelling at them because of a delay in getting the depositions of two physicians.
“It’s been six months,” the judge said loudly. “I can get the deposition of the president’s physician in six months. And these doctors aren’t even neurosurgeons. The hierarchy doesn’t even apply. You know – district court judges on top, then God, then neurosurgeons. It’s not that tough. Get the depositions in two weeks or the doctors don’t testify.”
It was like watching kids getting yelled at by their father. The attorneys just hung their heads, walked over to a desk, filled out some papers and gave them to the judge to sign.
I took my seat at the desk and noticed some pre-trial orders sitting there with our case caption on them. I nosed through them and got a little upset about one of the orders. It said that “defendants are barred from eliciting any testimony about, introducing any evidence about, or arguing about medical literature as substantive evidence in the defendant’s case in chief.” What the heck? Isn’t that what the practice of medicine is based upon?
There was also an order that barred the introduction of any evidence of conversations the family had with their regular family physician. It made me wonder. Did this physician ever get deposed? Did the family tell him something that would have hurt their case?
Hitch the bailiff was ornery as ever. When the attorneys walked into to the courtroom, before they even had a chance to shut the door, he yelled “shut the door, counsel.” Then he announced to all of us “don’t use the juror bathroom, only use the staff bathroom.”
“Where is it?” I asked.
Without looking up from his newspaper he says “that way.” Thanks for being so vague.
Then he decides that he has got better things to do than sit and read the paper, so he goes off to the back hallway to talk loudly again. I go through another door to the back hallway to look around. He sees me and suddenly has an interest in my ever expanding bladder. “Right in THERE. I told you.” Oh, you mean the door that looks like a closet with no label or lock on it? I see. How careless of me to think that it was a closet.
I was supposed to take off on a Thursday night and miss one Friday during the trial for a wedding. Today I learned that I can no longer go on my trip. They have me scheduled to testify on the day I’m supposed to be gone. There’s simply no other day I can testify. Oh well. There go the plane tickets. Everyone’s schedules have to be worked around the experts who can only testify one day per week.
I also had a surprise when my attorney asked me how I was going to explain away a bloody wound on the patient’s abdomen.
“What are you talking about? There was no bloody wound on the patient’s abdomen.”
“Well, the paramedics notes stated that there was blood coming from the patient’s abdomen when they were transporting the patient to the hospital.” Supposedly the plaintiffs are going to try to state that the presence of a bloody wound on the patient’s abdomen should have led to the earlier diagnosis of the patient’s disease.
I started to get angry. This is such a game. There was no blood present. Now I am being forced to explain away a physical finding that didn’t exist based on the notes of someone who didn’t even undress the patient. This was apparently the “new” information that the plaintiff’s attorney was trying to introduce during the last trial. Never saw the ambulance report until just now.
So we come up with a different explanation of the patient’s findings on the morning of the second trial. There may have been some blood there, but given the patient’s condition, the presence of blood would not have been unexpected.
The whole concept still ate at me. The patient was sent to the hospital from the physician’s office by ambulance. The family physician didn’t note any blood. How could the patient’s abdomen go from having no bleeding wound in the physician’s office to having a bloody wound 15 minutes later with the paramedics, to having no blood when I evaluated the patient twenty minutes later?
Vinny told me “don’t bring out inconsistencies like that — they can’t help us. If you bring out those inconsistencies, it makes it look like you would have done something different if you had noted the blood and makes you look like a dummy for not noticing the blood.”
“Jurors want to be able to fit the stories into a nice little box,” he continued. “Nothing should be outside the box.”
In other words, a physician is stuck with what is written on the chart. No matter what it says.
Lucky no one wrote that the patient had Martian ears.
It’s 10:00 AM and the attorneys are back arguing in the judge’s chambers. I sat in my chair reading through the medical record for the fifteenth time with forty different pairs of eyes staring at me from the spectator seats. I wasn’t as uncomfortable as I was before, but it still felt weird having all these people sitting there looking me up and down. Even though I was bored, I resisted the urge to play games on my phone. I didn’t want to do anything that would cause a bad impression.
I had a two bottles of Gatorade already that morning, so my bladder was on overdrive. Now I saw what Vinny was talking about when he said not to drink too much. I walked to the bathroom again. This time I didn’t even need directions.
Strolling back to my seat, I scanned the room. Many of the jurors’ eyes were on me. I smiled. This crowd seemed somewhat older than the previous crowd. No one was sighing. Darn. Now I can’t count the sighs. Many of the jurors were reading newspapers. A couple were even joking with each other. Seemed like a good crowd.
Suddenly, the judge and the attorneys made their entrance into the courtroom. Just like when a conductor taps on the table, everyone quieted down.
The judge began by thanking everyone for being there and went into a short explanation of how important the jury system is to the American jurisprudence system.
Voir dire, or the interrogation of the potential jurors, had officially begun.
See previous posts in this series here.
Posted in Uncategorized | 12 Comments »
Sunday, June 28th, 2009
Some parties against the institution of tort reform argue that fully or partially immunizing physicians from liability will encourage them to practice sloppy medicine.
I’m not aware of any studies on whether adverse outcomes increase in states where physicians have greater immunity for their actions, but intuitively, I don’t think the argument holds water. Do physicians who work in free clinics and who provide free care to indigent patients in exchange for immunity from liability routinely maim and neglect the patients they treat? Do physicians who work in both fee for service and charitable environments practice medicine in a Jekyll and Hyde manner? Doesn’t make sense without some data to back it up.
However, if we’re going to make the argument that immunity encourages bad professional practices, we need to make the argument on both sides of the professional coin.
If judges were not immune from lawsuits, would things like this still happen during trials?
Posted in Medical-Legal, Trial | 47 Comments »
Sunday, June 28th, 2009
Can’t link directly to the cartoon, so am posting a low-res image below and you can go to cartoonist RJ Matson’s site to find the full-sized version. Both insightful and sad at the same time – and likely a reason that any government-run system will not be an improvement on the current system.

Posted in Comics, Funny, Policy | 7 Comments »
Saturday, June 27th, 2009
A stepdad brings in his 15 year old stepdaughter after she suddenly started having “excruciating” lower abdominal pain. She is doubled over when walking into the emergency department and is crying.
The mother is finishing up her night shift and comes to the emergency department to meet her daughter and husband. When she arrives, she takes the patient to the bathroom and reports that girl is starting her period.
After using the bathroom, the patient’s pain decreases to 6 of 10 intensity.
Because the patient just started her period, I ordered a catheterized urine specimen so that there was no urine contamination from menses. The patient’s nurse refused, saying I was being “unreasonable.” She went in and talked to the family, then came out and said that the family also refused. Instead, she obtained a “clean catch” urine that showed 1+ bacteria and 10-20 WBCs per HPF.
I told the nurse that we needed to get a catheterized specimen. She yelled at me stating that she’s “not going to put a 15 year old through that.” “You know damn well that the pain is just from her period,” she said.
“Explain to me why there are bacteria and white blood cells in her menses, then.” I demanded.
“I don’t know.” She replied.
“OK, then why are you giving me such a hard time when you’re ignoring information sitting right in front of your nose?”
“I’m still not doing the catheter. You can do it yourself.”
“If the family doesn’t want it done, they can sign out against medical advice.”
“They won’t do it because insurance won’t pay for the visit.”
I handed her the chart and said “Then you can write the discharge orders, because the ED is full and I’m not arguing about it with you any more.”
“Well …” she started.
“We’re DONE discussing this patient.”
Eventually obtained catheterized urinalysis that showed some bacteria and a few WBCs. I treated the symptoms as a UTI, even though I wasn’t entirely convinced that the patient had a UTI and would ideally have done a pelvic exam.
I told the family that the patient had a mandatory follow up the following day for re-evaluation. The patient said “like hell” as she walked out the door.
You all give me a good reality check.
Was I being unreasonable?
Posted in Patient Encounters | 40 Comments »
Thursday, June 25th, 2009
I was just about to beat my phone at backgammon for the third consecutive game when the doors to the hallway opened. About forty people were standing in the hallway waiting to get into the room.
My phone suddenly vanished and my posture immediately improved.
All of the advice Vinny gave me on our walk to court began to run through my head. Smile and try to make eye contact. As they file into the room, I’m smiling and looking at each one of them. No one seems to care. A couple of people hesitated, glanced at me and then glanced at the plaintiffs. They all searched around for a place to sit. There were three rows of benches behind a gate separating the visitors from the courtroom. Forty people were herded into those seats with Hitch as their sheepdog.
“Slide in. Slide in, will ya?”
I was waiting for him to pull out his billy club so that his pants would fall down.
It suddenly became very uncomfortable now that 40 people were all sitting in a room with their attention focused on me. Obviously, I didn’t want to be messing with my cell phone, so I pulled out the medical records and began to read them. I knew what most of the records said already, but I wanted to look busy. I took notes on a legal pad, not because of some earth shattering discovery in the chart, but so I could remember my thoughts and write about the whole experience later. They couldn’t see what I was writing, but I looked busy.
I cast another glance over at the plaintiffs. They were sitting in the same position, staring at the opposite wall with their hands folded.
Everyone sat in silence for the next 30 minutes. Sniffles, coughs and shuffling newspaper pages were the only things that intermittently broke the silence. I noticed that I did not hear the lawyers arguing anymore. OK, I have been through the chart three times already. How many more times can I sort through this thing?
Then Madame Sigh caught my attention. She’s sitting less than ten feet away from me in the front row and she keeps sighing loudly every minute or so. I know lady, nobody really wants to be here. Try not to remind everybody about it. With the 15th sigh, I have now decided that she is getting kicked off of any potential jury. I’m not listening to that for the next two weeks. I start to make tally marks on my notebook with each whiff of her breath I catch. Something to do . . . hooray.
It has now been an hour and 10 minutes since I sat down in the courtroom. The jury has been sitting staring at me for just over 45 minutes. Madame Sigh is up to number 67. The sighs were starting to get more frequent. Was she in labor? No. No. Wait. Wait. She’s in DKA. Yeah. Or maybe a brainstem herniation? A “When Harry Met Sally” movie remake audition? I felt myself wanting to giggle, so I tried to stop that line of thought … which is like trying not to think of an albino elephant. Once the image is in your mind, it’s tough to just “forget” about it.
There was a small jury room next to the judge’s bench. One of the jurors asked Hitch where the bathroom was. He pointed her to the jury room then he sauntered into the back again. Now that everyone knew that the courtroom had a bathroom, suddenly everyone had to go. Within no time there was a line of at least 10 people waiting to go to the bathroom. That was a good thing. Now I can pass the time watching other people walk by me, and, as I scanned the room, I saw that everyone’s attention was no longer focused on me. There was now something else to look at. Thanks, Hitch.
A little while later, Hitch entered the room, adjusted his belt for a minute, cleared his throat and exclaimed loudly “I have good news and bad news for everyone.” The good news is that everyone can go back downstairs. You’re excused for the day.” He never did say what the bad news was. I kept waiting for him to look at me and say “The bad news for you, WhiteCoat, is that you have to sit here after lunch with 40 different angry people staring at you.” How many more times can I page through the chart?
The sheep all filed out of their stalls.
Madame Sigh, who, based on her fast respirations and rather unappealing breath, I had unofficially concluded was in the throes of DKA, waved her arms in the air and mumbled something about “missing out on a $100/hour job because of this.” I just smiled and nodded to several jurors as they filed out of the courtroom.
Well, it was back to just me and the plaintiffs sitting in the courtroom. I glanced over and they had hardly changed position. What WERE they staring at on that wall, anyway?
After everyone had left, a cadre of attorneys came in through a door on the opposite side of the courtroom from the judge’s chambers. How did they get there?
Vinny then told me the “bad” news that Hitch forgot to mention. The trial had been postponed.
Then he told me what all the arguing was about. It seems that even though the patient died more than 6 years ago, the plaintiff’s attorney had just found some new earth-shattering evidence against me and wanted to amend his complaint (i.e. change the bad things he said about me) on the day of trial. The judge nixxed that one. That was the “denied” statement I heard coming from the back earlier.
The Grinch also found a bunch of pictures of the patient taken on the day he died that he wanted to show to the jury. He wanted to argue that the patient’s appearance 9 hours later was the same as it was when I saw him. Of course, the patient looked horrible in the pictures. Didn’t make any sense to me because the plaintiff’s attorney was saying that my delay in diagnosis is what caused the patient to die, but he’s also arguing that there was no change in the patient’s condition for 9 hours, so the pictures should be admissible. I’m really not liking the Grinch very much right now. Judge didn’t rule on that request.
Then there were the experts. The only day one of the plaintiff’s experts could show up to testify was on the same day that Vinny’s son was supposed to have surgery. This expert apparently couldn’t get any other day free for a couple of months. He must be testifying against a lot of other physicians.
My attorneys wanted to proceed with trial and the plaintiffs wanted to delay it. The judge called the Chief Justice in the courthouse and they all went down to argue the issue in his chambers, hence the magic trick of leaving through one door and appearing through another door on the other side of the building. The Chief Justice agreed with the plaintiff.
So everyone donned their coats and left the courtroom like it was no big deal.
I took off two weeks of work for this damn trial and that’s it — “it’s been fun … we’ll do it again in a couple of months”?
This really sucks.
(read previous posts in this series here)
Posted in Trial | 16 Comments »
Wednesday, June 24th, 2009
Here’s a post for the medical brainiacs out there.
It used to be a “pimp” question during medical rounds: Why don’t you give calcium to someone taking digoxin?
Answer: It could either cause an arrhythmia or could cause tetany of the heart, also known as “stone heart.”
A clinical pearl just out from eMedHome.com shows that there have been only 5 reported cases of fatal dysrhythmias with concomitant digoxin and calcium use. The pearl also notes that theoretical and extremely rare risks of administering calcium in patients with digoxin poisoning must be weighed against the increased mortality in patients with digoxin toxicity who remain hyperkalemic. Since calcium exerts an antiarrhythmic effect in hyperkalemia, it is often recommended in the stabilization of someone suffering from high potassium levels. The question then becomes: Which is worse, giving the calcium or risking an arrhythmia?
One of the studies cited in the eMedHome article by Levine et al. showed that among patients with digoxin toxicity, calcium administration non-significantly increased mortality (22% versus 20%). On the other hand, each 1 mEq/L rise in serum potassium concentration made it 1.5 times more likely that a patient would die. Note that the study only included 161 patients and that only 23 of those patients received calcium, so the “n” isn’t huge. Still a judgment call, but it appears as if calcium in hyperkalemic patients with digoxin toxicity may help more than it hurts.
References used in the eMedHome article are below
(1) Levine M, et al. The Effects of Intravenous Calcium in Patients with Digoxin Toxicity J Emerg Med 2009 Feb 5.
(2)Fenton F, et al. Hyperkalemia and digoxin toxicity in a patient with kidney failure Ann Emerg Med 1996;28:440-441.
(3)Van Deusen SK, et al. Treatment of hyperkalemia in a patient with unrecognized digitalis toxicity J Toxicol Clin Toxicol 2003;41:373-376.
Posted in Medical Studies | 7 Comments »
Wednesday, June 24th, 2009
A promising new test for appendicitis involves only a patient’s urine sample.
In an Annals of Internal Medicine article published June 23, 2009 (still not online at this time), researchers at Children’s Hospital in Boston have found that the body excretes many proteins during acute inflammation of the appendix. The protein that was found to be most consistently present in acute appendicitis cases is called leucine-rich alpha-2-glycoprotein, or “LRG” for short. According to the Time article, the protein is specific to immune cells in the appendix, and LRG testing has “statistically negligible rates of false results,” meaning that it was very good at separating those who had appendicitis from those who did not. Unfortunately, the test has only been validated in children thus far, so more testing is necessary to see whether the test can be validated in adults.
The implications of this test are huge. Appendicitis is one of the more difficult diagnoses to make clinically and missed appendicitis is an often-litigated issue, prompting many physicians to order expensive CT scanning in anyone with right lower quadrant pain. As many as 30% of appendectomies end up showing no appendicitis. If LRG testing has a low false positive rate (i.e. test is positive when there is no appendicitis) and a low false negative rate (i.e. test is negative when appendicitis is really present), it would save a lot of unnecessary surgeries, would decrease the number of CT scans being performed, and would significantly reduce the transit times in ED patients who have lower abdominal pain.
Unfortunately, as GruntDoc often says, “the devil is in the details.” I suspect that other inflammatory conditions of the bowel such as diverticulitis, colitis, and even gastroenteritis will also cause extra amounts of the protein to be secreted, causing “false positive” tests. My guess is that LRG testing will be similar to D-dimer testing for pulmonary emboli in the future – useful to exclude appendicitis if it is “normal” but requiring more testing to definitively pin down a case of appendicitis in an adult if it is positive.
Nevertheless, this could be one more bullet in a physician’s diagnostic arsenal that will hopefully improve patient care. I just hope it doesn’t become one of those things that gets ordered as part of a battery of tests on an abdominal pain patient while docs just do a CT scan anyway.
Kudos to the researchers at Children’s Hospital in Boston for thinking outside the box on this one.
Posted in Medical Topics, News Commentary | 4 Comments »
Tuesday, June 23rd, 2009
WARNING – GROSS PICTURE BELOW
You probably know what this is, but can you spell it? What are risk factors for it? And how do you manage it?
Think about it for a minute and then scroll down for the answer.

Answer: Wound dehiscence with evisceration (the bulge from the wound at the 1:00-2:00 position is bowel)
A good nursing article about wound dehiscence is here.
The following are excerpts about wound dehiscence taken from Sabiston’s Textbook of Surgery, 18th ed.
Wound dehiscence occurs in approximately 1% to 3% of patients who undergo an abdominal operation – usually 7 to 10 days postop.
It may be related to technical errors in placing sutures too close to the edge, too far apart, or under too much tension.
A deep wound infection is one of the most common causes of localized wound separation.
Many factors contribute to wound dehiscence including technical errors in fascial closure, emergency surgery, advanced age, wound infection, obesity, chronic steroid use, previous wound dehiscence, malnutrition, radiation therapy, and other systemic diseases such as diabetes or renal failure.
Dehiscence may occur without warning. Evisceration, such as in this case, makes the diagnosis obvious. Serosanguinous drainage precedes wound dehisence in 25% of patients. Probing the wound with a sterile, cotton-tipped applicator or gloved finger may also detect the dehiscence.
Treatment depends on the extent of fascial separation and the presence of evisceration or significant intra-abdominal contamination (intestinal leak, peritonitis). A small dehiscence may be managed by packing the wound with saline-moistened gauze and using an abdominal binder. If evisceration occurs, cover the intestines with a sterile, saline-moistened towel and contact the surgeon immediately. The patient will require urgent surgical closure of the wound.
Management of wound dehiscence may involve placing absorbable mesh, skin grafts, and/or flaps to reconstruct the abdominal wall.
Wound vacuums remove interstitial fluid, lessen bowel edema, decrease wound size, reduce bacterial colonization, increase perfusion, and improve healing. Successful closure of the fascia can be achieved in 85% of cases of abdominal wound dehiscence.
Posted in Medical Topics, What's the Diagnosis? | 11 Comments »
Monday, June 22nd, 2009
Took the train into town again. Never easy to find parking in the city, it costs more than dinner at a restaurant, and rush hour in the morning is anything but.
When I got to Vinny’s office, he had books and boxes laying everywhere. There were three boxes stacked onto a rolling cart with the name “WhiteCoat” on them.
Vinny and Louise both looked like they’d had a Mongo expresso with a Red Bull chaser. I thought I was nervous. Louise repeatedly went into these foot tapping fits. I couldn’t tell whether it was subconscious or whether she was doing it to irritate Vinny.
When Vinny saw me, he began shuffling through papers on his desk. After a few seconds, he found the one he was looking for and handed it to me. “It’s a bunch of B.S., but I have to officially give you this letter.”
The letter was from plaintiff’s attorney and addressed to me. It demanded that I settle the case for my full policy limits of $1 million or else he will go after my personal assets. I suddenly became very angry. I knew it was part of the game, but I just thought he had a lot of balls making a demand like that with the quality of the case he had against me.
“I’ll take my chances,” I told him.
“I figured as much,” he responded.
Louise was still doing the rhythmic foot tapping thing and then she began periodically checking her watch between taps while Vinny was going through stuff on his desk. Finally, in obvious frustration, she says “we have to go.”
During the walk to court, I got to be a firsthand witness of the ravages that caffeine can cause on the human body. Louise was developing a facial tic, was walking with her knees pulled together, and was already calling some imaginary dibs on the bathroom in the court house: “There better not be anyone in there.” Be wary, o courthouse bathroom dwellers … this woman is desperate. She has a chewed up pen in her pocket and isn’t afraid to use it!
Vinny was literally stuttering when he talked.
Both of them pepper me with more random “do’s and dont’s.”
Do not talk about the case in the elevators. You never know if a juror might be in the elevator with you. In fact, do not say anything within three blocks of the courthouse. We were already breaking that rule.
Do not wear flashy clothing. Fortunately, I don’t own flashy clothing. The best I can do is a couple of suits on the 2 for 1 rack at JC Penney’s every couple of years. Besides, it’s a little late for that little piece of advice, isn’t it?
When introduced to the jury, stand up, smile, say good morning, and sit back down. And make eye contact with all of the jurors. All of them.
Don’t drink in front of the jury — they don’t have a pitcher of water in front of them and may get mad at you if they’re thirsty. It will also make you have to go to the bathroom more often. Just suck on breath mints instead.
I kept walking and nodding my head.
Getting into the courthouse meant being scanned for dangerous objects. No one mentioned that one to me, either. They confiscated my pocket knife and my nail clippers, because obviously I’m going to have a nervous breakdown at trial, disarm multiple armed deputies, and commit mass murder by cutting everyone’s nails too close and giving them intractable paronychia. However, Louise was able to flash some card to the guard and was able to cut the line and enter the court with her peptostreptococcus-infested pen of death. The rest of the day better not go this way.
When Vinny opened the courtroom door, it appeared like a movie set. Projectors, wires, computers, and monitors were everywhere. This isn’t Kansas anymore. Butterflies immediately hit my stomach.
Everyone hung their coats in a conference room behind the desk at which the defendants were supposed to be seated. A court reporter was setting up her machine in front of the witness stand. Vinny and Louise walked into the back of the court and told me to sit in my chair.
I could hear people arguing in the judge’s chambers. Voices became loud sometimes. Part of me wanted to walk back to the door to eavesdrop … er, um … look for a bathroom. I remained seated, instead opting for a game of solitaire on my cell phone.
It became quiet for a second, then I heard someone, presumably the judge, loudly and firmly say “DE-NIIIED.” I wonder which side lost that argument. Hopefully not mine.
A few minutes later, the plaintiff and her daughter walked into the courtroom. They didn’t even look at me. Instead, they walked across the room and took their seats at the table next to me. I looked up from my game and glanced over to their table. They were both staring at me and turned their heads away in unison as soon as I looked their way. Can only imagine what they were whispering back and forth about me.
Then the bailiff sauntered into the courtroom and sat on the railing separating the court from the spectators. He was heavy set and as old as the hills. The weight from his keys and gun pulled his pants down further than they should have been, so part of his shirt was untucked. His looks kind of reminded me of one of those old pictures of Alfred Hitchcock. He had a gruff voice and barked orders at everyone as soon as they opened the doors to the courtroom.
“Put your coats in there.”
“Take your briefcase off the desk.”
“Turn off your cell phone.”
He walked back to a doorway leading behind the judge’s bench and began talking loudly with another bailiff. Everyone else was whispering. I wondered if he realized how scared the people sitting in the courtroom were. There is this tremendous fear of doing something wrong that seizes your whole body and keeps you from being yourself. Obviously, he doesn’t have that fear. Probably a lot like what people feel when they come to the ED to see me, I suppose. I wondered how he would feel in an emergency department with me snapping the glove over my hand and opening up a packet of lubricant.
All of a sudden, ol’ Hitch yelled out “Hah! Metro General settled out!”
What a jerk. What if the jurors heard that? Would they think that there was guilt because one of the parties settled out? I felt like saying something. Either that or clipping his nails too short, but they confiscated my only weapon. Curses.
There was still lots of arguing in the back. The jury was supposed to be in the room 30 minutes ago. I bet that a lot of them were thinking that they would get lucky and get sent home early for the day. Those words sent out a cheer in the room when I was in jury duty. I glanced over at the plaintiffs again. They both were sitting there staring straight ahead at the wall with their hands folded.
I was sick of solitaire. I settled into a game of backgammon.
(read previous posts in this series here)
Posted in Trial | 20 Comments »
Friday, June 19th, 2009

When my oldest daughter was in preschool, she brought me home a rock as a father’s day present. She described in great lengths how she had spent all day painting it and she beamed as she handed it to me. A picture of it is at the right.
That was almost 8 years ago and the rock has sat above my computer monitor ever since.
The reason the rock sits above my computer monitor is because it reminds me of the story below. When faced with an option, if I’m sitting at my computer, as I often am, my daughter’s gift reminds me to always choose my rocks.
Unfortunately, I just discovered that one of my rocks requires my full attention.
Hopefully it will only be a short-term issue, but I have no way of knowing at this point.
I’ll be back as soon as I can.
By the way, you may get the honor of a special guest blogger in my absence.
UPDATE JUNE 22, 2009
The rock is better for now – thanks for all the good wishes.
Will have to take a planned leave of absence next month to deal with it further.
—————————————-
A philosophy professor stood before his class and had some items in front of him. When the class began, wordlessly he picked up a very large and empty mayonnaise jar and proceeded to fill it with rocks about 2″ in diameter.
He then asked the students if the jar was full. They agreed that it was.
So the professor then picked up a box of pebbles and poured them into the jar. He shook the jar lightly. The pebbles rolled into the open areas between the rocks.
He then asked the students again if the jar was full. They agreed it was.
The professor picked up a box of sand and poured it into the jar. Of course, the sand filled up everything else.
He then asked once more if the jar was full. The students responded with an unanimous — yes.
The professor then produced two cans of beer from under the table and proceeded to pour their entire contents into the jar — effectively filling the empty space between the sand.
The students laughed.
“Now,” said the professor, as the laughter subsided, “I want you to recognize that this jar represents your life. The rocks are the important things – your family, your spouse, your health, your children – things that if everything else was lost and only they remained, your life would still be full. The pebbles are the other things that matter like your job, your house, your car. The sand is everything else. The small stuff.”
“If you put the sand into the jar first,” he continued, “there is no room for the pebbles or the rocks. The same goes for your life. If you spend all your time and energy on the small stuff, you will never have room for the things that are important to you. Pay attention to the things that are critical to your happiness. Play with your children. Take time to get medical checkups. Take your husband or wife out dancing. There will always be time to go to work, clean the house, give a dinner party and fix the disposal.”
“Take care of the rocks first — the things that really matter. Set your priorities. The rest is just sand.”
One of the students raised her hand and inquired what the beer represented.
The professor smiled. “I’m glad you asked. It just goes to show you that no matter how full your life may seem, there’s always room for a couple of beers.”
Posted in Uncategorized | 21 Comments »
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Think You Have Appendicitis? Here, Pee In This.
Wednesday, June 24th, 2009A promising new test for appendicitis involves only a patient’s urine sample.
In an Annals of Internal Medicine article published June 23, 2009 (still not online at this time), researchers at Children’s Hospital in Boston have found that the body excretes many proteins during acute inflammation of the appendix. The protein that was found to be most consistently present in acute appendicitis cases is called leucine-rich alpha-2-glycoprotein, or “LRG” for short. According to the Time article, the protein is specific to immune cells in the appendix, and LRG testing has “statistically negligible rates of false results,” meaning that it was very good at separating those who had appendicitis from those who did not. Unfortunately, the test has only been validated in children thus far, so more testing is necessary to see whether the test can be validated in adults.
The implications of this test are huge. Appendicitis is one of the more difficult diagnoses to make clinically and missed appendicitis is an often-litigated issue, prompting many physicians to order expensive CT scanning in anyone with right lower quadrant pain. As many as 30% of appendectomies end up showing no appendicitis. If LRG testing has a low false positive rate (i.e. test is positive when there is no appendicitis) and a low false negative rate (i.e. test is negative when appendicitis is really present), it would save a lot of unnecessary surgeries, would decrease the number of CT scans being performed, and would significantly reduce the transit times in ED patients who have lower abdominal pain.
Unfortunately, as GruntDoc often says, “the devil is in the details.” I suspect that other inflammatory conditions of the bowel such as diverticulitis, colitis, and even gastroenteritis will also cause extra amounts of the protein to be secreted, causing “false positive” tests. My guess is that LRG testing will be similar to D-dimer testing for pulmonary emboli in the future – useful to exclude appendicitis if it is “normal” but requiring more testing to definitively pin down a case of appendicitis in an adult if it is positive.
Nevertheless, this could be one more bullet in a physician’s diagnostic arsenal that will hopefully improve patient care. I just hope it doesn’t become one of those things that gets ordered as part of a battery of tests on an abdominal pain patient while docs just do a CT scan anyway.
Kudos to the researchers at Children’s Hospital in Boston for thinking outside the box on this one.
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