WhiteCoat

Open Mic Weekend

Welcome back for another edition of the Open Mic Weekend

What’s been on your mind since last month?

All weekend everyone is welcome to post any medically-related comments, questions, or observations in the comments section. I’ll try to answer any questions on Monday.

As usual, the only rules for comments are that there are no personal attacks and that the comments/questions have to be medically-related.

Have a safe and enjoyable weekend.

24 Responses to “Open Mic Weekend”

  1. tracy says:

    Hi Dr. Whitecoat,

    i am interested in knowing how a Physican decides whether to use sutures or staples when fixing a wound.

    Thanks.

    • WhiteCoat says:

      Personal preference in most cases. Staples generally not indicated for face and for some joints. Staples have less chance of getting infected and less incidence of causing a foreign body reaction, plus they are much quicker to place on wounds. Sutures less likely to cause the “railroad track” scars, are necessary if a multiple layer closure is needed, and are usually used with complex lacerations, but they take a lot longer to insert.
      Much of the decision comes down to a time factor. With emphasis on getting patients in and out of the emergency department as quickly as possible (patient satisfaction relates to time spent in the emergency department, you know), look for more and more wounds to be closed by staples.

      • Long E.D. Doc says:

        Agree with WhiteCoat’s general principles on how E.D. docs decide on the staples vs. sutures topic. At least that’s how I learned it as well. There was at least one plastic surgery study showing staples in the face had the same cosmetic outcome as sutures, however. (Outcome was based more on length of time sutures or staples stayed in placed rather than material or method used.) I know, it’s hard to wrap my head around stapling the face shut.

        My lack of embracing the face stapling concept goes to show that once our medical “beliefs” are in place during residency, it’s hard to change our thinking on a topic. No surprise that medicine’s roots derive from religion and superstition. That may well be why physicians, myself included, find it so difficult to change our belief’s once we commit to them. Sounds exactly like religion (or politial parties…), right?

  2. Anonymous says:

    I’ve been waiting for open mic to ask this one:

    How in the hell is shoenice22 on youtube still alive? Downing a bottle of vodka…ok. But eating a tube of painter’s caulk? Are there people who have no gag reflex and a straight pipe from one end to the other?

    • WhiteCoat says:

      I have no clue.
      He would be a Poison Center’s nightmare (or maybe treasure trove). Eating deodorant? Eating Coke and Mentos? If he isn’t doctoring the things before he eats them (like filling the Bacardi bottle with some colored water), one of these days it will catch up with him.

  3. Raf says:

    Weird diabetes thing (not me, actually an employee) – young active woman without other significant health concerns, not overweight etc, has really brittle hard-to-control type 1 diabetes, diagnosed in adolescence.

    Today is the second time I’ve smelt ketones on her breath without her having any other symptom at all – she’s checked her sugars and they’re comfortably within range, she doesn’t have a bellyache or any other sign that anything’s wrong right now. BUT. Ketones. And definitely ketones, too – I’ve smelt it before, there’s no mistaking it.

    Any thoughts on what’s going on? Obviously full-blown DKA is a medical emergency and needs treating as such, but what about ketones on breath in the absence of any other symptom? She’s keeping a close eye on her sugars and is making sure she’s well hydrated, but understandably has no interest in going to hospital when she feels perfectly well.

    Has anybody else come across this?

    • WhiteCoat says:

      If they truly are ketones, they can come from other sources than DKA. Wayne mentioned the most common source these days – starvation or a low carb diet. Another source of ketosis is predominant source of calories from alcohol.

  4. Wayne Conrad says:

    @Raf, She’s not on a low-carb diet (e.g. Atkins), is she? I seem to recall ketosis being a possible effect of low carb diets.

    (I’m not a physician, and I don’t even play one on TV).

  5. Tanja says:

    I’ve had a c-section under spinal as well as a couple of minor surgeries under GA and am wondering why not more non-emergency operations are performed with a spinal rather than GA? It seems much easier to recover from, and have less dangers associated with it.

    • WhiteCoat says:

      That would be one for the surgeons/anesthesiologists to answer more fully.
      In order to do spinal anesthesia, the patient has to be able to get in a position to place the epidural and has to have a body habitus/type that facilitates epidural placement.
      I don’t believe that epidural is able to be used for surgeries above the abdomen (although with arm surgery, sometimes a regional block can be used).
      Patients under spinal anesthesia are also awake and can hear what is going on in the OR.
      May also relate to how much can be charged for the procedure.
      I’m sure there are other pro/con issues as well. These are just possible considerations from a non-surgeon.

      • Tanja says:

        Yes, I imagine the patient being awake could be problematic for the surgeon- both if they find something unexpected, such as during a diagnostic lap, and because they cannot talk freely. I remember while stitching me up after the c-section they talked about their golf plans for the weekend, but I couldn’t care less as I was holding my baby :)

  6. Midwest Woamn says:

    Since most of you think alternative medicine is vodoo, thought this was interesting.
    “After an afternoon of treatment, including acupuncture, and a 10-minute early evening session of stretching, jogging and then sprinting, injured Cardinals right fielder Carlos Beltran pronounced himself fit for duty Friday night for Game 5 of the National League championship series.”
    Acupuncture. Interesting.
    Btw, 12 in 12.

    • Tarl says:

      The main reason alternative medicine is voodoo is because once a treatment is shown to be reliable (and beyond placebo), it becomes mainstream.

      Treatments that are still alternative are those which have not passed that test.

      Acupuncture is inherently untestable via the gold standard of double-blind testing. They’ve tested single-blind (practitioner knows, but doesn’t tell the patient) and found it slightly useful, but we already know that just the physician alone having confidence distorts the significance of results. Presumably because the patient can often figure out whether the practitioner believes what he’s saying.

    • JJ says:

      I operated on a woman with glaucoma last week. Stopped her drops 5 years ago because the acupuncturist said it was curable (I have also heard the same thing from a chiropractic patient). Anyway, presented a few weeks ago with chief compaint of decreased vision. Its called legal blindness due to glaucoma. Alternative “medicine” may not be voodoo, but in some instances there is a find line between snake oil and treatment.

      • Long E.D. Doc says:

        Excellent point on the fine line between snake oil and legit treatment. Good thing every thing we non-alternative physicians do is sound, scientifically proven, and clearly beneficial to patients! Oh wait, we may have an example or two where that may not be the case…

        I’d strive to keep an open, yet at times skeptical, mind when it comes to treatment and definitely not point the finger too hard.

  7. DefendUSA says:

    I found a way to save money for a friend when it comes to needing lab work. But, what do you do if the regular doc won’t accept the results coming from LabCorp on an independent order? (PrivateMD)My gut says drop the doc. The regular doc will charge 150 for the visit to write the order, and then 150 to “interpret” what is freaking printed out by LabCorp because they have a contract with the doc. I think that is just wrong. They have the patient held hostage for RX writing as they will not refill any of the patient meds until the test is done. If a person has no insurance, and they need to save money, what kind of physician won’t accept those results as valid?

    • WhiteCoat says:

      This is a difficult situation.

      On one hand, patients want to save money by not going to the doctor. On the other hand, doctors need patients to come to the office in order to pay the bills (and those bills are substantial). Now what happens when insurance companies cut reimbursements? The $150 that the insurance company says it is paying ends up being maybe $70 after the doctor pays someone to fight the insurance denials on the phone for hours. Mrs. WhiteCoat has her own office and she pays one person full time just to call insurance companies and argue with them about denials.
      When insurance companies cut reimbursements, the doctors have to make up the difference by increasing patient visits.
      Patients without insurance get caught in the middle because the insurance company contracts don’t allow many docs to lower prices for patients who pay cash.

      In many cases, it isn’t appropriate to just keep filling someone’s meds without doing lab testing. Coumadin, thyroid meds, cancer meds, HIV treatment, many blood pressure meds, diabetic meds all come to mind. I’m sure there are multiple others.

      If they have lab results in hand, many patients just want an interpretation over the phone so that they don’t have to miss work. Happens all the time with Mrs. WhiteCoat. But insurance won’t pay for doctor phone calls. Then the doc spends hours at work calling back patients to discuss lab results and earns no income from it. That isn’t fair, either. So Mrs. WhiteCoat started having all patients make an appointment to discuss results as well. Many patients got mad and left. How would those same patients feel if their boss required them to spend three hours a day after work making company phone calls without being paid?

      There has never been a time since Mrs. WhiteCoat started her primary care practice in which she has earned more (after expenses) than her office employees. Once her office lease is up, I’m not sure she’ll continue practicing. And she is an outstanding doc who has caught many diseases that other docs have missed – including multiple cancers.

      What’s the happy medium?

      • Anony says:

        I agree that patients should schedule a visit to discuss lab results ONLY if they are in-depth and have many questions. I do not believe that one needs to be scheduled if it’s just a quick 2-3 minute thing. Hope that’s what you mean.

      • defendUSA says:

        Thanks, WC. Perhapes I should have stated what the meds were for. Patient gets yearly physical. Must take Adderall, sometimes needs sleep aid and was taking a statin drug. Meds had awful side effects to include muscle aching and pulling (hamstrings). Patient and doc agree to try more weight loss and diet changes over drug. Patient loses weight, eats well, very well…no ETOH, not even wine. BP 120/80–Total Chol. is 218, trig 87, gluc 81. But the LDL and HDL were not improved. New statin drug with diet and exercise also did not improve the numbers for a second time. So the statin drug is not even in the equation at this point. But they are withholding the RX for the sleep aid and the Adderall until a new lipid panel is done- the third one!!

        So, yes, I see your point about costs of visits, but to withhold other meds that patient has been on for 8 years because of that is wrong. Physical not due til February.

      • defendUSA says:

        Anony-
        I worked in a practice where we scheduled “nurse visits” for lab work and vaccinations at no charge. But 150 to schedule the test and then paying 159 for the lab work? I just don’t like it.

  8. Problem-solver says:

    Someone I know has been lying about me, spreading false rumors, excluding me, and telling other people not to talk to me. My feelings are hurt because I contributed hundreds of hours of my time to this organization and I do not understand why they are treating me so horribly. I had a great life and network before this. This person has gone out of their way to lie about me, spread misinformation, and to tell other people to exclude me from things I would normally attend. They are being deliberately non-communicative. I feel disenchanted because I cannot seem to do anything to fix it. I informed them of the misinformation, but they continued to lie and exclude me. I tried to problem solve, and I communicated my expectation that they treat me like a professional, which would mean they would stop spreading misinformation and false rumors and instead have a discussion. How can else can I solve this problem? How else could I correct the misinformation? What should I do when someone deliberately excludes me from my usual professional activities?

    • Pattie, RN says:

      ummm….delete you post?

    • Problem-solver says:

      If anyone would help with a solution when I first asked for help I would not have to keep looking for someone who could fix things — I wish I would not have to ask because I do not think I should be put in impossible situations like this?

      • Problem-solver says:

        I never would have chosen to be excluded nor any of these circumstances because this really hurt me. I am distraught they do not seem to care they are hurting me.

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