TB or Not TB: Isn't That the Question?

The only thing more confusing to me than this tuberculosis (TB) fiasco is how I am still the first to use this line for my title. The antagonist in the international bacterial bruhaha is a young personal injury lawyer who either knowingly or unknowingly flew off to his honeymoon in Greece with a multi-drug-resistant strain of TB (MDR-TB). Actually, the Associated Press reported yesterday that he had an even more resistant strain of Mycobacterium tuberculosis, called extremely drug-resistant TB (XDR-TB). Infectious disease is not my specialty but since when did we start assigning diseases cool prefixes that make them sound like luxury cars? We have heard rumors circulating that the 2008 model will be the YF'd-TB?

So the story goes that an excited newlywed personal injury lawyer goes to the doctor a few days before his honeymoon and is told that he "has TB". Speaker has also said that he was advised by Fulton County, Ga., health authorities that he was not contagious or a danger to anyone. Officials told him they would prefer he didn't fly, but no one ordered him not to, he said.

Let's stop here for a minute. There are really 2 kinds of "have TB"s. There is the positive PPD test for TB in which your body has formed antibodies to Mycobacterium tuberculosis after you have been exposed to it but you are symptom free and otherwise healthy, i.e. latent TB (LTB). Then there is the really have TB in which you are symptomatic, with clinical manifetations usually associated with the pulmonary system. Patients typically present with cough, fever, chills, night sweats, weight loss, bloody sputum, anorexia, etc etc. In this form, one is capable of actively spreading the infection.

Many, many Americans, and even more internationals "have TB" in the former sense and a great deal of them are probably unaware as they have never had a PPD test to detect its presence. And if all of those fliers with latent TB were quarantined, it would probably require a holding room the size of Giants Stadium. But very few Americans with dormant TB ever develop the active form of the disease unless they become immunosuppressed, as in the case of patients with HIV/AIDS or chemotherapy. Moreover, these carriers are not infective to anyone unless the disease becomes active. Lastly, his XDR-TB status does not make his disease any more transmissable than your run-of-the-mill TB, it is just harder to eradicate.

The fact that his new wife and he traveled to Greece makes you think (and hope) that he wasn't hacking up blood-tinged hunks of sputum during his "I do's". Thus, we are making the assumption that Speaker only had the presence of XDR-TB in his blood, making him no different from thousands of other air passengers who travel with latent TB on a daily basis. So what's the big deal? That's what we're trying to figure out. We are guessing all the tumult is a result of him ignoring the Man who told him not to fly.

But where did he get such an uncommon strain of the mycobacteria, that is found much more commonly in Asia and the former Soviet Union? Several reports have claimed that he was exposed when he visited a health clinic last year in Vietnam. We are not disputing that this is a possibility, but it turns out his father-in-law, Robert Cooksey, is a microbiologist for the Centers for Disease Control (CDC) who actually specialized in TB. [The plot thickens...] The same CDC that initiated Mr.Speaker's quarantine - the first of a human being since 1968. In medicine, we have a saying that common things happen commonly and if we follow that theory than it seems less likely that one week in Vietnam accounted for his infection than his chronic and long-term exposure to his microbiological father-in-law.

This is a bold call but we're betting serious money that the wife's father will be investigated and it will turn out that he, too, has XDR-TB (*cue the Law & Order dun-dun). Oh yeah, the father-in-law is the source and he is going down for this in the very near future. Or is he?

Currently, Speaker is taking up residence in a Denver hospital until he is given the green light to travel again. Perhaps we will find out that he indeed does have active TB infection but that will bring up an entire set of additional questions like why a young, healthy man in his thirties develops active TB infection in the setting of a normal immune system. (Dun-dun)

Organ Vendors

In Lahore, Pakistan yesterday, 6 people were arrested, including 3 doctors and the owner of a private hospital, after authorities identified them as key participants in an illegal kidney transplant "ring"? Can we even call it a "ring"? I'm not sure what one would call that.

Authorities in eastern Pakistan said that many men, like the ones seen here with healing nephrectomy scars, are selling their kidneys on the black market for about $1000 to pay off debts.


Turns out that rumors of people selling organs on the "Black Market" are quite true - as if there was a doubt. They may not be waking up in a bathtub with a note on the wall written in blood but whenever medicine is practiced secretively corners are cut (no pun intended) and there is usually little recourse for those under the knife.


It does bring up an interesting question, though. If done safely and properly, what is the harm of selling an organ that you can safely live without in return for monetary compensation? Before we continue the dialogue though, let me clarify that I would never, ever advocate such a practice - unless, of course, it was sanctioned by our federal government and overseen by a tightly controlling administrative body with all the proper governmental bells and whitsles, etc etc.


That said, the benefits to private citizens selling kidneys could, if done properly, save billions of dollars in the United States alone - not to mention thousands of lives. Hundreds of thousand of kidneys fail each year and patients often end up on chronic hemodialysis, despite the fact that renal transplant is the treatment of choice. Dozens of studies have shown that a successful kidney transplant improves the quality of life and reduces the mortality risk for most patients, when compared with maintenance dialysis. Chronic renal failure is a major cost burden on our health system and also brings with it or accelerates a slew of other concomittant diseases, like coronary artery disease, heart failure, hypertension, liver disease, stroke, and on and on and on.


In the US, there is an ever-rising incidence and prevalence of kidney failure and the number of patients enrolled in the end-stage renal disease (ESRD) Medicare-funded program has increased from approximately 10,000 beneficiaries in 1973 to 86,354 in 1983, and to 452,957 as of December 31, 2003. Impressive? How about this: The total cost of the ESRD program in the US was approximately $27 billion. Now, of course, not all of these patients who are maintained on dialysis would be candidates for a transplant, but if we had more kidneys, we would also be able to loosen our restrictions on who can and who cannot receive a kidney. Restoration of renal function to these patients not only changes the way theiur kidneys function but allows these patients to get back a significant portion of their life that is spent sitting in chairs receiving HD for 3-4 hours thrice weekly.


And what of the seller's role in all of this? Healthy kidney donors actually function quite well with one kidney. Is it better to have a back-up? Of course. But perhaps the seller really needs the money for his own health or children or whatever. We allow people to sell everything and anything in this country, why not body parts? In order for one to give up body parts , they actually have to be dead. And they don't even make any money from it? [Which brings up another interesting question? If they paid families for the organs of relatives that passed away, would the frequency of organ donation increase?] What about American football players? Are they not indirectly selling their body parts for a salary? A knee? A shoulder? A brain?


Another potential benefit to the practice of buying and selling kidneys on the free market would be the negative impact it would have on the so-called "black market". The desire to seek out dingy hospitals in the Third World to avoid waiting on the transplant list would be quelched if you could do the same thing at a strictly regulated American hospital.


In 2002, Charles Erin an John Harris put forth a rough sketch of how they thought this could work in the Bristich Medical Journal:

The bare bones of an ethical market would look like this: the market would be confined to a self governing geopolitical area such as a nation state or indeed the European Union. Only citizens resident within the union or state could sell into the system and they and their families would be equally eligible to receive organs. Thus organ vendors would know they were contributing to a system which would benefit them and their families and friends since their chances of receiving an organ in case of need would be increased by the existence of the market. (If this were not the case the main justification for the market would be defeated.) There would be only one purchaser, an agency like the National Health Service (NHS), which would buy all organs and distribute according to some fair conception of medical priority. There would be no direct sales or purchases, no exploitation of low income countries and their populations (no buying in Turkey or India to sell in Harley Street). The organs would be tested for HIV, etc, their provenance known, and there would be strict controls and penalties to prevent abuse.

So what is the argument against allowing citizens to sell organs in a controlled and organized fashion? I suppose that it might pose a significant health risk in that there is a surgical organ extraction and that later on down the line there might be an additive health risk associated with having one kidney or half of a liver. Actually the short-term complication rate of kidney donation has hovered around 20%, while the mortality rate is less than 1%. Moreover, the risk of chronic renal failure amongst those donating their kidneys is equal to that of the general population.


Perhaps people have a "moral" objection to the business of body parts? But synthetic or manufactured body parts are okay - just not organs that come form a living human?


Some have argued that the rich will benefit while the poor will continue to suffer and be more likely to represent the majority of organ sellers. And that differs from the current system how? No matter what schema or health care plan we use in this country, those with money will always obtain "better" (i.e. more expensive) care because they can pay for it, and ostensibly they have a higher level of education enabling them to ask the right questions and find the right people. However, if anything, legalized organ doantion levels the playing field as more organs will become available and a regulated system of organ procurement will prevent those with all of the advantages ftrom taking advantage.


Buying and selling of human organs is not a new topic of discussion. It is a popular topic of conversation in the medical literature - especially amongst those in the University and Hospital Ethics departments, where procrastination and idle discussions are a favorite pasttime.


The truth is, this would never happen in the U.S. - not becaue it is wrong, but because we value opinion and discussion and democracy. And there are just too many people that would make fighting this their cause. For what reason? Your guess is as good as mine, but if you doubt it, just look at how stem cell research - probably the most promising new technology of our century - has fared. Literally stifled by the President of the United States. And I have never heard him speak intelligently about that.

Top 5 Worst Hospital Jobs

1. Sharps Box Changer Guy – This guy is just plain crazy. His task in life is to remove plastic containers overflowing with butterfly needles and discarded IV’s contaminated with Hep C, HIV, and God knows what else. These guys should have a reality show and carry anti-viral medications in their pocket. The funny thing is that these guys never seem to wear any protective gear - I’d be wearing steel gloves and a football helmet.

2. Nurse’s Aid - It is difficult to imagine that there is a worse job in the world, let alone the hospital. A typical morning will involve weighing six to eight combative and/or demented patients. Then comes “bathing” time, in which the term “bathing” is used loosely; then re-cleaning them 30 minutes later when their Dulcolax has kicked in. This is often followed by the business end of the “Out of Bed to chair” order in which they get to lift the patient to a geri-chair. Finally, the shift ends with a round of vital signs. The only thing smaller than the qualifications needed for this job, is the pay that they receive. But at least they have their union.

3. ECG tech – Can you imagine a worse job than removing 20 patients’ gown(s), getting all up in their chest fat and breasts, and occasionally shaving excessively hairy individuals in order to paste on some stickers? Welcome to the wonderful world of the ECG technician. The best part? They get to it again 3 minutes later when they have to remove the stickers. And then come back the next day and repeat the process. Wanna really be grossed out? Stay tuned for our upcoming documentary: “Things Found in the Folds – the Story of one ECG tech and his battle to leave his job.”



4. Laundry – Ever wonder where those melena-laden sheets go after they’re thrown in the soiled utility? These people don’t. They use to smell them coming down the laundry chute but lost their olfactory senses a long time ago as a protective measure. Blood, shit, puke, urine, and all other bodily secretions end up in the laundry and these brave souls remove them. God bless them.

5. Intern - Take all the jobs above and add phlebotomist, proctologist, transporter, and general, all-around hospital bitch. That's an intern.

The Mighty Have Fallen

Crusading televangelist and father of the Christian Right, Jerry Falwell, has passed away.

CNN is reporting that Falwell was found unresponsive in his Liberty University office and despite aggressive resuscitative measures, could not be revived.

Falwell founded the Moral Majority in 1979 and is a nationally known voice for conservative Christian views.

The Associated Press reported that Dr. Carl Moore, Falwell's physician, said the evangelist had a heart rhythm abnormality. Most likely, this is atrial fibrillation for which Falwell probably took a blood thinner, i.e. warfarin (Coumadin).

While this may not have helped things, a-fib was almost certainly not the cause of death. Much more likely was the pastor’s history of coronary disease for which he had a stent placed in 2005.
When someone dies suddenly it is typically classified as a sudden cardiac death (SCD) and SCDs are usually the result of a very fast and unstable heart rhythm like ventricular tachycardia (VT) or ventricular fibrillation (VF).

Doctors Sue Back

According to the Associated Press, a group of doctors has filed suit against the state of Louisiana seeking $100 million they say they are owed for providing free care to poor and uninsured patients following Hurricane Katrina.

In all, 381 physicians at West Jefferson Medical Center, says the state failed to reimburse them for treating indigent patients since the Aug. 29, 2005, hurricane closed the state-funded Charity Hospital in New Orleans.

Despite many years of poorly reimbursed training, excessively long hours, and thousands of dollars in loans, you would be hard-pressed to find anyone crying for doctors. And I’m not saying we should start the water works just yet. But I am proud of my fellow colleagues for standing up for themselves and not simply accepting the role of martyr while everyone else collects a paycheck. I am quite sure the rest of the hospital staffers and administrators got their compensation – the union would make sure of it.

For years, physicians have taken a passive role in their reimbursement for a number of reasons. Firstly, they rightfully believe that people must be cared for regardless of compensation and like me, have a slight complex about “fighting” for money. Next, by convention, doctors are hard-working individualists who have to deal with complex billing systems and shrewd insurance companies. This makes for big trouble when trying to advocate on their behalf. Lastly, no one cries for doctors as most are quite comfortable.

It was probably a very difficult decision to sue the state of Louisiana after such a tragedy and I am sure it was not an easy undertaking to get these physicians to sign on. Many will scowl at the thought of doctors suing – as if they need the money. Evidently, they do. And they are not suing the indigent who received care, they are suing the state that is supposed to provide for their constituents – rich and poor, black and white, blue collar, white collar or no collar.

I am (quietly) proud of these physicians for taking a stand and not becoming the good martyrs in this instance. They trained long and hard for their degree and the privilege to call themselves physicians and they deserve compensation like everyone else. Chalk one up for the white coats – at least until the next billing scandal.

Enough is Enough: Cruise Goes from Bizarre to Retarded

What is going on in this world? It's not enough that Tom Cruise has more money than most small countries, but now Maverick is using it to exploit some scientology-based, bullshit treatment for 9/11 workers.

And no one is writing a thing.

The self-proclaimed president of the L. Ron Hubbard fan club (aka Hubheads) is on a fundraising mission as co-founder of the New York Rescue Workers Detoxifixation Project. Sounds legit, huh? They are advocating an untested, unreported, pseudo-medical, regimen created the by Hubbard, himself, who is about as qualified to treat toxic exposure patients as Snoop Dogg. Tickets for the April 19th gala, which will star Cruise, run as high as $100,000 for a table for eight.

And still, no one is saying a thing!

It would be one thing if Cruise preached this crap in Los Angeles where star status sometimes takes precedence over common sense and practical thinking. But he is spewing this garbage all over what I consider to be the greatest (and toughest) city in the world - a city that suffered a great tragedy but rebounded magnificently. A city that is world-renowned for its medical prowess and internationally-touted physicians and surgeons. A city that does not hide its opinion or tolerate crap from anybody.

And despite all of that - not a peep.

This detoxification process that Cruise is hawking consists of high doses of niacin, moderate aerobic exercise, intermittent dry saunas to "force sweating", and of course, vitamin supplementation. As medically sound as it seems (can you hear the sarcasm?), the detox regimen has never, ever been reported to yield any positive health effects. It is not cited in PubMed, you will not read about it in any medical journal, and it has never been reported in a case series, let alone a randomized control trial, demonstrating any therapeutic or clinical benefit.

Yet no one has come out publicly to say that this might even be harmful to men and women who made a great sacrifice for our great city.

Well, let us be the first with a medical background to shout loudly that this is a huge load of Scientologic excrement. If Travolta and Cruise and all of the other Hubheads want to donate money to the 9/11 workers, why not consult with the Mayor and ask where their dollars could be most helpful? And why hasn't Bloomberg, who usually does not hesitate to share his pragmatic opinions, weigh in on this matter?

It is completely irresponsible to offer a sham therapy in the hopes of converting some desperate folks and Cruise should be admonished for hocking his Scientologic mumbo jumbo. If he could offer even a shred of scientific evidence that this would benefit 9/11 workers we would not be so outraged but the only proof he can offer is his vacant grinning face and a wealth of scientology preachings.

Medicine in this country has shifted over the past twenty years to lean heavily on the evidence and base treatment on what has shown clincal benefit in large, multicenter trials. As physicians we have a responsibility to have an open mind but always fall back on the evidence. I have no problem with holistic forms of therapy and even placebo has shown actual clincal benefit in many forms - but using a hypothetical detoxification program to recruit new members and make promises of wellness reeks of dishonesty and ignorance.

So we said something.

The Price of Doctoring

What the f$#% is up with the ever-increasing price of study materials, test prep courses and the exam fees? Can we get a break anywhere? The test-taking business has become a lucrative for-profit industry that has ended up costing medical students and residents, already strapped by ridiculous loans, huge amounts of money.

Aren't preparation for national Board exams and USMLE tests the responsibility of medical schools and residency/fellowship programs? That's the deal we make with our benevolent program directors - we work like dogs for crappy pay and they provide us enough education to pass our tests. Lately, one party is not living up to their half of the bargain - and last time I looked residents' pay still sucked.

Prior to becoming the financial boon that it has become, the purpose of these tests were to assess the knowledge base of graduates and assure that those graduating physicians were studied enough to make reasonable decisions. Now they have become just another money-draining requirement along the way to becoming a "real" doctor. Why we need to pay hundreds of dollars just to take the test and thousands more for the numerous books, courses and additional fees is beyond me. Essentially, we're paying to be tested after paying to be educated.

When the vast majority of medical trainees are taking out more than $100,000 in loans just to attend medical school and then scraping buy during residency, they should not have to pay additional money out of their own pocket just to pass a test.

Perhaps no one ever talks about this because so many professors actually get paid by these test prep courses to teach these prep classes. But education has become exhorbitantly expensive and many of the readers of our website, an online community of medical students and residents called StopPagingMe.com, have echoed similar sentiments. Which is a nice way of saying that they don't stop bitching about paying $700 to take their medical licensing exam.

One partial solution could lie in our fantastically logical idea we fondly named: The Generous Professor Series. What is this, you ask? We have begun asking our (and your) favorite professors to make donations in the form of Boards-style test questions in their respective specialty. Of course, we credit them for their generosity and they are listed as one of the authors of this altruistic endeavor. When we have gathered enough questions in a particular residency or medical school specialty (e.g. anatomy, pathology, internal medicine) we will sell them online for super-cheap and force all of those overpriced study guides and Q&A books to match our quality and our price. This will get done much faster with your help, so if you think you're into the Generous Professor project, click here to WRITE us and start contributing questions ASAP.

The outcry against pharm reps has been a grassroots success against a major industry trying to penetrate the medical training field. Our opinion aside, a united medical student and resident voice has shooed may reps right out of their hospitals. Perhaps affordable and responsible education should be the next great cause. We don't even have to give up free lunch for it.

The Real March Madness

Forget bracketology and Dickie V's Final Four-cast - this madness is for real. Real jobs, real patients, real pain and suffering in the near future as the dreaded internship year begins to come into focus.

Monday, March 19th was a huge day for more than 20,000 medical students across the U.S. These future physicians learned at which hospitals around the United States they would be tortured for the next 3 to 8 years.

All the pictures we find on Google Images are of people hugging and smiling and laughing so we want to let those of you who are not doing those things that it is okay and you will be fine. The majority of applicants do not get their 1st choice and still end up doing wonderful things. I've always thought that it would be an interesting study to survey each specialties' thought leadrers to see how they fared in the The Match.

If you did not get your first pick or even your third pick, take it form us: it all works out in the end. What you thought was the best thing as a MS4 may not really be the best thing as a PGY-4,5 or 8. Residency, like everything else in medical training (and in life is what you put into it and you will find good and bad people whereever you go. If it turns out that you hate your instituion after a full year, you can always change.

So congratulations to all of you newly minted interns and let us be the first to inform you that there are some very psyched soon-to-be-PGY-2's ready to exert some influence.

Unfortunately more than 6,500 students, mostly at schools based outside of the United States got the news that they did not match earlier in the week. They were forced to suffer through the aptly named "Scramble" where the unmatched call, e-mail, and beg programs with unfilled vacancies to accept them - hardly a prideful moment for students who have worked so hard. Some succeed, but the process is pure torture regardless and seems quite antiquated considering the current state of technology and the fact that we are no longer scribbling on rock tablets.

Remember one thing, newly minted residents: the field you have chosen may look very different 18 months from now. If that should happen, you CAN change your specialty. Have the courage of your convictions. You can check out OpenSpots and have a look-see. You will not be alone. Chances are, you will stay in your specialty, you just have to get through the grueling years of long hours and no respect from higher-ups, nurses and patients. But remember, your mother loves you no matter what!

Now go out, get drunk, and play doctor!

Larry King Recovers from Cartoid Surgery

When it rains, it pours. And this week it was pouring 70-something talk show hosts with serious vascular issues. First Regis and now Larry King. Charles Grodin and Charlie Rose better pack a bag.

While Reege is hopefully thinking about discharge, the 73 yo King is fresh out of a carotid endarterectomy (CEA) and his camp says he'll be back by Monday to interview Sen. Barack Hussein Obama (that name is like a SNL joke - he couldn't have worse luck if his name was Stalin Bitler).

Larry King is no stranger to vasculopathy and has a history of 4-vessel CABG way back in 1987. Which also implies that he has probably had subsequent cardiac caths to open of some grafts or possibly even an ancient native vessel. King's propensity for vascular disease makes one wonder what risk factors he wields.

It is very likely he is hypertensive and most certainly takes a statin for high cholesterol. Is he diabetic, too? Probably not - all those years of poorly controlled blood pressure, cigarettes, drugs?, and booze is most certainly enough to give you the old coronary-carotid double feature.

Prior to surgery King definitely had a carotid ultrasound to assess the degree of stenosis. The question is, did symptoms prompt this vascular study or was it a smart doc who knew the talk show host's propensity for vascular atherosclerosis? Either way, he had enough of a lesion to dictate that medical therapy, compared with surgical revascularization, would be more likely to result in a stroke or even death.

What about his outcome? Well, all of the following characteristics have been associated with an increased risk of poor outcome (stroke, myocardial infarction, or death) at 30 days after CEA:

• Age 80 or older
• Severe heart disease
• Severe pulmonary dysfunction
• Renal insufficiency or failure
• Stroke as the indication for endarterectomy
• Anatomical issues including limited surgical access, prior cervical irradiation, prior ipsilateral CEA, and contralateral carotid occlusion

Surgical Methods

Carotid endarterectomy (CEA) is most often done through a neck incision either bordering the sternocleidomastoid muscle, or more esthetically, with a horizontal incision in a skin crease at the level of carotid bulb. Either way, the scar will be small and discrete enough to be covered by a good layer of pancake, so don't expect to see it on Monday unless King wants you to.

The underlying platysma (muscle) and sub-Q tissues are dissected and the carotid artery is isolated, from the common carotid to well beyond the bifurcation of its internal and external branches. After proximal and distal control of the artery is obtained, the patient is given anticoagulated. The internal, common, and external arteries are then clamped sequentially and a the artery is opened at the level of the bifurcation and extended proximally and distally. Some surgeons use a cerebral shunt which is inserted at this time.

The carotid plaque, consistently found at the carotid bifurcation and the origin of the internal carotid artery, is dissected out and removed through a dissection plane developed between the media and intima. Surgeons take great pains to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps which might lead to arterial dissection after flow is reestablished or perhaps become a nidus for platelet adhesion and thrombogenesis.

After careful inspection of the now clot-free surface, special attention is directed at repair. Some surgeons choose to repair primarily, while others patch the artery with saphenous vein or prosthetic material such as Dacron or polytetrafluoroethylene (PTFE).

Before the artery is closed, the internal carotid artery (ICA) is unclamped distally and flushed free of debris in a retrograde fashion. This vessel is then reclamped and the common and external arteries are opened. This way, all the left over aretreial "gunk" is jettisoned via the external carotid artery prior to restarting antegrade flow, i.e. that blood which goes to the brain. This technique is based on prior experience showing that patients were coming out of surgery with new neurologic events despite the best efforts of the surgeons to remove all the plaque adhered to the wall of the artery. [Interestingly, when carotid stenoses are done percuatneously, i.e. by catheter, interventionalists use a distal occlusion device to prevent embolic events. However, the interventional community is having a tough time showing benefit, or even equivalence to CEA.]

Once hemostasis is achieved, a Jackson Pratt drain is left in the wound to minimize neck hematomas and the muscle and skin are closed. when King was waking from his anesthesia, a neuro check was performed and repeated probably every 10 mins for the first hour and then every hour during recovery to make sure the talking head wasn't slurring as a result of the arterial manipulation.

Below is a sweet slide presentation we found that provides a step-by-step approach to carotid surgery.

http://www.pvss.org/Cases/CartEnd/car3.htm

Regis on the OR Schedule for CABG

Celebrity tak show host Regis Philbin dropped a bomb on his audience yesterday when he informed them that he would soon undergo coronary artery bypass surgery (CABG).

"I got to do it," Philbin said at the start of "Live With Regis & Kelly." "Darn it, I don't want to do it. Nobody wants to do it, I guess."

The diminutive but spry 75 yo male had been on a short hiatus, most likely to evaluate some ongoing chest pain issues that he had admitted to: "I had been feeling chest pains, you know, and, uh, shortness of breath and all those little symptoms that you hear about."

Philbin's refreshing candor about such a serious operation will most likely go a long way to educating his viewers about coronary artery disease and its treatment options. It also cuts out a lot of the investigative and speculative fun of our Celebrity Illness article, but don't worry, there's plenty to discuss.

Reege, as he is affectionately known, most likely presented to his PMD with c/o chest pain and fatigue and who knows what else. The guy is a huge college football fan and constantly boasts about his superior physical shape which will serve him well during this process.

Upon hearing his symptoms, it is possible that Reege was sent directly for cath, (i.e. cardiac catheterization) but more likely had a exercise-nuclear stress test first which should have suggested significant ischemia. Either way, coronary angiography was performed.

Why isn't he going for stent you ask? Currently, there are only a few hard and fast indications for CABG: 1) Left main (LM) coronary artery blockage >50%; 2)Triple vessel disease or 2-vessel disease involving the early portion of the left anterior descending artery (LAD).

If it was the former, there would have been no discussion and Reege would have most likely already been on the OR table by now. Thus, it is much more likely that he has stable multivessel disease and will have a left internal mammary artery (LIMA) graft to the LAD as well as some saphenous vein grafts harvested form his legs.

Coronary artery bypass graft surgery is associated with significant morbidity. Major complications include death, myocardial infarction (MI), stroke, wound infection, prolonged requirement for mechanical ventilation, acute renal failure, and bleeding requiring reoperation. This doesn't even include the nearly 50% incidence of post-op atrial fibrillation and all fo the complications inherent in AF. Using registry data in the United States, the perioperative and in-hospital mortality rate after CABG averages about 1% for the lowest risk elective patients, and 2-5% for all patients.

There are a few risk-predicting algorithms as outcome is hinged on comorbids but we're not gonna go there. Here are some factors that have a major impact on survival and complications:

- Pre-op LV function
- Age
- Kidney function
- Coronary diameter
- Operator experience


Are we getting too data-y for you? It's a tough surgery and you should know this before you send patients (or go for it as a patient) for what has become thought of as a fairly routine deal. It is also important to keep in mind that it has amazing benefits in almost 98% of patients.

Philbin will be facing a difficult recovery as his sternum will be sawed open to expose the heart and although he will be under general anesthesia at the time - he hopefully won't stay that way. After the recovery room, he'll be monitored in a special cardiac surgery ICU where they will hope to extubate him as soon as he can tolerate it. He will also have chest tubes and a pericardial drain following the surgery, all which will hopefully come out after POD#3. He should be out of the hospital b/n 5-7 days where he will gently recuperate and be maintained on good pain meds.

After about a month, Reege will be able to get his groove on again and we predict a late April/early May return for the daytime maven of talk.

We wish Philbin a speedy recovery and hope that he uses this opportunity to educate his audience about his experience and the preventive measures that can take in order to avoid a similar prognosis.

Depp's Daughter Recovering After Foot Puncture Infection

The Associated Press is reporting that Johnny Depp's 7-year-old daughter with longterm partner Vanessa Paradis is "doing much better" after a nine day hospital stay in London.


Several articles report that Lilly Rose was originally admitted for "blood poisoning" after stepping on a rusty nail at Depp's country home.


'Blood poisoning?' Another one of our favorite media pseudo-medical phrases. Why can't they use bacteremia, or infection, or even blood infection.


We decipher "blood poisoning" to mean bacterial infection disseminated to the blood causing a sepsis like picture. And considering the circumstances, i.e. rusty nail, one would have to assume that the offending bug would be Clostridium tetani, or tetanus. Or is it?


Actually, probably not. While more than 90% of pedal puncture wounds result from stepping on a nail. The most common organisms implicated in penetrating wounds are Staph aureus, beta-hemolytic streptococci, and then various anaerobic bacteria. Also, Pseudomonas aeruginosa is often responsible for infection when the injury is due to object penetration through shoes and socks.


Importantly, puncture wounds have the capability to infect deep spaces of the foot, including bones, joints, tendons, and deep fascia, and serious complications can arise. Therefore, the depth of penetration is hugely important.


The signs of more extensive injury are those typical of any infection, i.e. redness, warmth, pain, and swelling. If the offending object is still partly in there, e.g. broken glass or sea shell, it must be removed and the wound must be extensively debrided. Empiric ABx should be started to cover the most common bugs, i.e. S. aureus but anti-pseduomonals should be strongly considered as psudomonal osteomyelitis/-chondritis can be catastrophic.


It is our suspicion that Depp's daughter probably was treated inadequately or conservatively at first or perhaps even his the injury from her parents as kids can do and then presented 2-3 days after the injury with a warm, red, swollen foot. Imaging studies were performed for sure which included plain old x-rays to look for air and possibly a CT. CBC, Chem, and ESR were quite important in documenting infection and blood cultures were probably being sent every time the little one spiked a fever.



When she manifested systemic evidence of infection, broad spectrum IV antibiotics were certainly started and the wound was opened, any pus was removed, and the wound was most likely left open to heal on its own rather than sew it shut again.


Typically, in systemic bacterial infection, i.e. bacteria in the blood (bacteremia) patients will experience signs of sepsis: hypotension, tachycardia, fever, increased WBC. In addition to stroing anti-microbial therapy, IV fluids were probably used and maybe even pressors for blood pressure support.


This is a very scary situation for a little girl and her parents. We are happy to hear that she is out of the hospital and recovering. An interesting infectious disease topic nevertheless which proves our mantra: It sucks to be an interesting patient, but it's great to have an uneventful recovery.







Baldwin G, Colbourne M: Puncture wounds. Pediatr Rev 1999 Jan; 20(1): 21-3[Medline].


Patzakis MJ, Wilkins J, Brien WW, Carter VS: Wound site as a predictor of complications following deep nail punctures to the foot. West J Med 1989 May; 150(5): 545-7[Medline].

The IN's and OUT's of Hospital Style

While your choice of hospital shoes still says a lot about who you are, trends are moving up the body and now scrubs and accessories have started to become more fashionable. In this version of In’s & Out’s, we declare what is hot and what is not on the floors, in the OR, and beyond.

WHAT'S IN:
1. Racing Stripe Scrubs – The old days of shapeless, burlap-like, draw-string scrubs are done. Taking a cue from Dr. 90210’s freakish Robert Rey who tailors his OR apparel to show off his biceps, more and more hospital staffers are customizing their scrubs. While we have not seen the Rey-esque tank-top scrubs yet, we have seen quite a bit of the snazzy scrubs with bold racing stripes down the legs. They come in all sorts of non-hospital-like colors, e.g. navy blue, dark green and even brown. They also come in male and female varieties and unlike their predecessors, are able to highlight those hospital workers with nice features.

2, Low-rise Scrubs (a.k.a. Hipsters) – Following the trends from the denim world, now you can see your favorite nurse or doc’s coin slot with the evolution of low-rise scrub pants. Points to the RN’s and MD’s who can find low-rise scrub pants with racing stripes.

3. Schlogs – They’re part shoe, part clog. When you see them from the front, you might think that they’re standard leather shoes of the Ecco variety but pull up that scrub leg and they are backless with a cushiony insole. Oooh la la, comfort and style. More impressively, these shoes have actually done the rare cross-over as both surgeons and medicinites are donning the schlogs.









WHAT'S OUT:

1. Crocs – Here’s a tip: when it crosses over into the general public, it is no longer cool (see: red leather Dansko clogs circa ’01). Hence, as soon as 7-year-old boys were skipping around in crocs, they no longer were considered cool hospital footwear. They’re done.



2. iPod – This is one of those rare fads that was out as soon as it was in - sorta like neck tattoos. It seems to be most popular amongst the interns, particularly the prelims and transitionals who may be using it as a subtle ‘F--- You’ to their seniors. We love gadgets as much as the next guy but do you really need to listen to music while you change that wound dressing or write orders? If you want to demonstrate your bitterness about being low man on the totem pole, do what every other intern does - ignore pages. Huh?

3. Fanny Packs – Just a reminder: fanny packs have never been and never will be an acceptable accessory! Ever.

4. BlueTooth headset – This trend lasted all of 5 minutes and belonged exclusively to the attendings. Now that they sell the ear-gadgets at gas stations, it is definitely over. However, it has now become a simple way to identify those doctors who you would never want treating your family.

Top 5 Most Annoying Hospital Noises

1. Telemetry – Beep, beep, beep, beep, Booonng! Booonng! Booonng! Annoyed yet? Multiply that times 400,000 and you have recreated the telemetry floor experience. Sitting next to alarming monitors and trying to write your notes is almost as torturous as resisting the urge to put your foot through one of them.

2. The Unanswered Phone – Will no one pick up that friggin phone? Nurses and ward clerks have developed some weird defense mechanism to a ringing phone. Not only do they lack the natural guilt that should go along with ignoring someone’s call but they almost relish the annoyance that others feel after the 9th, 10th and even 11th ring.

3. The Repeating Patient – I know, this one will not make the Top 5 Politically Correct list but at least we’re honest. Whether it is the aye-fibbers (“aye-aye-aye-aye”) or the Help-Me’s (no explanation needed), hearing a patient yell anything over and over and over again often makes you want to gauge your own eyes (or ears) out. If you’re lucky, they might throw in an inappropriate phrase occasionally to keep you on your toes.

4. Suction – Do we really need to elaborate on this one?

5. Pager – This website didn’t get its name for nothing. Go ahead and switch the beeper tone all you want, it won’t help. Even more annoying is when someone’s pager goes off in grand rounds and everyone in the room checks their pager, even if they are 100 yards away. Putting your pager on vibrate solves all of the above problems, except of course the annoyingness of being paged. We fear the day of downloadable pager tones.