Yesterday, our weekly small group topic "Transitions in Health Care," referring to the process of transitioning pediatric patients with special needs/chronic illnesses from pediatricians to adult providers. The take home was that such transitions are hard and need to facilitated long before the child reaches "adult age" or age 18.
A couple examples of cases used in class: 20 yo Hispanic female with h/o Type 1 diabetes presenting to ED with out of control blood glucose after losing her health insurance at age 18 (why the heck does she have to be Hispanic??). 22 yo college student with h/o ALL treated at age 5 presenting to student health center for routine physical. Her pediatrician back home has been looking out for her before this. What issues need to be considered? How can we facilitate management of conditions that began in childhood in an adult setting?
One of my astute classmates asked at the end: "Why don't pediatricians and the new adult provider pick up the phone and have a 15 minute conversation about the patient?" Duh. Seems like a no-brainer. After all, in inpatient medicine, we have sign-out at the end of every shift, right? Yet, of course, the answer lies in financial incentives: because insurance companies don't reimburse for this, then these conversations just don't happen. Grr... another piece in this frustrating reality of how reimbursement strategies often limit effective healthcare delivery!
Thursday, August 26, 2010
Tuesday, August 24, 2010
Monday, August 23, 2010
Ants in my pants
I haven't wanted class to end so badly since high school. Something about sitting in a dark room, at 4:30 pm on Friday, at hour 8 of radiology lecture. Depressing. But I truly have nothing to complain about - I'm done by 5 pm every day on this rotation! If only we didn't have to sit in the dark...
Saturday, August 14, 2010
Please, please, please wear a helmet
I was shadowing in the ED radiology reading room the other day when we received a stat request for a CT read. 20ish female bicyclist* with severe head trauma after crashing into a car on a neighborhood road, flipping over it, and striking her head. Glasgow Coma Score at the scene was 6. She had not been wearing a helmet.
As soon as we began reading her CT scans, we knew the prognosis was extremely poor. Multiple skull fractures, subdural, subarachnoid, and intraparenchymal hemorrhages, dissection of a carotid that explained the pulsating blood coming from her ear. It was truly heartbreaking. In the words of the ED radiologist, "I have to detach myself from this. Otherwise I could never read these images."
I never saw the patient, as she was rushed off to the OR soon after arrival. A few days later, I learned that she had died that day on the operating table.
People, please, please wear a helmet. I don't care if you think you're skilled enough to not need one, or think it doesn't look cool - it's going to be way less cool if you scramble your brains. At my college, most people rode bikes to get to class, and I was always stunned that the vast majority of students never wore helmets. Biking accidents are common and while most are minor, sometimes, the terrible occurs. Remember to learn to ride safely and please wear a helmet and protect yourself.
*details of case have been changed to protect privacy
As soon as we began reading her CT scans, we knew the prognosis was extremely poor. Multiple skull fractures, subdural, subarachnoid, and intraparenchymal hemorrhages, dissection of a carotid that explained the pulsating blood coming from her ear. It was truly heartbreaking. In the words of the ED radiologist, "I have to detach myself from this. Otherwise I could never read these images."
I never saw the patient, as she was rushed off to the OR soon after arrival. A few days later, I learned that she had died that day on the operating table.
People, please, please wear a helmet. I don't care if you think you're skilled enough to not need one, or think it doesn't look cool - it's going to be way less cool if you scramble your brains. At my college, most people rode bikes to get to class, and I was always stunned that the vast majority of students never wore helmets. Biking accidents are common and while most are minor, sometimes, the terrible occurs. Remember to learn to ride safely and please wear a helmet and protect yourself.
*details of case have been changed to protect privacy
I love my iPhone!
Currently tickled by: my iPhone, clearly. Today in the main corridor of the hospital, I ran into a Mandarin interpreter whom I had worked with on a couple occasions. He looked to be dashing off to his next interpreting job but kindly flagged me down and showed me how to use the International Languages feature on my iPhone. Silly me...I should have known that iPhone is enabled for multiple languages. The coolest thing is that you can write Chinese characters on the iPhone and the characters are recognized by the phone. And there's pinyin too, for fake Chinese School graduates like me! More about working with an interpreter in another post...
Thursday, August 12, 2010
That pesky little thing called lactose
I have spent the day benefiting from the fact that I am 1) stubborn 2) live to eat and 3) cannot learn my lesson...all due to a lovely glass of ice cold milk.
In college, I practically lived off milk. I relished drinking a large glass of it at every meal, without fail, partly because I loved the taste and partly because I am paranoid about osteoporosis. Early into second year of med school, I started experiencing random episodes of "GI distress" (I'll leave you all to interpret that as you wish, okay?) At first, I thought they were due to mild food poisoning or perhaps stress. After all, I was busy and sometimes, I may have pushed my luck with those leftovers one day too far.
I distinctly remember sitting in the basement cafeteria of a local hospital (studying for boards, yes, actually, in a hospital basement) with my study buddy and literally running to bathroom every hour. After the first few trips, my concerned friend asked what the problem was, and after some explanation and sympathy, he suggested that I might be lactose intolerant. But how could this be, I thought? I had never had a problem with lactose intolerance before. (Recall: 3 large glasses of milk a day in college). Yet the proposal was entirely reasonable. Desperate for relief and thinking that I simply could not afford to be disabled by further GI bouts, I made the decision to cut out milk entirely. A few days later, like magic, no more GI issues.
A few weeks later, we had our GI block and learned all about intestines, enzymes, hormones in great, fun detail. Importantly, I learned that most cases of lactose intolerance are acquired. In fact, most of the world is lactose intolerant, such that some scientists have suggested that the thinking about lactose intolerance should be reversed, with "lactose persistence" considered abnormal. Only certain populations of Northern Europe ancestry, where it was advantageous to be able to digest milk and dairy products, does the lactase enzyme persist beyond infancy.
How to determine for certain whether one is lactose intolerant? Most of the time, people eventually figure it out on their own. But for trickier cases, there's something called a hydrogen breath test. Basically, you're fed a certain dose of lactose and then your breath is measured for hydrogen. If you lack sufficient lactase enyzme to break down lactose, the extra lactose enters your large bowel, where it's broken down by bacteria that produce hydrogen gas and all those wonderful symptoms. There's also an easier test that my GI discussion leader proposed: just drink 16 oz of milk and wait for the fun (or not) to happen.
Granted, I'm lucky. I've determined that I suffer from only a mild case of lactose intolerance. I believe that this is why it took me so long to figure out that I am indeed lactose intolerant. After boards, I took my GI leader advice and downed that 16 oz of milk. Several hours later, sure enough, bloating and diarrhea. Fortunately, I still can eat copious amounts of yogurt without problem and sometimes up to a glass of milk or so. Not so fortunately, some days I miss plain milk too much, temptation gets the better of me, and well, I pay for it.
Currently tickled by: 2010 Visa Championships or U.S. National gymnastics championships, an annual competition where the best gymnasts across the country compete and are selected for the U.S. National teams. Most people don't know that I'm a huge gymnastics fan. I got into it in college, after watching my two dormmates, who both competed for the gymnastics team, in a few live meets. Gymnastics is such an amazing sport to watch - the stuff that these athletes can do is incredible! Check it out at www.usa-gymnastics.org.
In college, I practically lived off milk. I relished drinking a large glass of it at every meal, without fail, partly because I loved the taste and partly because I am paranoid about osteoporosis. Early into second year of med school, I started experiencing random episodes of "GI distress" (I'll leave you all to interpret that as you wish, okay?) At first, I thought they were due to mild food poisoning or perhaps stress. After all, I was busy and sometimes, I may have pushed my luck with those leftovers one day too far.
I distinctly remember sitting in the basement cafeteria of a local hospital (studying for boards, yes, actually, in a hospital basement) with my study buddy and literally running to bathroom every hour. After the first few trips, my concerned friend asked what the problem was, and after some explanation and sympathy, he suggested that I might be lactose intolerant. But how could this be, I thought? I had never had a problem with lactose intolerance before. (Recall: 3 large glasses of milk a day in college). Yet the proposal was entirely reasonable. Desperate for relief and thinking that I simply could not afford to be disabled by further GI bouts, I made the decision to cut out milk entirely. A few days later, like magic, no more GI issues.
A few weeks later, we had our GI block and learned all about intestines, enzymes, hormones in great, fun detail. Importantly, I learned that most cases of lactose intolerance are acquired. In fact, most of the world is lactose intolerant, such that some scientists have suggested that the thinking about lactose intolerance should be reversed, with "lactose persistence" considered abnormal. Only certain populations of Northern Europe ancestry, where it was advantageous to be able to digest milk and dairy products, does the lactase enzyme persist beyond infancy.
How to determine for certain whether one is lactose intolerant? Most of the time, people eventually figure it out on their own. But for trickier cases, there's something called a hydrogen breath test. Basically, you're fed a certain dose of lactose and then your breath is measured for hydrogen. If you lack sufficient lactase enyzme to break down lactose, the extra lactose enters your large bowel, where it's broken down by bacteria that produce hydrogen gas and all those wonderful symptoms. There's also an easier test that my GI discussion leader proposed: just drink 16 oz of milk and wait for the fun (or not) to happen.
Granted, I'm lucky. I've determined that I suffer from only a mild case of lactose intolerance. I believe that this is why it took me so long to figure out that I am indeed lactose intolerant. After boards, I took my GI leader advice and downed that 16 oz of milk. Several hours later, sure enough, bloating and diarrhea. Fortunately, I still can eat copious amounts of yogurt without problem and sometimes up to a glass of milk or so. Not so fortunately, some days I miss plain milk too much, temptation gets the better of me, and well, I pay for it.
Currently tickled by: 2010 Visa Championships or U.S. National gymnastics championships, an annual competition where the best gymnasts across the country compete and are selected for the U.S. National teams. Most people don't know that I'm a huge gymnastics fan. I got into it in college, after watching my two dormmates, who both competed for the gymnastics team, in a few live meets. Gymnastics is such an amazing sport to watch - the stuff that these athletes can do is incredible! Check it out at www.usa-gymnastics.org.
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