Communist Medicine

For the second straight year I received my flu shot because I was forced to do so.  I had no choice but to risk my job by saying no.  There is a huge push in this country to practice evidence based medicine and not to treat unless absolutely indicated.  Despite this, every where you look you are bombarded with information on the flu shot.  You can't even go to the gas station it seems like without seeing signs advertising places where you can get your flu shot.  There is huge pressure from society to get this shot that quite frankly doesn't even work that well.  According to the CDC, for the 2010-11 flu season the vaccine overall was only 60% effective.  Furthermore it works best for the people who need it the least: young, healthy individuals.  It frustrates me that so much emphasis is placed on a medicine that only works so-so.  Also, I read a lot of epidemiological studies (that's how I know that sinus infection you've got most likely is caused by a virus) and I have never once found any evidence that me getting the flu shot protects anyone (i.e. the patients I see) other than me, and yet I am forced into getting it.  It is absolutely absurd, non-logical medicine.

While I'm ranting on the tests I am forced to get, I get one to two PPD tests per year to test me for tuberculosis.  In my entire educational career I cannot remember one person who has had tuberculosis, save for one guy who had Pott's disease.  I would love to see the number needed to screen to get one positive on that test.  Meanwhile, the government says we need to cut back on screening for breast cancer, a disease that effects one in eight women, which is much more common than tuberculosis.

Pet Peeves

Unlike many other cities such as Chicago where the traffic is just awful all of the time, you never really know what to expect here in Indy when it comes to the traffic on the morning commute.  On the best days there is minimal traffic and flow is uninterrupted.  On the worst days flow will be thick throughout with occasional bumper-to-bumper interruptions.  What's particularly interesting is that there seems to be no pattern to the change in traffic flow.  It can be at any time during the commute and on any work day.

Last Thursday happened to be pretty bad in terms of traffic and there was one reason: the police.  There were police everywhere with multiple cars pulled over.  One part of the expressway goes from 3 lanes to 2 lanes and has an immediate 90 degree turn (I would love to meet the engineer who designed this route...) and this morning a cop had a car pulled over right before the drop to two lanes, resulting in a nearly mile long line of stop and go traffic.  I drive the morning commute every day here and the overwhelming majority of people are driving sanely.  Why, why, why do the police find it necessary to send half of their force out to pull people over during this time of the day?  It creates ten times more problems than it solves.  There has to be something better for them to be doing.

No new ridiculous ER visits.  I take that back, there have been a couple but when I ask them the logical question (Did you call your doctor?  This, of course, is assuming they have a doctor.) they often tell me their doctor told them to come to the ER, despite the fact that it was obviously not an emergency.  I could probably write an entire book on gaps in our health care system, but suffice it to say that in my opinion we need to re-evaluate how health care is delivered in our country.  The old fashioned model of the doctor's office with appointments may not be adequate in today's society.  Places like immediate care centers are helping to fill these gaps and reduce resource wasting like ER visits for sore throats.  

Area Woman Rushed to the ER with Fatigue for One Year

Area woman presents to the ER looking pale as a ghost and complaining of fatigue for one year.  Labs showed that she was quite anemic and iron deficient.  When asked why she waited so long to be checked out, she was unable to provide an answer.

Area Woman Has Emergent Menstrual Period

Despite having no indication of being pregnant, such as missed period, morning sickness, breast tenderness, 24 year old area woman reports to the local emergency room at the time of her normal period complaining of vaginal bleeding thinking she was having a miscarriage.  When asked if she was pregnant, she responded "I don't know."  When asked if she had taken a home pregnancy test, she answered "no."  A serum beta HCG was run stat which was negative, and a much relieved patient was discharged home I am sure to return to her much productive life.

Tales From the ER

I finished pediatrics last week and have since moved onto emergency medicine.  I enjoy seeing kids quite a lot but not enough to do it full time.  I like the variety of seeing both kids and adults.  One of the things that makes pediatrics challenging is that it involves a fair amount of hand holding (i.e. reassurance) and you get a lot of non-medical questions.  In medical school we learn about things like omphalocele and intussuception.  In reality, most of the questions in pediatrics seem to involve how much formula the baby should be drinking and how often they should be pooping, neither or which was discussed much or at all in school.  Just like everything else in life, the more you do something, the better you get.  I am much more comfortable discussing such things now than I was a year ago.

As I mentioned, I have started emergency medicine.  Working in the ER is quite a bit different than working in outpatient medicine.  There is really one goal: decide if the patient is sick enough to be admitted or treated at home.  Despite being clearly labeled as a room for emergencies, it is really quite fascinating the number of patients who walk in who clearly do not have an emergent condition.  I am sure there are a number of reasons for this and to investigate these numerous reasons would be way beyond the scope of this post.  At any rate, I thought it would be amusing to share some of the chief complaints and diagnoses that come into the emergency room, most of which clearly aren't emergencies.  In a tribute to one of my favorite web sites, I will try to write the posts in a news story fashion, a la the Onion.

Reproductive Endocrinology 101

I'm doing this post in an effort to explain what is going on with the IVF stuff.  In order to explain IVF, a simple understanding of the female menstrual cycle is required.  The above picture is a perfect example of the phrase "a picture is worth a thousand words" as it graphically explains what happens during a normal menstrual cycle.

Basically, hormones from the brain (FSH & LH) stimulate multiple follicles in the ovary.  As the follicles grow, increasing amounts of estrogen cause tissue in the uterus to grow, preparing for implantation of an embryo and pregnancy.  Eventually one of the follicles is selected as the "dominant follicle," the other follicles die off, and a massive surge in LH causes the dominant follicle to ovulate.  At this time, the hormone levels drop off with the exception of progesterone.  Progesterone is produced by the unit that contained the follicle before it was ovulated.  Progesterone maintains the uterine lining in preparation of implantation and pregnancy.  If pregnancy occurs, the placenta develops and it takes over the role of producing progesterone.  If pregnancy does not occur, progesterone levels decrease and the uterine lining built by estrogen cannot be maintained.  The lining sheds resulting in a menstrual period and the cycle starts over for the next month.

For IVF, medicines like follistim and menopur are given to help encourage follicle growth.  After a short trial of these medicines, lab work and ultrasounds are done to assess follicle growth.  Once an appropriate number of follicles are produced, another medicine such as ganirelix is given to prevent the natural LH surge and ovulation.  This is to allow for continued growth of the follicles.  The goal is to grow as many follicles as possible without over stimulating the ovaries, which can be dangerous.  Once an appropriate number of follicles are present, a "trigger shot" is given to induce ovulation.  Shortly after the trigger shot, just prior to ovulation, the follicles are retrieved using a long needle.  The follicles are then taken to a lab where a sperm cell is injected into the egg.  The embryo is then implanted into the uterus resulting in pregnancy.

In order for the female ovulation and menstrual cycle to work correctly, it requires an amazing and  complex set of hormones and body systems communicating in perfect harmony.  I think it's absolutely amazing how this system works as well as it does.  It's also pretty cool how it can be manipulated to achieve what we want it to do, like pregnancy.

Lost In Translation

One of the clinics I work at has a large Hispanic population, most of whom speak only Spanish and require a translator.  Generally speaking I am not used to working through a translator and this additional step can make things a bit difficult (as if the job of taking a history, doing a physical, coming up with a diagnosis, and then coming up with a treatment plan wasn't difficult enough).  You really need a good translator to effectively communicate.  Last time I worked at this clinic my translators were only OK.  I found people giving inconsistent histories and explaining symptom complexes that really didn't make any sense.  I truthfully wasn't sure if it was the language barrier or different cultures or if the patients weren't really all that sick.  But what can I do?  I don't speak Spanish, so I just tried my best with what I had to work with and moved on.

Speaking of moving on, the Olympics ended a few weeks ago and now Sarah and I have found another sporting event to dominate our time for the next couple of weeks: the US Open.  We're both pretty big tennis fans.  I love prime time at the Open.  Some of those matches go on way into the night.  Here's hoping for some closer matches in the upcoming days.  Sharapova has steamrolled through the first couple of rounds.