Monday, June 12, 2006
The Joy of Medical School Graduation
Well this entry documents an example of the extra joys of the profession which occasionally occur outside the realm of the operating room. That does not mean that there is not an OR connection. This year for the UB Medical School graduation one of the graduating seniors asked me to be the individual to place her hood on as she received her degree. This is a long and sacred tradition in most schools. Usually there is a Hooding Committe which is various members of the faculty. However, physican parents or relatives and professors of special meaning to students are allowed to place hoods. Obviously for physician natural parents or relatives this is a continuation of a lifelong pride. However, for those professors asked to place hoods based upon the brief duration of medical school; it becomes something more meaningful. For me the experience was very exciting. I can count over thirty medical school graduations in my career; however, none was more special than this year. I had the opportunity to place the hood on a young woman going into my specialty of surgery. There are two things which make the experience special; first and foremost, the remarkable young woman, second, she is going into surgery. The young woman is a terrific individual with numerous wonderful traits. That she is going into surgery is even more special because she will be that kind of caring, devoted surgeon that I would wish to take care of me if I needed surgery. One of the greatest Joys of Surgery for an academic surgeon is to serve as a role model for the future generations of surgeon. All my best. JTE.
Friday, March 31, 2006
A very Provocative Article
http://www.medscape.com/viewarticle/527605
Policy and Politics: No Method, Thus Madness?
Arthur L. Caplan
Hastings Cent Rep. 2006;36(2):12-13. ©2006 The Hastings Center
Posted 03/29/2006
If you ask most medical school deans if they have a course, program, or center doing bioethics, they will enthusiastically assure you that they do. And their enthusiasm for bioethics grows exponentially in proportion to their interest in showing that they are doing something about managing research ethics issues at their institutions. The same can be said about the entire biomedical research establishment—from private companies to independent research centers to professional organizations—bioethics is on the masthead, the organizational chart, and the agenda of the annual meeting. Not to worry—medicine's got ethics.
It is certainly fine to feature bioethics as a topic area. But there is mounting evidence that perhaps bioethics is not all or even primarily what the doctor should be ordering just now. Some of the problems now ailing medicine require admitting that what has befallen medicine and the health sciences is an epistemological crisis as much as a moral one.
Now this may seem an odd claim since it is hard, or rather, completely impossible, to avoid the phrase "evidence-based medicine" in the august halls of academic medical centers in the United States, Europe, Australia, and New Zealand these days. There are journals, resource centers, toolkits, web sites, and more publications than anyone interested in evidence-based medicine could possibly ever read.
So how could it be that a field that is embracing evidence at every turn, teaching about outcomes, drilling the need for verifiable data into the heads of the next generation, and extolling the virtue of evidence at every conference, meeting, seminar, and water-cooler, possibly be in the midst of an epistemological crisis? Where is the evidence?
Contemporary medicine is sailing on very rocky seas these days. It is being buffeted by ever-rising costs, doubts about its efficacy, and intrusions on its turf from competitors that range from optometrists, psychologists, chiropractors, midwives, and nurse-anesthetists to the friendly folks at the herb and vitamin store. Recently, there seems to be real uncertainty on the part of medicine's leaders about what to say in the face of a continuing stream of fraud and misconduct. The editors of the Lancet, Science, Nature, and the New England Journal of Medicine—the key guardians of the evidence gates—face a stream of questions about how they plan to secure the gates following the shenanigans of the South Korean researcher who lied about producing stem cells from cloned human embryos and a Norwegian cancer researcher who fabricated findings about ways smokers could reduce their risk of acquiring oral cancer, and their tortured agonizing is painful to watch. Far from having an answer to the question of what distinguishes medicine as a mode of healing and a field capable of minimizing fraud, the leaders of the medical professional cling to the phrase "evidence-based medicine" as if intoning the word "evidence" will act as a talisman to keep all the troubles at bay.But the fervency of the embrace of evidence-based medicine reflects a deeper and much more serious problem among the stewards of medical knowledge—a crisis of faith in the methods, processes, and checks and balances that have, at least since the nineteenth century, been the infrastructure that has permitted medicine to make the transition from an art to a science. Consider the response to the recent battle over what to do about fetal pain.
In the August 24, 2005, Journal of the American Medical Association, an article claimed that a review of all the available published medical evidence showed that fetuses do not feel pain until they are at least seven months old. The JAMA article appeared at a time when efforts are underway in Congress and state legislatures to use the topic of fetal pain as a way to discourage women from seeking elective abortions. The JAMA article contended that there is no medical evidence showing that fetuses can feel pain at twenty weeks. Moreover, it argued that the provision of fetal anesthesia would carry risks to the mother without providing benefit of any sort either to the fetus or the mother.
Many raised questions about the study's findings. But they did so in a most peculiar way—they "outed" some of the authors of the study as being involved with abortions or the advocacy of abortion rights.
When JAMA published the paper, a disclosure was included that the authors had no financial interests in any drugs or devices discussed. Requiring authors to disclose financial conflicts of interest is by now a standard requirement for all major medical journals. But there was no disclosure of the fact that one of the five authors runs an abortion clinic at San Francisco's public hospital while another worked temporarily more than five years ago for an abortion rights advocacy group.
Douglas Johnson, legislative director of the National Right to Life Committee, professed to be shocked by this omission. "These are people with years of professional and ideological investment in the pro-abortion cause, not some neutral team of medical professionals," he told the Chicago Tribune. "We think readers and viewers have a right to know who's filtering the information they're being presented with."
It is hardly surprising that someone active in the movement to criminalize elective abortion would yell foul at the idea that JAMA could have run this article without a disclosure of the proabortion involvement of some of the authors. What is astounding, and indicative of the sad state of epistemological affairs in medicine, is that two former editors of the New England Journal of Medicine agreed with Johnson.
Arnold Relman told the Chicago Tribune that the editorial staff at JAMA "must have known there would be criticism from the right-to-life people. In a situation as contentious as this, it seems more disclosure should be the rule rather than less."
Marcia Angell concurred. "Suppose it were the other way. Suppose there were an article that said that (fetuses) do feel pain and it was written by people who were involved in the right-to-life movement. Would I want to know that? I think I would."
If these claims are right, then medicine is truly and utterly lost. If every potential source of bias is to be revealed alongside every published article, then medical and biomedical journals will consist of nothing but long biographical essays about the authors. There will be no room for science in any journal that seeks to identify and disclose all of its authors' possible biases.
There is nary an author publishing today in biomedical journals who lacks ambition, enemies, vices, dreams, aspirations, patriotic feelings, pride, or an ego. These are all powerful sources of bias. So are such factors as where one went to school, one's religious affiliation, political commitments, economic status, social upbringing, cultural outlook, and character. Is all of this to be disclosed by every author? Must we know that an author is pursuing tenure, wants to impress his peers, has hated a key rival at another medical school ever since they were together as undergraduates, is desperate to belong to the local country club, hopes to finally make his parents proud, lusts after a colleague's spouse, abjures meat, looks at pornography on the Internet, leaves bad tips, is a Scientologist, or is gay? Is all this necessary to assess the author's claim, based on a review of the literature, that a fetus does not feel pain until twenty-eight weeks?
Medicine needs to both know what its methods are for dealing with bias—and for that matter for detecting fraud—and then believe that it can weather the storms induced by politics, money, ambition, and greed. To put the point another way, talking about evidence without being sure what methods, techniques, and strategies can be relied upon to produce valid evidence is talking through your epistemological hat.
Now as it happens, medicine does have such methods, techniques, and strategies. They consist of the randomized trial, the case-control study, the drive to subject hypotheses to confirmation and falsification, the need to demonstrate a degree of consistency among new theories and old ones, the family history, and the correlation of the pathologist and the postmortem with the diagnostician, among others.
But few physicians or those who work with them have any sophistication about the philosophy of science. Even fewer have ever been taught anything about the philosophy of medicine. And fewer still can give a coherent presentation on what the core infrastructure is that distinguishes the science of medicine from the faith and testimonials of religious healers or the loopy claims of the talk radio nutritionists.
This has got to change. The only way for medicine to weather its current storms is not to adopt the mantra of evidence but to know where evidence comes from and why it is to be trusted. If our medical schools and academic research centers do not take this need far more seriously then they now do, if they do not make the philosophy of medicine a part of the culture of academic medicine and a key element that is presented when medicine travels in public, then soon enough those who cry bias, greed, conflict of interest, ideology, or misconduct at any claim they do not like will only have to make the charge to make it stick.
Policy and Politics: No Method, Thus Madness?
Arthur L. Caplan
Hastings Cent Rep. 2006;36(2):12-13. ©2006 The Hastings Center
Posted 03/29/2006
If you ask most medical school deans if they have a course, program, or center doing bioethics, they will enthusiastically assure you that they do. And their enthusiasm for bioethics grows exponentially in proportion to their interest in showing that they are doing something about managing research ethics issues at their institutions. The same can be said about the entire biomedical research establishment—from private companies to independent research centers to professional organizations—bioethics is on the masthead, the organizational chart, and the agenda of the annual meeting. Not to worry—medicine's got ethics.
It is certainly fine to feature bioethics as a topic area. But there is mounting evidence that perhaps bioethics is not all or even primarily what the doctor should be ordering just now. Some of the problems now ailing medicine require admitting that what has befallen medicine and the health sciences is an epistemological crisis as much as a moral one.
Now this may seem an odd claim since it is hard, or rather, completely impossible, to avoid the phrase "evidence-based medicine" in the august halls of academic medical centers in the United States, Europe, Australia, and New Zealand these days. There are journals, resource centers, toolkits, web sites, and more publications than anyone interested in evidence-based medicine could possibly ever read.
So how could it be that a field that is embracing evidence at every turn, teaching about outcomes, drilling the need for verifiable data into the heads of the next generation, and extolling the virtue of evidence at every conference, meeting, seminar, and water-cooler, possibly be in the midst of an epistemological crisis? Where is the evidence?
Contemporary medicine is sailing on very rocky seas these days. It is being buffeted by ever-rising costs, doubts about its efficacy, and intrusions on its turf from competitors that range from optometrists, psychologists, chiropractors, midwives, and nurse-anesthetists to the friendly folks at the herb and vitamin store. Recently, there seems to be real uncertainty on the part of medicine's leaders about what to say in the face of a continuing stream of fraud and misconduct. The editors of the Lancet, Science, Nature, and the New England Journal of Medicine—the key guardians of the evidence gates—face a stream of questions about how they plan to secure the gates following the shenanigans of the South Korean researcher who lied about producing stem cells from cloned human embryos and a Norwegian cancer researcher who fabricated findings about ways smokers could reduce their risk of acquiring oral cancer, and their tortured agonizing is painful to watch. Far from having an answer to the question of what distinguishes medicine as a mode of healing and a field capable of minimizing fraud, the leaders of the medical professional cling to the phrase "evidence-based medicine" as if intoning the word "evidence" will act as a talisman to keep all the troubles at bay.But the fervency of the embrace of evidence-based medicine reflects a deeper and much more serious problem among the stewards of medical knowledge—a crisis of faith in the methods, processes, and checks and balances that have, at least since the nineteenth century, been the infrastructure that has permitted medicine to make the transition from an art to a science. Consider the response to the recent battle over what to do about fetal pain.
In the August 24, 2005, Journal of the American Medical Association, an article claimed that a review of all the available published medical evidence showed that fetuses do not feel pain until they are at least seven months old. The JAMA article appeared at a time when efforts are underway in Congress and state legislatures to use the topic of fetal pain as a way to discourage women from seeking elective abortions. The JAMA article contended that there is no medical evidence showing that fetuses can feel pain at twenty weeks. Moreover, it argued that the provision of fetal anesthesia would carry risks to the mother without providing benefit of any sort either to the fetus or the mother.
Many raised questions about the study's findings. But they did so in a most peculiar way—they "outed" some of the authors of the study as being involved with abortions or the advocacy of abortion rights.
When JAMA published the paper, a disclosure was included that the authors had no financial interests in any drugs or devices discussed. Requiring authors to disclose financial conflicts of interest is by now a standard requirement for all major medical journals. But there was no disclosure of the fact that one of the five authors runs an abortion clinic at San Francisco's public hospital while another worked temporarily more than five years ago for an abortion rights advocacy group.
Douglas Johnson, legislative director of the National Right to Life Committee, professed to be shocked by this omission. "These are people with years of professional and ideological investment in the pro-abortion cause, not some neutral team of medical professionals," he told the Chicago Tribune. "We think readers and viewers have a right to know who's filtering the information they're being presented with."
It is hardly surprising that someone active in the movement to criminalize elective abortion would yell foul at the idea that JAMA could have run this article without a disclosure of the proabortion involvement of some of the authors. What is astounding, and indicative of the sad state of epistemological affairs in medicine, is that two former editors of the New England Journal of Medicine agreed with Johnson.
Arnold Relman told the Chicago Tribune that the editorial staff at JAMA "must have known there would be criticism from the right-to-life people. In a situation as contentious as this, it seems more disclosure should be the rule rather than less."
Marcia Angell concurred. "Suppose it were the other way. Suppose there were an article that said that (fetuses) do feel pain and it was written by people who were involved in the right-to-life movement. Would I want to know that? I think I would."
If these claims are right, then medicine is truly and utterly lost. If every potential source of bias is to be revealed alongside every published article, then medical and biomedical journals will consist of nothing but long biographical essays about the authors. There will be no room for science in any journal that seeks to identify and disclose all of its authors' possible biases.
There is nary an author publishing today in biomedical journals who lacks ambition, enemies, vices, dreams, aspirations, patriotic feelings, pride, or an ego. These are all powerful sources of bias. So are such factors as where one went to school, one's religious affiliation, political commitments, economic status, social upbringing, cultural outlook, and character. Is all of this to be disclosed by every author? Must we know that an author is pursuing tenure, wants to impress his peers, has hated a key rival at another medical school ever since they were together as undergraduates, is desperate to belong to the local country club, hopes to finally make his parents proud, lusts after a colleague's spouse, abjures meat, looks at pornography on the Internet, leaves bad tips, is a Scientologist, or is gay? Is all this necessary to assess the author's claim, based on a review of the literature, that a fetus does not feel pain until twenty-eight weeks?
Medicine needs to both know what its methods are for dealing with bias—and for that matter for detecting fraud—and then believe that it can weather the storms induced by politics, money, ambition, and greed. To put the point another way, talking about evidence without being sure what methods, techniques, and strategies can be relied upon to produce valid evidence is talking through your epistemological hat.
Now as it happens, medicine does have such methods, techniques, and strategies. They consist of the randomized trial, the case-control study, the drive to subject hypotheses to confirmation and falsification, the need to demonstrate a degree of consistency among new theories and old ones, the family history, and the correlation of the pathologist and the postmortem with the diagnostician, among others.
But few physicians or those who work with them have any sophistication about the philosophy of science. Even fewer have ever been taught anything about the philosophy of medicine. And fewer still can give a coherent presentation on what the core infrastructure is that distinguishes the science of medicine from the faith and testimonials of religious healers or the loopy claims of the talk radio nutritionists.
This has got to change. The only way for medicine to weather its current storms is not to adopt the mantra of evidence but to know where evidence comes from and why it is to be trusted. If our medical schools and academic research centers do not take this need far more seriously then they now do, if they do not make the philosophy of medicine a part of the culture of academic medicine and a key element that is presented when medicine travels in public, then soon enough those who cry bias, greed, conflict of interest, ideology, or misconduct at any claim they do not like will only have to make the charge to make it stick.
Wednesday, February 15, 2006
How does a shotgun pellet migrate from Slate
Hi. Let me urge everyone to go to www.slate.com for this story and more. This is the one I gave the interview for earlier today.
explainer Answers to your questions about the news.
How Does a Shotgun Pellet Migrate?
Plus, can birdshot give you lead poisoning?
By Daniel Engber
Posted Wednesday, Feb. 15, 2006, at 6:10 PM ET
The man Dick Cheney inadvertently blasted with a shotgun suffered a minor heart attack on Tuesday morning. A pellet lodged in Harry Whittington's torso appears to have migrated to his heart. Doctors say that Whittington may have between six and 200 pieces of birdshot lodged in his body. How does a pellet move around once it's inside you? And can birdshot give you lead poisoning?
Gravity can move a pellet of birdshot lower in your body, at least until enough scar tissue has built up to hold it in place. If the pellet ends up in a hollow organ like the stomach, it can jostle around or make its way through your digestive tract. Bullets in the brain seem to pose an especially serious risk of further injury—people who get shot in the head have to worry about "moving bullet syndrome."
Bullets or pellets can also move around in your bloodstream. If a pellet manages to pierce one side of a blood vessel but not the other, it might get swept into circulation. The smaller the projectile, the more likely it is to move around in the blood. Heavier bullets tend to migrate downward, while a tiny pellet might be carried along toward the heart. In 1992, the Associated Press described a man who had been shot in the left side of his face. A fragment of the bullet had lodged in his jugular vein; doctors finally removed it from one of the chambers of his heart.
Can birdshot cause lead poisoning? Yes, but it doesn't happen very often. Birdshot is usually made of either steel or lead, but doctors routinely leave pellets (or bullets) in the body because the risks of surgery are deemed greater then the possibility of poisoning. We don't know what kind of birdshot Cheney was using; experts quoted in the news seem to discount the dangers of lead for his victim. Still, numerous case reports and several studies have demonstrated that gunshot injury can cause lead toxicity. A recent survey of about 500 shooting victims in South Central Los Angeles found a significant and consistent increase in blood lead levels over the months following an injury.
The chance of getting lead poisoning increases with the number of bullet fragments or pellets you have lodged inside of you. A large number of very small lead pellets—perhaps like those lodged in Whittington's head, neck, and chest—would be the most dangerous on account of their large surface area. Pellets that end up near large joints are especially problematic; the synovial fluid contained in these spaces seems to increase the rate at which lead dissolves.
The symptoms of lead poisoning might appear within a few days after someone gets shot, but they can also turn up decades later.
Got a question about today's news? Ask the Explainer .
Explainer thanks James Evans of the State University of New York and William Manton of University of Texas.
Related in Slate
explainer Answers to your questions about the news.
How Does a Shotgun Pellet Migrate?
Plus, can birdshot give you lead poisoning?
By Daniel Engber
Posted Wednesday, Feb. 15, 2006, at 6:10 PM ET
The man Dick Cheney inadvertently blasted with a shotgun suffered a minor heart attack on Tuesday morning. A pellet lodged in Harry Whittington's torso appears to have migrated to his heart. Doctors say that Whittington may have between six and 200 pieces of birdshot lodged in his body. How does a pellet move around once it's inside you? And can birdshot give you lead poisoning?
Gravity can move a pellet of birdshot lower in your body, at least until enough scar tissue has built up to hold it in place. If the pellet ends up in a hollow organ like the stomach, it can jostle around or make its way through your digestive tract. Bullets in the brain seem to pose an especially serious risk of further injury—people who get shot in the head have to worry about "moving bullet syndrome."
Bullets or pellets can also move around in your bloodstream. If a pellet manages to pierce one side of a blood vessel but not the other, it might get swept into circulation. The smaller the projectile, the more likely it is to move around in the blood. Heavier bullets tend to migrate downward, while a tiny pellet might be carried along toward the heart. In 1992, the Associated Press described a man who had been shot in the left side of his face. A fragment of the bullet had lodged in his jugular vein; doctors finally removed it from one of the chambers of his heart.
Can birdshot cause lead poisoning? Yes, but it doesn't happen very often. Birdshot is usually made of either steel or lead, but doctors routinely leave pellets (or bullets) in the body because the risks of surgery are deemed greater then the possibility of poisoning. We don't know what kind of birdshot Cheney was using; experts quoted in the news seem to discount the dangers of lead for his victim. Still, numerous case reports and several studies have demonstrated that gunshot injury can cause lead toxicity. A recent survey of about 500 shooting victims in South Central Los Angeles found a significant and consistent increase in blood lead levels over the months following an injury.
The chance of getting lead poisoning increases with the number of bullet fragments or pellets you have lodged inside of you. A large number of very small lead pellets—perhaps like those lodged in Whittington's head, neck, and chest—would be the most dangerous on account of their large surface area. Pellets that end up near large joints are especially problematic; the synovial fluid contained in these spaces seems to increase the rate at which lead dissolves.
The symptoms of lead poisoning might appear within a few days after someone gets shot, but they can also turn up decades later.
Got a question about today's news? Ask the Explainer .
Explainer thanks James Evans of the State University of New York and William Manton of University of Texas.
Related in Slate
My recent Slate interview - migrating bullets and Cheney
Dear readers, Well I just finished an interview with one of the contributors to the online magazine Slate (www.slate.com). The topic was the "moving bullets and pellets". The obvious reason for the discussion is the recent shotgun injury to Mr. Whittington of Texas. The reason the reporter called me is the fact that I am the senior author of a recent medical journal article on moving bullets.
Reference = Bullet migration within the inferior vena cava.
South Med J (United States), Jan 2003, 96(1) p96-8
Raghavendran K, Evans JT
I explained at length the problems of bullets and pellets that are lodged in blood vessels following firearms injury. There is the problem of obstructing a vessel, serving as a nidus for clot formation, and mycotic aneurysm formation.
Furthermore, I went into the problems of foreign materials such as clothing and debris including wadding which can also become imbedded in patients shot with shotgun pellets.
The reporter also asked about the problem of lead levels indicating that physicians have been downplaying the need to remove lead fragments and shrapnel. I told him that was not as well documented as since the medical profession had not generally done sufficient research on that topic to provide definitve evidence, but that I had personally changed my trauma practice to now include removal of suspected lead fragments based on the well done though small study from LA. Reference quoted below:
The effects of retained lead bullets on body lead burden.
J Trauma. 2001; 50(5):892-9 (ISSN: 0022-5282)
McQuirter JL ; Rothenberg SJ ; Dinkins GA ; Manalo M ; Kondrashov V ; Todd AC
Department of Oral and Maxillofacial Surgery, Charles R. Drew University of Medicine and Sciences and the King/Drew Medical Center, 1731 East 120th Street, Los Angeles, CA 90059, USA. jmcquirter@dhs.co.la.ca.us
BACKGROUND: Numerous case reports have demonstrated that lead poisoning with potentially fatal consequences can result from retained lead projectiles after firearm injuries. To assess the impact of retained projectiles on subsequent lead exposure in the population, one cannot rely on self-selected cases presenting with symptoms of lead intoxication. This preliminary study seeks to identify increased lead burden and identify risk factors of elevated blood lead levels for individuals with retained lead bullets. METHODS: Forty-eight patients were originally recruited from gunshot victims presenting for care at the King/Drew Medical Center in Los Angeles, California. An initial blood level was measured for all recruited patients and repeated for the 28 participants available for follow-up, 1 week to 8 months later. Medical history, including a history of prior firearm injuries and other retained projectiles, was taken, along with a screening and risk factor questionnaire to determine other sources of lead (occupational/recreational) to which the patient might have been, or is at present, exposed. The participants also had K-shell x-ray fluorescence determinations of bone lead in the tibia and calcaneus in order to determine past lead exposures not revealed by medical history and risk factor questionnaire. Multivariate models of blood level were made using risk factor and bone lead concentration data. RESULTS: We demonstrated that blood lead tends to increase with time after injury in patients with projectile retention, and that the increase in significant part depended on the presence of a bone fracture caused by the gunshot. CONCLUSION: We encountered evidence suggesting that the amount of blood lead increase in time after injury is also dependent on the tibia lead concentration. There were too few cases in the study to fully test the effects of bullet location, or the interaction of bullet location with bone fracture or bullet fragmentation.
Well readers, that's all for now. JTE aka Jedimaster.
Reference = Bullet migration within the inferior vena cava.
South Med J (United States), Jan 2003, 96(1) p96-8
Raghavendran K, Evans JT
I explained at length the problems of bullets and pellets that are lodged in blood vessels following firearms injury. There is the problem of obstructing a vessel, serving as a nidus for clot formation, and mycotic aneurysm formation.
Furthermore, I went into the problems of foreign materials such as clothing and debris including wadding which can also become imbedded in patients shot with shotgun pellets.
The reporter also asked about the problem of lead levels indicating that physicians have been downplaying the need to remove lead fragments and shrapnel. I told him that was not as well documented as since the medical profession had not generally done sufficient research on that topic to provide definitve evidence, but that I had personally changed my trauma practice to now include removal of suspected lead fragments based on the well done though small study from LA. Reference quoted below:
The effects of retained lead bullets on body lead burden.
J Trauma. 2001; 50(5):892-9 (ISSN: 0022-5282)
McQuirter JL ; Rothenberg SJ ; Dinkins GA ; Manalo M ; Kondrashov V ; Todd AC
Department of Oral and Maxillofacial Surgery, Charles R. Drew University of Medicine and Sciences and the King/Drew Medical Center, 1731 East 120th Street, Los Angeles, CA 90059, USA. jmcquirter@dhs.co.la.ca.us
BACKGROUND: Numerous case reports have demonstrated that lead poisoning with potentially fatal consequences can result from retained lead projectiles after firearm injuries. To assess the impact of retained projectiles on subsequent lead exposure in the population, one cannot rely on self-selected cases presenting with symptoms of lead intoxication. This preliminary study seeks to identify increased lead burden and identify risk factors of elevated blood lead levels for individuals with retained lead bullets. METHODS: Forty-eight patients were originally recruited from gunshot victims presenting for care at the King/Drew Medical Center in Los Angeles, California. An initial blood level was measured for all recruited patients and repeated for the 28 participants available for follow-up, 1 week to 8 months later. Medical history, including a history of prior firearm injuries and other retained projectiles, was taken, along with a screening and risk factor questionnaire to determine other sources of lead (occupational/recreational) to which the patient might have been, or is at present, exposed. The participants also had K-shell x-ray fluorescence determinations of bone lead in the tibia and calcaneus in order to determine past lead exposures not revealed by medical history and risk factor questionnaire. Multivariate models of blood level were made using risk factor and bone lead concentration data. RESULTS: We demonstrated that blood lead tends to increase with time after injury in patients with projectile retention, and that the increase in significant part depended on the presence of a bone fracture caused by the gunshot. CONCLUSION: We encountered evidence suggesting that the amount of blood lead increase in time after injury is also dependent on the tibia lead concentration. There were too few cases in the study to fully test the effects of bullet location, or the interaction of bullet location with bone fracture or bullet fragmentation.
Well readers, that's all for now. JTE aka Jedimaster.
Tuesday, January 24, 2006
On Being a Patient
Well readers, here is an update on what it is like for a surgeon to be a patient. I just got out of the hospital myself. The offending culprit for causing my admission was a kidney stone. And yes, the pain is as great as described in the textbooks. However, I am happy to report that modern analgesics can alleviate that pain. I suppose that the discoveries I made are mostly related to the technology and its benefits and non-benefits. I never realized that the automated IV pumps have motors that are so loud that they prevent sleep. Also, the accompanying alarms are sufficent to potentially cause seizures in someone who has auditory seizures and maybe even in some normals. Naturally, the physician and nursing care that I received was superb - what else would you expect when you are admitted to the hospital where you practice, on the floor where most of your patients are treated, and you know everyone. I have never understood the tendency of some health care providers to avoid their own facilities in favor of so calle privacy. I'll take superb care anyday. Since I already know how great the staff ay my hospital ECMC is anyway, why even think about anyplace else! While I would not describe my hospitalization as pleasant, I would say that under the circumstances, it was as good as to be expected. My room was cleaned regularly, the linen was clean and changed as needed, the nurses were attentive, the diet was as prescribed. Yes, I am glad to be home. JTE.
Thursday, January 05, 2006
A Bonus Day
Well today was what I call one of those bonus days. A day when you get to do something really worthwhile. As the President-elect of my Medical staff, I got to make a presentation of a check for over $10,000 to the Food Bank of WNY. The Food Bank is a really great charity and I was proud to be able to help lead the organization to donate. See you on the other side. JTE.
Wednesday, December 14, 2005
A GIST day - Joy
Hello everyone, Well today was interesting. The challenge of the day was to operate on a patient who had presented with a significant gastrointestinal bleed. The GI service had confirmed the bleeding site as an ulcerated GIST tumor of the duodenum. We had the patient prepared for a pancreaticoduodenectomy if necessary. However, after exploration and performing a Kocher maneuver, we were able to identify the tumor in the 2nd portion of the duodenum and outline clear margins. We then performed a segmental resection with a transverse closure and only minimal luminal reduction. The operation went well and the patient had no intr-operative or immediate post-operative problems. Now to await the pathology and the mitotic count. What a Joy to be able to do such a useful operation for the patient. JTE.
Wednesday, November 23, 2005
The Joy of a new student rotation
Well this was my first call with the new 3rd year students who started their clerkship this week. One of the students scrubbed in and got to help with deridement of necrotic tissue from a man who had been in an ATV accident and was pinned under the machine while the wheels kept spinning. JTE.
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