MedWorm.com provides a medical RSS filtering service. Over 5000 RSS medical sources are combined and output via different filters. This feed contains the latest items from the 'richard[WINTERS]md' source. Sat, 16 Aug 2008 14:47:04 +0100 http://www.richardwinters.com/richardwintersmd/2005/10/taser_defibrill.html Time to defibrillate is key in resuscitating a cardiac arrest. The shorter the time since onset of ventricular fibrillation...the better people do. Lots of people are buying personal defibrillators. Storing them in the trunk of their car or in their closet. Waiting for that one day when they will shock someone back to life. I think Taser should consider making a defibrillator gun. I'd like to be able to defibrillate someone while standing 30 feet away. I'd see v-fib on the monitor. I'd whip out the Taser Defibrillator Gun. I'd shout "CLEAR!" The patient would wake with a jolt of biphasic joules. Of course, I might miss and hit a nurse. That might hurt nursing recruiting. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460881 Sat, 08 Oct 2005 12:37:29 +0100 460881 http://www.richardwinters.com/richardwintersmd/2005/05/pill_calories.html My patients come in with long lists (suitcases) of medications. I wonder how many calories of pills are they taking? Could they exist on pills alone? Should they be on a multivitamin? How long does it take to swallow the pills? Are they are exceeding the FDA recommended daily allowance of Xantham Gum? Is there a recommended daily allowance of Xantham Gum? Should I write a book? Destined to be the new diet craze. The Pill Diet. (aka "rock hard abs in 20 minutes") Unfortunately, the pill diet seems to produce either morbid obesity or cachexia. Finally the obvious question, do they really need to be on 20 medicines? They are seeing me in the emergency department after all. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460882 Wed, 25 May 2005 05:31:00 +0100 460882 http://www.richardwinters.com/richardwintersmd/2005/04/jetlagged.html Time jumped forward today one hour and I am so jet-lagged. Yeah right. I'm a shift working emergency physician. As if I have any circadian rhythm. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460883 Mon, 04 Apr 2005 07:19:29 +0100 460883 http://www.richardwinters.com/richardwintersmd/2005/01/drunk_logic.html Guy has his 21st birthday. At midnight he enters a bar and drinks large volumes of alcohol in a small amount of time. Gets dropped off in a cab at our emergency department at 2am. Vomits on our EMT. Placed on a gurney in a monitored room to sleep it off. At 6am I hear from the room, "Shut up you stupid monitors! Shut up!!! Stop beeping!" ...drunken pause... "Wait. Don't shut up." ...drunken pause... "If you shut up that means I'm dead." (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460884 Sat, 22 Jan 2005 11:39:39 +0100 460884 http://www.richardwinters.com/richardwintersmd/2004/10/rabbit.html I cycle somewhere between 100 and 150 miles per week. When I see someone riding in front of me I've noticed something strange. Yesterday I heard myself say softly, but aloud while riding, "We have a rabbit." "Who is we?" (talking to myself now) It's just me pedaling along on a bicycle. The other guy is 100 meters ahead. Is this line from a movie? It is hard to repress the instinct to pedal faster to catch and then blaze by the "rabbit". All doing so while attempting to look calm. Saying "Good Morning" as I pass without any hint of breathlessness. Perhaps even reaching down and taking a drink from my water bottle in a nonchalant way. Then noticing that my carefully planned workout in which I scheduled myself not to exceed a heart rate of 163...has been thrown out with my heart racing at 174 in my feigned relaxed state. What a competitive dufus I can be. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460885 Fri, 15 Oct 2004 21:05:01 +0100 460885 http://www.richardwinters.com/richardwintersmd/2004/10/phone_number.html I go to Best Buy to purchase a battery for our wireless phone. I give the clerk my credit card. She says, "What is your phone number?" I say, "559-411-0911" She says "I can't take that...it's not a real phone number." I ask, "Why do you need my phone number to purchase batteries?" She says, "It's for corporate use. They never call." I say, "What's your phone number?" She says, "I don't give that out." I say, "Exactly." (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460886 Fri, 15 Oct 2004 18:05:09 +0100 460886 http://www.richardwinters.com/richardwintersmd/2004/10/infant_diarrhea.html Alarmingly to most parents and understood by most physicians...most diarrhea complaints are associated with an inability to give stool in the ED even when the patient is there for 4 to 5 hours. I had a 1 year old come in with diarrhea this week. Perfect vitals. No fever. Moist mucous membranes. But definitely diarrhea. Intelligent reliable parents who were doing a good job of giving her fluids to drink. With any diarrhea I think of funky E coli (particularly O157:H7) as being a cause for any kid who actually exhibits diarrhea while in the emergency department. Since this young girl had diarrhea in the ED I sent off some labs to make sure she didn't have any severe illness associated with the diarrhea (ie Hemolytic Uremic Syndrome). Her blood count showed no anemia, no schistocytes and a normal white blood count. Her metabolic panel showed no signs of dehydration, normal electrolytes and normal kidney function. I sent off cultures but the results at our hospital aren't available for a few days. The amateur thing to do with pediatric diarrhea is to give antibiotics. It seems counter-intuitive but in some particular E coli (bacterial) diarrheas it can make things worse. Most diarrheas end up being viral. Regardless of the cause (viral or bacterial...even funky E coli) the majority diarrheas resolve with fluids. Fluids. Fluids. Fluids. With normal labs, fluid bolus, and intelligent parents she was home to follow-up with her pediatrician with instructions to return if looking more ill or unable to drink. Some diarrheal illnesses if they progress in fact do need hospitalization. Her diarrhea progressed and her parents very appropriately took her to one of the other local hospitals. Losing the battle of the fluids coupled with the institutional availability of a rapid E coli test (which was positive) they decided she needed admission. Unfortunately, it appears that in the process they received offhand comments by some staff at the other hospital that she should have been admitted in the first place. (See post below) Now the parents are understandably upset and think me to be a reckless medical fool. They are spending a lot of negative energy thinking of my early death...in addition to worrying about their precious daughter. They don't know that I have a daughter of the same age. In the same Gymboree class. They don't know that I was thinking of what I would do if it was my daughter. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460887 Fri, 15 Oct 2004 15:05:52 +0100 460887 http://www.richardwinters.com/richardwintersmd/2004/10/should_have.html The care of a patient by a healthcare professional is often second guessed after the fact. This is a very good thing. It allows us to relook at medical treatment to make sure that what we are doing or what we have done is correct. Decide if there are changes in process that need to be made. Decide if further education is needed. However, there is a sort of second guessing that can be destructive to patients. It frequently comes in the form of phrases like: "I can't believe that Dr. X didn't order this." "Dr. Y should have admitted you." "Dr. Z should never have done that procedure." Offhand remarks made by some nurses, EMTs, health department workers and unfortunately physicians. These phrases are usually stated directly to the patient or the patient's family members. They are usually stated second hand with little information. No talking to the initial caregiver. No chart in hand. No information other than snap judgements. "Thank God you are here. Only we know what to do." Especially uttered at trauma centers, hospitals for children and other tertiary care centers where I have worked. Self-serving negative remarks. I spend a good deal of time trying diffuse both self-aggrandizing talk made to my own patients by my own staff that needlessly flatters our care and negative comments made by other providers about our care. You want patients to be informed about all aspects of their care. However, there is no need to inflame a patient's sense of helplessness and victimization with uneducated blaming. It is unprofessional. It is unhealthy. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460888 Fri, 15 Oct 2004 13:40:21 +0100 460888 http://www.richardwinters.com/richardwintersmd/2004/09/road_usability_1.html Road signs confuse me. I'm driving on the highway and see there is an exit coming up. Then I see a road sign. "Food and Gas Next Exit" Does that mean the next exit after this exit? Does it mean this exit? I'm driving 65 mph (the local speed limit) and I have to decide what they mean. It should say: "Food and Gas This Exit" or "Food and Gas 2nd Exit" (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460889 Sun, 12 Sep 2004 04:32:15 +0100 460889 http://www.richardwinters.com/richardwintersmd/2004/09/road_usability.html I'm the stadium physician for Fresno State football and basketball games. Usually a pretty mellow affair. I carry around an EMS radio and listen to the paramedics get calls for drunk falls and asthma exacerbations. I'm there to back up the medics in case they need help. The only time I have to do something is if someone dies or is very close to dying. The last call I had our team mascot slammed down the other team's mascot. High acuity stuff. It should be an interesting season. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460890 Sun, 12 Sep 2004 04:07:11 +0100 460890 http://www.richardwinters.com/richardwintersmd/2004/09/vuelta_a_espana.html Professional cycling has 3 "major" tours each year. The Giro d'Italia, the Tour de France, and the Vuelta a Espana. The Giro and the Tour were on Outdoor Life Network (OLN) and I didn't miss a minute. I love watching professional cycling. So many stories. Tactics. Attacks. Nail biter finishes. I was bummed to find out that OLN was not going to carry the Vuelta. I thought I was going to miss it. I'm happy to find that I am able to get daily coverage on the spanish station TVEI (407 on DirecTV). I watched US Postal kick butt in today's Team Time Trial. The only problem is that it's in spanish. But I should know spanish. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460891 Sat, 04 Sep 2004 18:28:56 +0100 460891 http://www.richardwinters.com/richardwintersmd/2004/09/oblique_chainri.html Several professional cyclists are using oddly shaped chainrings. Chainrings are the cogwheels that pull the chain. These odd shaped chainrings reportedly minimize the dead spots and maximize the power portion of the pedaling stroke. When the pedal is up [at 90 degrees] a rider's strength is minimal so the ring radius is small as well. When the pedal comes near to horizontal, the rider's strength is more, so the chainring is bigger to take advantage of that. The creators report between 5- and 15-percent gains in efficiency with 3-percent gains in speed (given identical input effort). (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460892 Thu, 02 Sep 2004 04:13:00 +0100 460892 http://www.richardwinters.com/richardwintersmd/2004/08/job_rejection_l.html I have been doing this blog thing for a while. Though not as much recently. At this point I'll rehash a post of job rejection letters from June of 2001. It goes something like this: Dear Sir: Congratulations! You got the job! That is probably what you were hoping this letter would say. But it doesn't, because you didn't. Sincerely, Personnel Department read on (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460893 Wed, 01 Sep 2004 01:56:51 +0100 460893 http://www.richardwinters.com/richardwintersmd/2004/08/crepuscular.html I've been looking up some basic things. Things like: "What is the difference between a butterfly and a moth?" My daughter will certainly ask about this when she is beyond the age of eating bugs...and more into the age of knowing about bugs. First taste, then understand. I was a biology major. None of it stuck. So off again to read the basics. The best way to differentiate the two is that butterfly antennas are thin with small clubs at the end. Whereas moth antennae are variable (fluffy or thin) with no clubbing. Beyond this there are other tendencies. Butterflies are diurnal. They are active during the day. Moths are crepuscular. They are active during twilight. Some are more vespertine (active in the evening twilight). Some are more matinine (active in the morning twilight). Butterflies tend to rest with there wings folded up. Moths tend to rest with their wings lying flat. The butterfly chrysalis is a hard shell. The moth cocoon is spun silk inside leaves. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460894 Sat, 28 Aug 2004 11:15:31 +0100 460894 http://www.richardwinters.com/richardwintersmd/2004/08/rtt_with_bbb.html I see a fair amount of people who present as RTT with BBB. Rata-Tat-Tat with a Baseball Bat. It seems there are still some criminals who prefer 'old school' bludgeoning to them modern day guns. It's my theory that they get inspiration from the old movie/play/book West Side Story. They have the Jet Song running through their heads and they dance: Here come the Jets, Yeah! And we're gonna beat Ev'ry last buggin' gang On the whole buggin' street! I think that movie sets a dangerous example for our children and should be banned. Well...that and music. Interestingly most of the victims don't result in "MFB, CFD" as GruntDoc discusses. Here is a good list of other medical acronyms. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460895 Fri, 27 Aug 2004 14:33:05 +0100 460895 http://www.richardwinters.com/richardwintersmd/2004/02/announcement_.html I will never bare my right nipple during the half-time show of the Super Bowl. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460896 Thu, 19 Feb 2004 03:46:23 +0100 460896 http://www.richardwinters.com/richardwintersmd/2004/02/ladybugs_picnic.html I have a seven month old daughter. One of the things certain to make her smile is singing a simple children's song. She'll go from crying to laughing. Great for car rides. I'm one of those people who constantly has some song going through my mind. I hear a couple notes or someone says a couple words and instantly a related song is going through my head. The clerks phone at work chirps three tones when it rings. They just so happen to be the first three notes to the theme from Dallas. The 1980s television show with J.R. Ewing. Recently I found myself at the head of the bed of a confused elderly lady in severe respiratory failure. I've given her medication to sedate and paralyze her. I'm intubating her. I hear myself quietly singing: One two three Four five six Seven eight nine Ten eleven twelve And they all played games At the ladybugs' picnic (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460897 Thu, 19 Feb 2004 03:28:49 +0100 460897 http://www.richardwinters.com/richardwintersmd/2004/02/note_to_aspirin.html Your girlfriend is having her right buttock abscess drained by the doctor. This is not the time to ride the hospital elevators and graffiti on the elevator walls. There is a security camera. You will be seen by security. You will go to jail. Although if you must decorate the walls I would appreciate: "Dr. Winters gives good moderate sedation!" Or perhaps something a little more eloquent. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460898 Thu, 19 Feb 2004 02:42:30 +0100 460898 http://www.richardwinters.com/richardwintersmd/2004/02/digital_justice.html I got hit by a minivan while cycling yesterday. His rearview mirror clipped my handlebars causing my wheel to turn out. I slid into then van and skidded along the ground to a stop. I recall thinking "there's the wheelwell...miss it." I have some road rash to my right hand. Some bumps and bruises. Not too bad. It's still a bit cool here and the layers of clothing protected me pretty well. It's a bit odd to see the undercarriage of a car while lying in the road. I got up and looked in the minivan at the driver who had stopped at the stoplight just ahead. He gestured at me. Then he drove off. I just got a new digital camera. About the size of an Altoid box. Had it in my back shirt pocket. My back tire was wobbly. My seat scratched. Some scattered scratches on the frame. Thankfully I was a couple blocks away from the bike shop. I went in and they trued the back tire for free. This allowed me to finish my 25-mile workout. I called the police and they said "Are you the guy with the digital camera?" The Minivan driver had called them. He had told the officers he had tried to stop safely. He said he turned his bike eater around to help (run over me again?) but that I had already gone. Four lane residential road with very little traffic. It took me a good 5 minutes to straighten myself and the bike out enough to ride again. I thank him for his kindness. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460899 Fri, 06 Feb 2004 09:34:43 +0100 460899 http://www.richardwinters.com/richardwintersmd/2004/01/the_new_food_py.html Have you had your daily serving of Cracker Jacks? I specifically like the jar of salsa in the vegetable section. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460900 Sun, 25 Jan 2004 07:51:30 +0100 460900 http://www.richardwinters.com/richardwintersmd/2003/12/bullet_shot_up.html I've been seeing lots of images on television of people firing their guns into the air. I'd heard a bullet coming down hurt could someone. But how much do wind and air resistance effect a bullet's velocity? In 1920 the U.S. Army conducted experiments on this very topic. They fired .30 caliber, 150 gr., Spitzer point bullets, at a velocity of 2,700 f.p.s. Using the bullet ballistic coefficient and elapsed time from firing until the bullet struck the water, they calculated that the bullet traveled 9,000 feet in 18 seconds and fell to earth in 31 seconds for a total time of 49 seconds. Out of the more than 500 shots fired from the test platform only 4 falling bullets struck the platform and one fell in the boat near the platform. One of the bullets striking the platform left a 1/16 inch deep mark in the soft pine board. The bullet struck base first. Based on the results of these tests it was concluded that the bullet return velocity was about 300 f.p.s. For the 150 gr. bullet this corresponds to an energy of 30 foot pounds. Earlier the Army had determined that, on the average, it required 60 foot pounds of energy to produce a disabling wound. Based on this information, a falling 150 gr. service bullet would not be lethal, although it could produce a serious wound. Load Ammo has other interesting ballistic related info. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460901 Tue, 16 Dec 2003 02:23:25 +0100 460901 http://www.richardwinters.com/richardwintersmd/2003/12/saddams_lice.html So Saddam comes in to the ED last night. We're getting creamed. Twenty patients in the waiting room. We're holding 21 telemetry and ICU patients. Ambulances lined up at triage. I'm resuscitating people in the hallways. I walk in. He says, "I think I have lice." I says, "Did you call your primary care physician?" He says, "She told me to go to the Emergency Department." Then he asks if I will prescribe him Vicodin. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460902 Mon, 15 Dec 2003 08:04:44 +0100 460902 http://www.richardwinters.com/richardwintersmd/2003/11/remote_control.html I pull up to a stop light. I casually reach for the garage door opener. I press the button. Nothing happens. What's up with that? (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460903 Wed, 19 Nov 2003 12:30:03 +0100 460903 http://www.richardwinters.com/richardwintersmd/2003/11/ripe_limes_are_.html We have a bunch of fruit trees in our backyard. Limes, lemons, valencia and navel oranges, olives, peaches, and persimmons. I'd like to know how to take care of these trees. Google is great for searches that don't use the words "when", "where", "how" etc.. However, it is difficult to find a page that tells me "when is the proper time to harvest a valencia orange"? Another difficult one is "how do you cure a nicoise olive"? On my quests I did find out that: "Limes turn yellow when they are fully ripe (mature). There is nothing wrong with the fruit. Consumers expect limes to be green and thus they are picked green. All limes will turn yellow when ripe. They are still very good. Limes are best picked for that unique lime flavor when just a blush of yellow shows on the skin of the fruit." I thought that was interesting. And an excuse to blog. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460904 Mon, 17 Nov 2003 07:23:20 +0100 460904 http://www.richardwinters.com/richardwintersmd/2003/10/spinning_1.html Distance: 15.09 miles Time: 37:59 Avg: 23.8 mph Max: 30.8 mph Cadence: 90-100 Heart Rate Zone: Recovery Ceiling Level: +1 Encounters: walls of house, carpet, wife, dad gone to get tony roma's (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460905 Mon, 13 Oct 2003 03:35:14 +0100 460905 http://www.richardwinters.com/richardwintersmd/2003/10/gorilla_medicin.html There are procedures in medicine that require more gorilla force than finesse. Reduction of a hip dislocation is a gorilla procedure. A hip dislocation is when the ball of the femur pops out of the socket of the pelvis. The patient presents with pain and a leg that is shortened and rotated. No fun. Some dislocations occur from trauma...but most occur in individuals who have had total hip replacements. The metal ball falls out of the metal socket. The way to relocate the the dislocation is to pull the leg back into place. It often isn't easy. This is one of those procedures that can injure the physician doing it. It generally requires that you stand up (balance) on the gurney while cradling the knee of the dislocated leg. Then you lean back and pull as hard as you can. You wiggle the leg. You internally rotate it. The blood vessels in your forehead bulge. The back of your shirt is wet with sweat. Your back and arms fatigue with the effort. Am I going to pull the lower leg off granny? In the emergency department you use heavy medications to sedate the patient so the result is that they usually wake up with their leg back in place...with no knowledge of your sweating. Today I had a former pro athlete with a large leg and more muscles in his hip than I have in my body. I used huge doses of medication (fentanyl 1200mcg and versed 22mg) and he still would wake up (has another opiate thirsting chronic illness). Very ungratifying. Hip didn't go back in. He ended up going to the operating room and having it reduced under general anesthesia. Sometimes I'm more chimp than gorilla. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460906 Sun, 12 Oct 2003 15:00:19 +0100 460906 http://www.richardwinters.com/richardwintersmd/2003/10/spinning.html Distance: 10.47 miles Time: 35:44 Avg: 17.6 mph Max: 20.7 mph Cadence: 90-100 Heart Rate Zone: Recovery Ceiling Level: +2 Encounters: walls of house, carpet, iPod (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460907 Sat, 11 Oct 2003 03:32:00 +0100 460907 http://www.richardwinters.com/richardwintersmd/2003/10/mama.html Why does my 3 month old daughter keep staring up at the ceiling fan? ...and why do I keep staring at the ceiling fan? (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460908 Fri, 10 Oct 2003 07:02:27 +0100 460908 http://www.richardwinters.com/richardwintersmd/2003/10/google_calculat.html A useful (but often unknown) feature of google is it's built in calculator. In the google search field just type an equation and you'll get the appropriate answer. For example, I saw an article that stated that David Millar of Britain won the men's time trial at the cycling world championships on Thursday, covering the 41.6 km course in a time of 51 minutes and 17.29 seconds. I wanted to know how fast he was going in miles per hour. So in the google search field I typed: 41.6km/(51minutes17.29seconds)=?miles/hour google gave me the result: (41.6 km) / (51 minutes 17.29 seconds) = 30.2397726 miles / hour So google is telling me that David Millar's average cycling speed is as fast as I can go down steep hills....without fearing to put on some brakes. Play around with it and you can get currency, cooking and temperature conversions also. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460909 Fri, 10 Oct 2003 06:20:45 +0100 460909 http://www.richardwinters.com/richardwintersmd/2003/10/home_to_old_fri.html Distance: 23.43 miles Time: 1:27:58 Avg: 15.9 mph Max: 28.7 mph Cadence: 90 Heart Rate Zone: Lactate Threshold with some intervals on hills Encounters: teenage girl with loud rap music honking her horn who said hello, small old dog scared by bike, horses and cows indifferent, mom at bella pasta (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460910 Fri, 10 Oct 2003 03:04:00 +0100 460910 http://www.richardwinters.com/richardwintersmd/2003/10/the_review_of_s.html A patient comes in with formication, track marks, and paranoia. First of all for clarification formication is quite different from fornication. ForMication is the sense of having bugs crawl on your skin. Bugs that aren't there. The "formic" part of the word comes from the formic acid that ants secrete when they sting you. ForNication is entirely different. Usually involving dinner and a movie as a preamble. Though I have also seen this in the Emergency Department. So we have a patient with formication, track marks, and paranoia. This patient could have a crazy infectious disease or a funky neurologic disorder, however, most likely the symptoms are a result of chronic aggressive methamphetamine use. Now the dance begins. I can't go in the room and say, "so how long have you been using?" Though this would be most expeditious, it would not start the visit off on a therapeutic foot. Ockham's razor in cases like this needs to be dismissed at least outwardly until after you go through the motions of the full H&P. Invariably, however, after asking patiently for the history and getting the positive review of systems with its myriad of questions... you get to the social history. Direct eye contact (but not overly direct). Unassuming body position (but not bored looking). Calm nonjudgemental voice (matter of fact vocalizations). Do you smoke? Do you drink? Do you use drugs such as heroin or crank? "I do not use drugs!!! Why are you asking me?! I want another doctor!" Dang. I can't dance? (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460911 Thu, 09 Oct 2003 09:37:34 +0100 460911 http://www.richardwinters.com/richardwintersmd/2003/10/home_to_woodwar.html Distance: 22 miles Heart Rate Zone: Recovery Ceiling Encounters: little lizard on the road, discourteous county truck on bike trail with wide mirrors, cyclists that wave, cyclists that don't wave (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460912 Thu, 09 Oct 2003 01:32:46 +0100 460912 http://www.richardwinters.com/richardwintersmd/2003/10/not_dead_yet.html What have I done on my summer blog vacation? 1. I didn't blog. Despite teasings from my friend Gruntdoc, my weblog is not deceased. It was just out in the sun doing other things. 2. We had a baby girl. We welcomed Anli into our humble lives. Anli means peace (An) and beauty (Li) in chinese. First child. She rocks! 3. Taken up cycling. I've started bicycling. About 15 - 30 miles per day. Not the future Lance. But I am signed up to do some Centrury races/rides. If I can refrain from elderly injury. 4. Been working. I've switched to 3 nights on and 4 nights off. Works great for me. My usual sleep clock has me awake all night anyways. 5. Welcomed my parents to our house. My mother and father are helping us with Anli. We are very fortunate and very happy. My wife (a surgeon) is working half days and taking call. Nanna (my mom) is Nanny. 6. Working on Big Needle. We plod slowly along and surely. Lots of coding. It will launch in the future and provide CME in cooperation with various medical societies. 7. Switched to Apple. I had been using a combination of Windows XP and Linux. By switching to Mac I can do everything on one box. Mac is a much better platform. It would be hard to go back. 8. Switched to Type Pad. I like Radio Userland, but it's painful when you have to try to switch to a different computer. Type Pad is web-based and allows you to publish to your own domain. Very easy to work with. I probably won't be able to figure out a way to import my old Radio posts (past 2 1/2 years) into Type Pad...so I'll just link to them in my archive. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460913 Wed, 08 Oct 2003 06:41:00 +0100 460913 http://www.richardwinters.com/richardwintersmd/2003/05/foot_in_mouth_s.html I'm showered. Cleanly dressed. Teeth have been brushed. The department is hectically busy. I walk in to see my first patient of the shift. I start by asking him the basic questions. "Hi! I'm Dr. Winters. How can I help you?" He looks at me and laughs. (not an unnatural response to seeing me) "What brings you to the emergency department today?" He looks at the woman with him who is silent and then looks at me and laughs. I stand there silent for a second. More stuttered laughter. "Would you like me to come back a bit later to ask you these questions?" He's silent. The woman next to him screams "How rude!! He's laughing because he had a stroke!! You would know that if you had read his extensive medical records!! He had the stroke because of your hospital and doctors like you!! It's involuntary laughter! He can't control it!! But you wouldn't know that would you!!" I apologized. Then I apologized again. Then I took care of him (and his wife). (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460914 Sat, 10 May 2003 12:56:41 +0100 460914 http://www.richardwinters.com/richardwintersmd/2003/05/geometric_progr.html A meme paraphrased from Malcolm Gladwell's excellent book The Tipping Point: If you were to fold a piece of paper and then fold it again. And then again fold it 50 times...how thick would the piece of paper be? About the thickness of a book? The height would approximate the distance from the earth to the sun. And if you folded it again it would be double that distance. This is an example of geometric progression. People can't fold a piece of paper (no matter how large the paper) more than 7 times (no matter how large the person). Note: This last fact has been debunked. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460915 Sat, 10 May 2003 12:31:26 +0100 460915 http://www.richardwinters.com/richardwintersmd/2003/04/food_as_diet.html I'm certain there are foods in which you spend more calories eating than you gain eating. For example, I don't understand the fascination some people have with sunflower seeds. They're work to eat. Deshell in mouth. Put shells to one side. Put nuts to other side. Swallow nuts. Spit out shells. I invariably take 5 minutes per seed, swallow the shells and spit out the nuts. The process of eating sunflower seeds must have a negative caloric value. I've found a similar food on this trip to New Orleans. Crawfish. Or Crawdads. Crawthings. I went to a local place to get boiled crawdads. Break off the tail. Suck the torso juice. Remove the first couple segments of shell from the tail. Hold the distal end of the tail. Attempt to pull the 2.5 cm of crawdad meat to eat. Only get 1 cm of crawdad meat. Break apart more of the tail. Get the rest of the meat. Remove the mud tube. Eat the meat. The result is a crawdad torso, a segmented tail, a very small amount of meat and a shirt full of grease. And hands with a fish smell that wont soap off. They do taste good. But too much work for me. And you throw away a lot of crawdad parts. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460916 Wed, 30 Apr 2003 04:02:40 +0100 460916 http://www.richardwinters.com/richardwintersmd/2003/04/richard_winters.html In looking through my referral list it shows that someone from the England Google server linked to my site after searching for the terms "Richard Winters Sex". Who would be searching these terms? My parents are in England. Could it be that they forgot the sexual identity of their son? Just doing a search to make sure. Thankfully my site comes up as number one and number two on the results list. I decided to see what results would come out for more descriptive terms to see how I would rate. The good news is that "Richard Winters Sex Bad" comes up with no links to me. While "Richard Winters Sex Good" comes up with me as the number one and two searches for those terms. Unfortunately "Richard Winters Sex Duck" comes up with me as the number one hit. I am sure it is related to my blog about the use of duck-billed masks to prevent SARS. I hope it is. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460917 Tue, 29 Apr 2003 18:07:18 +0100 460917 http://www.richardwinters.com/richardwintersmd/2003/04/bars_mild_new_o.html I'm currently attending the ACEP Connections conference in New Orleans. One of the "have to have" foods is something called a beignet. Pronounced Bin Yeah. It's basically fried dough covered with powdered sugar. Tons of powdered sugar. Tonight Allen and I went to Cafe du Monde on Decatur in the French Quarter. They only serve these Atkins-fearing beignets...in addition to coffee, water, and carbonated sugar water. For under $2 you get three beignets...and a 5 point addition to your body mass index. I'm challenged when it comes to eating foods with powdered sugar. I can never figure out how to breathe correctly....or if I should just hold my breath. Disaster results from a mouth full of powdered sugar and a deep breath. Powdered sugar beignet + deep breath = BARS BARS = Beignet Acute Respiratory Syndrome PSARS (Powdered Sugar Acute Respiratory Syndrome) is the more generic equivalent that involves any powdered sugar covered food and a deep breath. PDARS (Powdered Doughnut Acute Respiratory Syndrome) is known to be transmitted at Dunkin Doughnuts. The main symptom of BARS, PSARS, and PDARS is a sweet cough productive of white sputum. And weight gain of 3 pounds. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460918 Tue, 29 Apr 2003 10:08:42 +0100 460918 http://www.richardwinters.com/richardwintersmd/2003/04/medical_blogs.html Yahoo has a nice list of medical blogs. Medical Weblogs maintains running RSS newsfeeds from multiple medical weblogs. (probably the easiest way to sample the various medical weblogs) American Medical News has an article about medical weblogs. I was interviewed and have a couple of run on sentence quotes...which is how I generally talk. Me and my mouth-o-rrhea. Good article. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460919 Thu, 24 Apr 2003 05:53:15 +0100 460919 http://www.richardwinters.com/richardwintersmd/2003/04/20_week_foot.html With five toes. (from February) (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460920 Mon, 21 Apr 2003 14:56:40 +0100 460920 http://www.richardwinters.com/richardwintersmd/2003/04/where_is_the_ru.html A cardiologist pilot flew his private plane in to Meigs Field in Chicago at the end of March to attend the American College of Cardiology annual meeting. After the conference when he went to fly home he found the runway had been ripped up and the airport closed. Meigs Field was closed by the City of Chicago at dusk on March 30 and in the middle of the night bulldozers ripped up the runway. Thus trapping 16 planes. There are 18,000 physician pilots. Including the one at the former Meigs Field. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460921 Mon, 21 Apr 2003 13:12:19 +0100 460921 http://www.richardwinters.com/richardwintersmd/2003/04/selection_bias.html You could look at the World Health Organization web site and see that there have been 3547 reported cases and 182 reported deaths of SARS worldwide. You could do a simple calculation: (182 deaths/3547 cases = 0.05) And you could believe that if you catch SARS you have 5% chance of dieing. I am in fact starting to see people do that very same calculation. Michael calculated a 3.5% mortality rate based on a WHO daily report early in April. Joshua (a good guy with a good blog) believes that if he goes to Hunan that he has a 50% chance of contracting SARS and thus a 2% chance of dieing on the trip from the SARS virus. Don't believe it. Do you go to the hospital every time you have a common cold? Do you present to the emergency department every time you have a cough, fever, and/or sore throat? The answer most likely is no. There are very likely a large number of individuals in SARS virus endemic areas who would answer the same. In fact, the coronavirus that causes SARS very likely exhibits a wide spectrum of effects...from a simple sore throat to the life-threatening severe interstitial pneumonitis. There is a lot of stigma to having the disease. Many would fear being quarantined. Many don't want to know if they have the disease. Many don't want their neighbors to know they have the disease. They don't want everyone in their building quarantined too. Remember that the numbers being reported are out of those seeking health care...who happen to have the disease...who happen to have the signs and symptoms picked up by their healthcare worker...who happen to test for it...and who happen to get a positive result. We often experience a selection bias. When I work in the trauma center it seems like everyone is trying to kill each other. When I work at the cardiac center it seems like everyone is having heart attacks. When I work in the behavioral care unit everyone seems mentally ill. When you live in Texas everyone else seems wrong (a subtle poke at my very intelligent but slightly xenophobic Texan friends). You can't take the number of individuals who present to any given location or setting to be representative of anything other than the kinds of individuals who present to that location or setting. SARS is a very serious and deadly emerging disease that needs to be controlled aggressively. However, we must resolve to not torture math. It is scary enough. Of course, I wouldn't plan on going to Hunan now either. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460922 Mon, 21 Apr 2003 12:41:06 +0100 460922 http://www.richardwinters.com/richardwintersmd/2003/04/status_bar_in_i.html I like to see the status bar at the bottom of the Internet Explorer window. The status bar allows you to see the addresses of links when you hover over them with your mouse. It gives you an idea of where you'll be taken if you click on a link...which can be a good thing. Sometime over the past year I started noticing that the status bar would disappear. It has driven me mad. I would click View...and check Status Bar...but it would not remember these settings when opening a new window. I found a solution using a google search at Kevin Donahue's web site. To make the status bar appear whenever you open Internet Explorer: 1) With (only one) IE open, click View, select: Status Bar 2) Right-click on IE's Toolbar and select: "Lock the Toolbar" 3) Hold down the Ctrl key and click the close button (upper right) 4) Open Windows Explorer, click View, select: Status Bar 5) Right-click on Explorer's Toolbar and select: "Lock the Toolbar" 6) Click Tools | Folder Options | View tab 7) Click the "Apply to all folders" button. 8) Hold down the Ctrl key and click the close button (upper right) 9) Open IE to any page, right-click on a link and select: "Open in New Window" (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460923 Mon, 21 Apr 2003 01:40:21 +0100 460923 http://www.richardwinters.com/richardwintersmd/2003/04/fashionable_but.html This article points out what most people who have taken a microbiology class already know. Surgical masks (even the fashionable ones shown below) provide no effective barrier against the transmission of viruses (eg SARS). It's like a gnat flying through chicken wire. We have funny looking duck-billed masks that we use in the hospital which are more effective. These masks are able to filter out particles down to 0.3 microns 95% of the time. Of course the coronavirus is 0.1 microns. However, there are masks that should work 100%. The biochemical warfare masks with their HEPA filters. Biochemical warfare masks are all the rage. They are this year's black. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460924 Tue, 08 Apr 2003 02:01:02 +0100 460924 http://www.richardwinters.com/richardwintersmd/2003/04/sars_masks.html The Trademark Blog points to an article that points out the increasing market for unauthorized designer masks. It has always been interesting to me that in many Asian countries sick individuals politely wear masks to protect other kind souls from their viral effluvia. It is quite the opposite in the United States. People here seem to spew their fomites at random with no regard for the health of others. Maybe people think you look like a dweeb in a mask. Michael Jackson certainly hasn't been a good poster boy for the hygeine movement. I think that this could be a huge market so I decided to make my own version. Does anyone of my readers wish to partner with me to make surgical masks that have an imprint of the person's own smiling face on them? Or perhaps the face of Brad Pitt or J. Lo? By the way my J. Lo name is R. Wi. I prefer chilled bottled water and green Mamp;Ms in the doctors lounge. Thank you. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460925 Sun, 06 Apr 2003 01:27:40 +0100 460925 http://www.richardwinters.com/richardwintersmd/2003/04/number_one_at_g.html Thanks to my "Placenta....Plunk" post I have moved to the number one spot at google. Just search for the terms "lifesize plastic models of genitalia split through the middle"...and there I am. In fact, I own that search. Thanks to the academy. And to my parents. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460926 Sat, 05 Apr 2003 23:27:37 +0100 460926 http://www.richardwinters.com/richardwintersmd/2003/04/youre_standing_.html Saw a patient recently. Nice introductions. Talked about why she was here. Talked about how I was going to help her. Told her the tests I was going to do and how I would make her feel better. I start to step back and notice that my shoes are slippery. I look down and see a clear fluid. "Did someone spill something there?" I ask. "No. I vomitted there." she says. "Charming." Note to patients: It's polite to inform your physician before (s)he steps in your vomit. And even more polite to say something if (s)he is wading in it while (s)he is trying to help you. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460927 Wed, 02 Apr 2003 01:47:46 +0100 460927 http://www.richardwinters.com/richardwintersmd/2003/03/placentathunk.html Fairly frequently a patient's family member will ask if I ever pass out from all of the gross stuff I see. It doesn't happen anymore. But it used to. I never thought I could ever be a doctor because I would pass out at any prompting when I was younger. I recall being 13 years old. Our class was attending a Birds and the Bees talk. It was one of those "teach the kids about sex with lifesize plastic models of gentalia split through the middle" talks. I remember sitting with the other kids on the steps of the mini-amphitheater and some older lady pointing to the plastic uterus. Tunnel-vision, weak all over... My teenage survival instincts told me to pretend to sleep on the steps. Along with all of the other pre-syncopal children. I recall working as an orderly ("Patient Care Technician") in a local hospital and watching a rather eager nurse insert a urinary catheter into a rather uneager demented older gentleman. Tunnel vision...weak all over...sweating... I found a chair on wheels that sped away as I grappled to sit. Suddenly I was the focus of attention. There was the time in medical school when we dissected the placenta. I let the others partake in this educational opportunity as I hobbled in my black-out fog to the more private bathroom. There was the time as a resident emergency physician that I was peeling fruit and accidentally created a 3 mm (dinky) cut in the web space of my left hand. I thought I would try to explore my incision locally to assure myself that there was no tendon damage in this obviously benign wound. I awoke on the floor. I haven't passed out from the site of blood and guts since. Everything at some point switches from the emotional "passing out" section of your brain...to the very logical analytic "red blood cells have no nuclei and mitochondria is inherited from the mother" portion of your brain. You forget that these things even used to be gross. It all makes sense. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460928 Mon, 31 Mar 2003 23:35:19 +0100 460928 http://www.richardwinters.com/richardwintersmd/2003/03/rss_feeds.html I agree with Tales of Hoffman...not having an RSS feed for your weblog is sooooo 2002. RSS stands for Really Simple Syndication. It allows a site to offer its content in XML so that programs other than Web browsers can fetch and format it. I use Radio Userland to both publish this weblog and to maintain a list of 74 weblogs/news sources. This allows me to very quickly read the content I am interested without forcing me to click 74 bookmarks every day. The amount of information that people "syndicate" using RSS varies. Some sources (like my weblog) syndicate their entire content. Some sources only syndicate headlines and a brief description....which you click on to read the full post (article) if you are interested. RSS allows me to easily see when a site I like has posted new content...as opposed to clicking on 74 bookmarks just to see if something has changed. The sites that just post headlines and descriptions are able to pull people into their site where they can still make money by serving ad on the full content. They also likely get more visits as people click on individual articles of interest...as opposed to looking at a huge page looking for interesting stuff. Most sites that have an RSS feed tell you by saying something like "RSS feed" or by posting an icon with the words "RSS" or "XML". Here are the XML links to some of the sites I have RSS subscriptions to: Medical GruntDoc Family Medicine Notes Medscape Headlines RangelMD Tales of Hoffman DB MedRants New York Times Health I would guess that 10-15 of the visits each day that MedPundit gets to her wonderful weblog are from me hoping that there is a new nugget. An RSS feed from her would allow me to not have to click the MedPundit bookmark so often...which would allow me to do more work....read more medicine...save more lives. Others Chris Pirillo CNET News Metafilter New York Times Business New York Times Science New York Times Technology Slashdot Techdirt Search for RSS Newsfeeds Syndic8 You can subscribe to and read RSS using many different programs. You can download NewsDesk (for Windows) or NetNewsWire (for Mac OS X). On the web you can use NewsIsFree. I personally use Radio Userland to author my blog and to read RSS newfeeds. Blogger Pro, Radio Userland, and Movable Type all easily generate RSS feeds. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460929 Fri, 28 Mar 2003 22:13:17 +0100 460929 http://www.richardwinters.com/richardwintersmd/2003/03/cdc_terrorism_a.html CDC has set up a mailing list to provide clinicians with real-time information to help prepare for (and possibly respond to) terrorism and other emergency events. Go to their site and enter your email address to receive regular updates on terrorism and other emergency issues relevant to clinicians. (Source: richard[WINTERS]md) richard[WINTERS]md blogs http://www.medworm.com/rss/comments.php?id=460930 Fri, 28 Mar 2003 20:18:38 +0100 460930