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Below are the 20 most recent journal entries recorded in Steven DeFord's LiveJournal:

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Sunday, August 19th, 2012
2:34 pm
First champagne tap!
8/18/2012 23:43
GLUC CSF: 113 (H)
Friday, March 9th, 2012
8:48 pm
Free Market Drug Manufacturing
Many drugs, even generic ones, are made by only a small number of drug manufacturers, and every so often they have problems, be they paperwork with the FDA, manufacturing (remember the Tylenol recall?), or business related. This, of course, puts some medications in short supply. This is the list of drugs currently in short supply. This includes such common drugs as

Alcohol Dehydrated
Plain ol' alcohol in water, to be given IV

Amikacin Injection
A fairly commonly used antibiotic

Bupivacaine Hydrochloride Injection
local anesthetic, such as your dentist would use

Caffeine, anhydrous
You can now get it "inhaled," but doctors can't get it IV

Calcium Gluconate
Used to correct fatal arrhythmias in patients

Diazepam Injection
Better known as valium-- used to stop seizures, which are fatal if not stopped. This, lorazepam, and midazolam are the three medications that can be used to control life-threatening seizures (status epiliepticus), and all three are in shortage

Diphenhydramine Hydrochloride Injection
IV benadryl, used for life-threatening allergic reactions

Etomidate Injection
one of the best drugs for intubation (to place a breathing tube and use a ventilator), as it has little affect on blood pressure

Fentanyl Citrate Injection
One of the most commonly used IV pain medications, after morphine

Haloperidol Decanoate Injection
Long-lasting antipsychotic

Isoniazid Tablets
One of few effective antibiotics against tuberculosis

Ketorolac Injection
Powerful non-narcotic pain medication

Levofloxacin Injection
Broad-spectrum antibiotic used in patients with severe infections

Lidocaine Hydrochloride Injection
Even more commonly used local anesthetic than bupivicaine (above)

Lorazepam Injection
another anti-seizure medication. This, diazepam, and midazolam are the three medications that can be used to control life-threatening seizures (status epiliepticus), and all three are in shortage

Magnesium Sulfate Injection
Treats a life threatening heart rhythm (torsades de pointe), and is about the only thing that does

Mannitol Injection
Reduces life-threatening brain swelling (after bleeding or trauma

Metoclopramide Injection
Used for vomiting and severe migraine headache

Midazolam Injection
This, lorazepam, and diazepam are the three medications that can be used to control life-threatening seizures (status epiliepticus), and all three are in shortage.

Morphine Sulfate Injection
The most commonly used narcotic IV pain medication. This, fentanyl, and hydromorphone are the three commonly used narcotic pain medications, and all are in shortage.

And this just brings us halfway through the alphabet, and only the drugs I use (or encounter) on an everyday basis. As mentioned above, most of these are used to treat immediately life-threatening conditions, and yet, since "there's no money in it," no one wants to manufacture them, and those that do consolidate into a single plant which is occasionally shut down (due to manufacturing defects) for months at a time while providers scramble to try to find other medications to cover the gap. While from an educational standpoint, these shortages are good, in that they remind us that older drugs exist, such as vecuronium (a paralytic since rocuronium and succinylcholine are on shortage) and metaclopramide (a nausea medicine since ondansetron and prochlorperazine are on shortage), this does not make for good patient care. I guess we'll have to wait for Sasha Obama to come down with some horrible infection that we can't cure because levofloxacin is on back-order before something's done to correct this affront to good patient care.

If this is the pharmaceutical industry's method for getting us to stop talking about re-importation of drugs, I guess it works.

Monday, August 15th, 2011
10:14 am
Medical Research

(click through to get the mouseover text)

Friday, July 1st, 2011
2:32 pm
Tick models
I think it'd be handy to have a reference set of various ticks, both for teaching my wilderness first aid classes, as well as for in the hospital for seeing if a brought-in tick was an ixodes (potential for Lyme) vs. dermacentor (dog tick, no lyme), vs. other sort of tick. Would any of my friendly neighborhood biologists (or people in tick-endemic areas) out there be able to identify and, say, cast in plastic resin, such things? Seems like a project that'd be right up Xylocopa's alley. :)

Friday, November 26th, 2010
10:50 pm
Style points
Doctors, of course, need to document their patient care and visits. Generally, this is done via dictation. The usual practice seems to be to do this out of the patient room, but I have seen one surgeon do his visit dictations in the room with the patient.

I ask the non medical professionals out there-- which would you prefer your doctor do-- dictate in the room with you listening, or outside. The University of Rochester would probably recommend the former, to show that you're spending time paying attention to the patient (which, to be fair, is a frequent problem-- people tend to complain "The doctor only spent 10 minutes with me" even though we've probably spent an hour or more documenting, chasing down lab results, reviewing images, writing discharge instructions, speaking with consultants, and the like.

Tuesday, July 27th, 2010
6:43 pm
As more proof that the WMS can make even topics that seem incredibly boring really cool, we got a talk on hypothermia that had a bunch of stuff I didn't know about and is often kind of cool (no pun intended). One piece of equipment mentioned was the HEATPAC, which is a personal active rewarming device that runs on [proprietary] charcoal and a D cell battery. It apparently makes ~250 watts of heat for ~8h on one charcoal "fuel element." Also, interestingly, the Alaska Guidelines (mentioned in a prior entry) recommend against CPR in the hypothermic patient if transport time to the hospital is less than three hours (since they've got to be warm for their heart to provide perfusion). There was a fun anecdote about the lecturer being called out of bed for "Severe hypothermia, core temp 86 F" and upon meeting the helicopter, being greeted by a patient who was awake and talking to him. (Apparently he was trapped in an ice cream freezer and sat on a crate of ice cream-- when the OSH took his rectal temp, it was artificially low.)

::realizes he's not doing much other than transcribing notes and train-of-thought responses; will post more when he's in a more polished writing mood. :)::

6:33 pm
Top 10 Aritcles in Wilderness Medicine
As proposed by Dr. Scott Mcintosh.

  • Health Risks and Risk-Taking Behaviors Among International Committee of the Red Cross (ICRC) Expatriates Returning From Humanitarian Missions: Some interesting epidemiology about people's risk-taking behavior on humanitarian missions through the Red Cross. Nearly 1/3 of people returned reported having a casual sexual encounter while abroad! And this is self-reporting!
  • WMS Consensus Guidelines for thePrevention and Treatment of Acute Altitude Illness: Evaluates the quality of evidence for acetazolamide, dexamethasone, and the like.
  • Comparison of a SAM Splint-Molded Cervical Collar with a Philadelphia Cervical Collar: apparently a SAM splint restricts movement just as well as a Philly collar.
  • Comparison of Commercially Available Disposable Chemical Hand and Foot Warmers: (Really? This is one of the top 10 articles of 2009??) Basically, hand warmers are highly variable between brands, models, and even between individual packs in one box (one lasted ~2h while another from the same box lasted 15h).
  • Abnormal blood flow in the sublingual microcirculation at high altitude: A bit of more benchy research showing really sluggish/sludgy blood flow at altitude using some fancy optical refraction techinque.
  • Watch Out for Nuts in Your Travels: An Unusual Case of Drug-Facilitated Robbery: this was one of my favorites-- some con man stuck clonazepam in some doctored hazelnuts and offered them to unsuspecting people. After he was caught, each hazelnut (of which people'd generally have only 2-3 before succumbing) had an average of 166 mg of clonazepam (usual dosing for those who don't know is around 0.5-1 mg three times/day-- that's nearly 2 months worth in one hazelnut!).
  • A Long-Duration (118-day) Backpacking Trip (2669 km) Normalizes Lipids Without Medication
    Health screening on high mountains: (as well as improving blood pressure and the like). And it wasn't even some toned athlete with a BMI of 22 and high VO2-- he was almost obese (BMI=29) which improved to about 25. Just reminds me that I really need to get out and exercise. More proof that residency is unhealthy!
  • The Impact of Global Warming on Mount Everest: Despite the fact that the temperature on Everest has only gone up 0.6 degrees C in 5 decades, the partial pressure of oxygen at the summit is appreciably higher (to the point that supplemental oxygen may be less necessary).
  • Optic nerve sheath diameter correlates with the presence and severity of acute mountain sickness: evidence for increased intracranial pressure: Ooh, more sexy ultrasound research!

6:18 pm
(As an aside, the Alaska Frostbite Guidelines covers most of this.)

Other cool things:
  • Aloe Vera has a potent anti-prostaglandin; it may be beneficial as a topical dressing for rewarmed frostbite, replaced Q6H.
  • Oxygen therapy is appropriate for hypoxia (generally likely above 4,000 m).
  • Gold standard for imaging for determining viable tissue is Tc99 bone scan and/or MRI/MRA: frostbite can look much worse than it actually is, or vice versa. Delay amputation.
  • Dr. Christopher Imray in the UK is a frostbite expert, and offers [free?] expert consultation-- check out his website at http://www.christopherimray.co.uk/contact.htm

And remember, if your hands are cold, you can always windmill your arms to try and get some warm blood down to them. (It apparently works.)

Chris Van Tilburg presented again, this time on medical kits, and once again proved the adage that there is no "best" kit, although it's true that it's really hard to improvise Epi, CPR masks, and tape (although you might not have thought about that one). Also, Dermabond isn't very heat stabile, and cable ties/webbing straps can be versatile and useful. Vital signs reportedly makes a collapsible BVM (has two chambers-- one you blow up manually to provide the structure), although I can't seem to find it online. Other than that, what you bring is a matter of what you need for your specific circumstance (location, length, training, etc).

More in further entries. I'm only what, 3 days behind yet? :)
Sunday, July 25th, 2010
8:59 pm
WMS Conference Sessions
There were several excellent ones today:

Dr. Luanne Freer did a talk on Expedition Medicine-- basically the things you need to think about if someone approaches you to be a trip physician. Some points I hadn't considered:
  • Ask if you'll be caring for the locals, too
  • Patients are the same everywhere-- lying about medical conditions, expecting you to be able to pull cures out of your ass, etc
  • Remember the Dept. of State Citizen's Emergency Center #: 202-647-5225
  • Remember the F's of ID: Food (eg. gastro), Flies (eg. malaria), and Flirtation (she gave us an anecdote about the worst case of gonorrhea she'd ever seen)
  • Bring, for example, tent repair stuff-- people'll come to you and expect you to repair their tent with, say, 3-0 nylon.

Dr. Chris VanTilburg had a gripping talk about his experiences as a mountain rescue doc (referencing his book with the same title) and a few recommendations (Bring a GPS and a cell phone). Also, I may have to bring some "Special Pancake Mix" (beer) to the next AMRG search. (The rescue he was on was being highly covered by the media, and so he was asked to bring up "special pancake mix" since they couldn't professionally say "Bring the case of beer up" over the radio.)

Later in the day, Dr. Freer came back to give a talk on frostbite, including some new stuff for me: clear bullae are probably superficial (and arguably should be drained), whereas bloody bullae are more likely deep (and usually shouldn't be drained). I didn't know about the ACE-DD allele, which increases your risk of frostbite, as well as vibration, African American, female, and increased altitude. The really sexy stuff, though, was the information about frostbite and thrombosis and the amazing things that have been done with intra-arterial tPA and vasodilator medicines.

More later; my dinner just arrived.
12:07 am
WMPP Day 2 and Conference Opening
Nope, day 2 was pretty much more of the same as day 1. New things I learned:

1: If you make a lower leg splint with a sleeping pad, you can roll up the end and cinch it down to help splint the ankle. (Beats the classic pillow splint.)

2: If you're doing the ski-pole traction splint, and it's too short, you can put it medially (like the two options with a Sager splint) by putting a shoe in the crotch and sticking the end of the ski pole into the shoe.

3: Tegederms (and their other-brand equivalents) are useful dressings in the woods once you've cleaned the wound out.

The conference itself looks more promising. After a somewhat boring "State of the Society" speech that discussed our budget &c, Dr. Luanne Freer gave a talk about the creation of the Everest ER, some of the interesting stories from it, and plans for the future (technical rescue training for Sherpas), which was quite interesting and fun.

(The entire Everest ER: a tent with 4 cots in it, as well as Dr. Freer.)

Looking forward to tomorrow!
Friday, July 23rd, 2010
11:32 pm
Preconference Day 1 (NOLS WMPP)
So I begin to fear that I paid a lot of money to attend classes about stuff I already know. They went over the process of assessment (scene size up, ABCDE, SAMPLE/VS/PEx), clearing c-spine via NEXUS criteria, simple moves (log rolls, BEAM move), litter carries, and splinting. Total things I learned today:

1: Body mechanics-- teaching "lift and sniff"-- keep your nose up and sniff when you lift-- helps remind you to keep your back straight. Might even beat out Cora's "Bend yo' knees!"

2: MSK injury principles-- it doesn't matter whether it's a strain, sprain, fracture, etc-- what matters is whether it's usable (eg. weight bearing) or not.

3: How to tape an ankle

4: Some trivial epidemiology (NOLS has 6 helicopter rescues/year on average).

Here's hoping tomorrow's more useful.
Thursday, July 22nd, 2010
11:57 pm
Wilderness Medical Society Conference in Snowmass, CO
Well, after doing laps around Aspen in our Canadair Regional Jet so many times we had to diver to Grand Junction to refuel, I'm safely ensconced in my hotel. I hope to be blogging nightly about cool and interesting things from the conference. (If not, keep me honest and yell at me to write more!)

Tuesday, May 18th, 2010
4:42 pm
Via Movin' Meat: Curing Malaria with Lasers

Move over Wesley Gibson.

Sunday, May 9th, 2010
6:32 pm

That wouldn't "make it so you feel no pain" in the way you think it would.

Thursday, April 22nd, 2010
3:21 pm
PA EMS Scope of Practice
(From The PA Code)

SkillAmbulance AttendantFirst ResponderEMT-BEMT-P
Childbirth (abnormal/complications)NoNoYesYes
Childbirth (normal)--cephalic deliveryYesYesYesYes

"Okay, Mr. First Responder-- we know a priori this will be an uncomplicated delivery, so we're going to sign off and leave this for you. Ciao!"

"Oh, crap, I see a prolapsed cord! I guess I have to stop taking care of you now!"

Saturday, April 10th, 2010
1:55 pm
A bit of levity
Asked by a rather large man walking onto the labor deck:

"Where do I go for..uh...C-section?"

(A c-section? I'm sorry sir, we can't help you there.)


P.S. (He did find his MOB a minute or two later.)
Monday, June 22nd, 2009
4:09 pm
Why am I not hearing about Swine Flu anymore?
Because we're a bit less scared by it now. Despite the WHO raising the pandemic level to 6 (full pandemic), the severity of the disease isn't turning out to be what we feared. At this point, practically all (98%) of laboratory-confirmed cases of the flu are novel-H1N1 (swine) flu, and yet mortality's fairly close to baseline. Now only one CDC region (Region II: NJ/NY, Puerto Rico and the Virgin Islands) is reporting above-baseline rates of influenza-like-illness, and the chart of mortality due to pneumonia and influenza looks pretty much like it always does (although it's technically a tenth of a percent (7.0%) above the "epidemic threshold" (6.9%) for this week, as opposed to, say flu season '08 where it was about a full percent above (~9% vs. ~8%). Now, we're not totally out of the woods, since the 1918 flu also apparently showed up, lay low for a while, and then came back more virulent than before, so we'll have to see what the next flu season brings about.

Dr. Steve
Sunday, May 24th, 2009
1:47 pm
Planning Ahead
I just got this email. Mind you, I only just graduated 9 days ago.

      My name is Chiquita Hardaway and I am physician recruiter for several hospitals nationwide including New York. I have several Emergency Medicine positions available and wanted to inquire if you were interested in any of them or have you already secured a position. If you have, please accept my apologies for any inconvenience that I may have caused, and if not feel free to let me know the locations that you are interested in.


Chiquita Hardaway, Executive Recruiter
C&P Consulting Firm, LLC
850-475-1658 Work
703-552-1554 Fax

"Helping you find quality professionals today, for your future success of tomorrow!"

Saturday, May 23rd, 2009
11:41 am
Swine Flu Update
(featuring a nice map from the CDC)

(Map is of cases of flu, rather than just swine flu, although approximately 2/3 of new cases of flu detected in the US are H1N1 (swine) flu.)

Approximately 6,500 cases in the US, with 9 deaths so far. No big changes in recommendations-- wash your hands, stay home if you're sick, and so forth.

Take care, everyone.
Sunday, May 3rd, 2009
7:37 pm
Swine Flu Updates
If you're interested, you might want to check out the WHO RSS feed at http://www.who.int/feeds/entity/csr/disease/swineflu/en/rss.xml (LJ Feed at http://syndicated.livejournal.com/whoswine/).

Also, there's a picture of the current infection state of the world at http://www.who.int/csr/disease/swineflu/GlobalSubnationalMaster_20090503_1630_lrg.jpg, duplicated below:

18 countries, 898 cases of H1N1 flu.
226 in the US in 30 states, still only 1 death.

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