Michael Heller, MDLast December we examined the magical thinking that has led to a hand-washing campaign as a weapon against influenza (even though the bug is not transmitted like that) and a mandate to use transport condoms on endovaginal probes apparently on the theory that the atmosphere of the planet would contaminate the probe and those bugs would crawl through the latex covering during the ultrasound exam thereby exposing that previously sterile environment, the human vagina, to contagion.

The current missive will consider the oft-repeated warnings to medical personnel and restaurant workers- hell,  to just about everybody- to wash their hands after utilizing the rest room. A recent consult with an ED nurse (Ref 1) confirmed that these warning are prominently displayed in women’s rest rooms as well and apparently make no distinction between the two most common activities performed there (technically known as “Number One” and ”Number Two”.)  In fact the ubiquity of this caveat in our society led to the ultimate endorsement-a Seinfeld Episode on the topic- which strongly implied that failure to wash the hands after taking a leak posed a grave threat to life as we Manhattanites we know it and condemned the non-washer to the derision of his/her fellow man/women.

Here’s the problem. The dirtiest (ie most bacteria per cubic millimeter) places on the human body are the ventral surface of the hand. The penis ( I have no data on the female nether regions) is one of the cleanest. And it gets worse. The dirtiest (same definition) part of the restroom is the door knob (or handle). So, it makes no sense at all to admonish patients, employees and health care providers to wash hands after peeing and before leaving the rest room. In fact, it would make much more sense to encourage washing of the penis after urinating now that the male member has been contaminated by the germ-laden hands. Whether Cidex or autoclaving the organ in question would provide even greater protection is currently the subject of a randomized trial (recruitment is taking longer than expected. Ref 2)

So, what to do?  I’d suggest the following as a rational approach:

1) take the endovaginal probe cover with you to the bathroom.

2) wash hands first as you may have touched a doorknob on the way in

3) encase the hand with the probe cover.

4) urinate as per usual

5) exit the bathroom with the hand still encased with the probe cover or utilize the “backside-push” technique if the door opens outward.

6) put the probe cover back on the probe to keep the Infectious Disease folks happy.

References:

1. Shulman A.  Personal communication 01/10/2010. Beth Israel ED, NY
2. Heller M, Bukata W, et al. A Randomized controlled trial of steam heat versus gluteraldehyde for disinfection of Mister Wiggly. Publication pending  01/2020

As the nation’s health care system undergoes its’ stress test, and the nation’s population ages gracefully, the emergency system buffers the rough waters like a solid breakwater. But in many metropolitan areas, the system has been severely tested by the destructive process known as “diversion” or “rerouting”. Whatever it is called, or whatever local rules come to guide the process, it results in compromised patient care and angry emergency department staff...by Jim Augustine, MD

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Neal Little, MDBack to back encounters, almost. “So, how many steps did you fall down? “ “I don’t know.” “ Did you lose consciousness?” “I don’t know.” “Was anyone around?” “I don’t know.” “ How long have you been on donepezil, and mematine?” (No, of course I used the brand name- I can’t remember the generics- quick, what are these meds, without looking them up?)You get the picture. Trying to see how much of a workup the patient needs. Then, a key question- “Why were you going down the steps to the basement?” “To un-jam the shotgun shell in my hunting rifle!” “How were you getting to the field to hunt?” “Drive” ( the “you idiot”  was more of an unspoken part, but just as clear- it’s all in the inflection)

Or, while shouting into the squealing hearing aid so that EVERYONE in the rest of the ED can hear, except him, “So where were you going when you drove off the road?” “Right here.” “Where are you now?” “ Right here” Each answer it its own way somewhat correct- partial credit on those, but you get the picture.

And of course, nursing then says “ if you want to take their car keys away in the ER, then how are you planning to send them home?” “ What’s your daughter’s phone number?” “I, don’t….”

So, when people fill their prescriptions for these meds, should they have to turn in their car keys? But then, how will they get home from the pharmacy?

Raj Chand, MDI hate being beaten—especially by neurosurgeons.  Although, this time the neurosurgeons are clearly ahead of the game.  Stacey Burling from the Philadelphia Inquirer reported this week that the American Association of Neurological Surgeons annual meeting in May will be completely paperless.  All attendees will receive an iTouch that is preloaded with all conference documents — agendas, abstracts, vendor information, and advertising.  With 3500 attendees, they estimate saving half-a-million pages. 

5000 people attended the 2009 ACEP Scientific Assembly, and ACEP’s 2010 roster of meetings runs eight single spaced pages deep.  One can only imagine how much paper emergency physicians are consuming at our professional events.

Yes, there are limitations to this approach.  Not everyone has a handheld device, and some people still prefer paper.  However, many physicians use iPhones, Blackberries, and other devices every day—and the numbers continue to grow. 

Conferences ought to spend resources on developing eco-friendly tools, rather than the compulsory logo emblazoned bags and binders we receive at registration and often leave behind after the event.  A recent trend in food shopping is bringing your own reusable grocery bags.  Like the grocery store, physicians should bring our own handheld devices to conferences and help eliminate some of the waste choking our plane

Image courtesy of www.moonshadowmobile.com

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For those of you interested in the how health IT affects emergency medicine, there are two upcoming conferences that will be focusing on the latest trends.  I will be covering both conferences for em-blog.com so stay tuned here for updates:

International mHealth Networking Conference, February 3-4, 2010, Washington, DC

The mHealth initiative focuses on 12 domains where mobile technology is poised to advance healthcare.  Topics include enhancing patient-provider communication, impact of new applications to bedside care, disease management, monitoring, reimbursement, and policy.

HIMSS 2010, March 1-4, 2010, Atlanta, GA

HIMSS (Health Information and Management Systems Society) is the granddaddy of all health IT conferences.  It promises to be a huge event with nearly 30,000 attendees expected, and well known keynotes—Dan Hesse (CEO of Sprint), David Blumenthal (National Coordinator for Health Information Technology), Sanjay Gupta (CNN), Harry Markopolos (Fraud Investigator), and Sully Sullenberger (US Airways pilot).

I will be twittering live from each event.  Follow me @rajchand, or use the hash tags below to track my comments on the conferences:

-       mHealth conference:   #mhealthconf

-       HIMSS 2010:   #emhimss

On Dec 20, 2009, Neal wrote that in Canada, “not all bugs need drugs” was a campaign to decrease antibiotic usage. I think the C. Difficile scare with high mortality rates in Ontario and Quebec might also have played a role. Throughout my career, I have always wondered why we prescribe so many antibiotics. In the 1950’s we treated otitis media with antibiotics to prevent the severe suppurative complications that could arise – and not to treat the self limited ear infection. We have demonstrated convincingly since then that mastoiditis and brain abscess arose due to poor public health, inadequate nutrition and lack of vaccines – none of which exist in most of North America today. European and North American studies have shown that analgesics work as well as antibiotics for the symptoms of otitis media. We treated strep throat in the 1950’s and 1960’s because of the real threat of rheumatic fever – again, not for the limited local infection. In more than 98% of North America there is now zero risk of rheumatic fever. So I have to ask: why the antibiotics?...by Jim Ducharme, MD

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