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BIRMINGHAM, AL – Completely unimpressed by his patient’s routine ECG this morning, cardiologist Paul Framingham has formally downgraded the diagnosis from an A-fib to B-minus. 

“It’s not that it’s bad fib, it’s just that I’ve seen better, you know?” said Framingham, yawning as he reviewed the ECG once more at our request.  “This just isn’t A or A+ quality.  It’s a B-minus or maybe a B-fib at best. Could be even better with a little more effort.”

Gomerblog reviewed the ECG. It has no distinct P waves and no regular RR intervals.  It’s definitely not atrial flutter nor any other arrhythmia or rhythm.   It’s consistent with atrial fibrillation.

“Yeah, but when you think of A-fib is this the ECG you think of?” Framingham asked.  “I certainly don’t. There isn’t even any rapid ventricular response.”

We asked Framingham if he has ever been so impressed by an ECG with V-fib that he gave it an A?

“Now that’s just silly,” he responded. “Now get out of my office before I cath you.”

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PHOENIX, AZ – A frantic search and rescue is underway after third-year medical student Barry Manama was unexpectedly whisked away by a colonic mudslide during a routine manual disimpaction on his patient this afternoon.

“The good news is that Manama’s hard work, going wrist and even elbow deep into his patient’s colon did finally relieve his several-week bout of obstipation,” explained Laura Waits, an emergency crew member searching for Barry.  “The bad news is the rush of stool – both solid, liquid, and every consistency in between – flushed Manama out of the patient’s room and he has yet to be found.”

One of the realities of manual disimpaction is that you might come face-to-face with death.  Or face-to-ass.  At least 50 medical students perish each year to manual disimpaction-turned-Noah’s Flood i.e. the colonic mudslide.

The impressive stool burden left by Manama’s left hand looks as if the sixth floor med-surg unit at Phoenix Medical Center had fallen victim to a brown avalanche.

There are several reasons why rescue workers are worried.  First, if Manama is buried under several feet of feces, then he is at risk of death by suffocation.  Second, if Manama aspirated any of the intestinal contents, well, then, gross. 

If there is one minor advantage of a snow avalanche over a stool avalanche, experts explain, it’s that the cold temperature of snow can help lower metabolic activity, perhaps help preserve brain function through therapeutic hypothermia.  However, a stool avalanche is warm and its fumes are potentially toxic, especially if a little C. difficile or melena is part of the mix.

Along those lines, Interventional Radiology has offered to help localize Manama with a tagged med student study if search and rescue operators have no success by nightfall. And if that doesn’t succeed, then general surgeons are ready to resort to exploratory defecotomy.

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On a quiet Tuesday afternoon, the dermatology clinics at GMH (General Medical Hospital) are filled with the sounds of clicks and types. As each aftervisit summary is hand-filled with “apply topical corticosteroid before bed”, Chad, a third-year medical student at BMS (Best Medical School), is in the bathroom putting on his white coat and draping his stethoscope around his neck in preparation of his one-hour shadowing commitment per week.

He looks in the mirror, his piercing eyes look back at him, and he back
at them, and them back at him, until he is lost in his own self absorption. A few minutes pass by as he ponders how impressive he is, and he leaves to meet with his resident and attending for the day. When he walks down the hall, he thinks “all these people
are jealous of me.”

Attendings know his name. Residents roll their eyes at him and talk about him behind his back. First-year students idolize him. He is just as far from being a Mohs surgeon as all of his other classmates, but you would not guess that by the way he carries himself. In full Brooks Brothers regalia and strapped with a Shinola watch, he has already adopted the spending habits of his chosen specialty. He is, afterall, the president of the Dermatology Interest Group, and he has to look the part.

“Hey, Dr. Chen!” he says as he catches up to his attending and resident in the hall.

“Hi, Chad. Nice of you to join us. We were just discussing our last patient. Why don’t you let us finish up while you go in to see the next patient. You’ve met Sarah before, right?” Dr. Chen said as she gestured to PGY-1 SarahwithanH.

“Nice to meet you. Sarah, was it? Don’t worry about intern year — I’m sure you’ll get through it,” said Chad, graciously offering her advice from his eons of wisdom.

“We’ve worked together before,” said SarahwithanH.

Chad walked into the patient room, announcing “Hi, I’m Dr. Chad, a student doctor doctoring with Dr. Chen today. What brings you in?”

“Nice to meet you! You’re a medical student?” said the patient, a 34-year old woman with a PhD who works at the university affiliated with BMS.

“Student doctor.”

“Ok, well, I’m coming in for this mole on my face. It seems like it’s asymmetric, the borders are weird, the color’s not even, the diameter is definitely bigger than my fingernail, and it’s evolving into a rather sightly spot.,” she said.

“Have you ever thought about cutting back on your drinking?” asked Chad, as he started his CAGE questionnaire. Twenty-five minutes
later, after a lengthy interview spanning every domain he was taught in his communication course, he stood up to examine the patient with his pocket light, which was gifted to him by a company he tagged in his Instagram posts of him wearing scrubs and walking
his dog.

“Looks like cancer. I’d remove the thing myself if they’d let me but let me go talk with the boss and see what we can do,” said Chad as he left the room.

Back in the hall, Chad presented the patient to Dr. Chen. Glancing at his watch, he noticed it was already 4:30 pm. Man, work hours need to be better regulated, he thought to himself. He excused himself from clinic, as he had to go home and go through UWorld for the sixth time this month.
I cured someone’s cancer today, he thought.

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Last month the first images of a black hole were released to the public. Early excitement was quickly tempered by concerns from a group of cardiologists. “While this signifies an enormous achievement in human history, we are gravely concerned about the black hole’s health status. Cardiovascular diseases are the number one cause of death in humans and it would be arrogant to assume that this would not pertain to any other entity within our universe including black holes.”

Per their assessment, the TC-99m SPECT clearly shows severe LAD disease, potentially even left main disease. “It’s hard to say, we only have the short-axis views. Vertical and horizontal long-axis views would be helpful, but we have to assume the worst.” Given the black hole’s voracious appetite, one has to assume significantly elevated LDL levels adding to the already unfavorable cardiovascular risk.

Cardiac interventionists have already made the strong recommendation that the black hole’s possible cardiac tissue appears viable and nothing but a cardiac cath with PCI would be appropriate in this situation. When asked about their approach to cathing the black hole, the interventionist said; “well, we can start with access via a wormhole in the right groin – although admittedly that’ll be challenging to identify given the elliptical shape of the patient. We’ll need a lot of dye, and I mean – A LOT – and then we’ll probably do some IVUS, a little FFR and I would probably choose a 9 quintillion mm third-generation drug-eluting stent.” This assessment did not remain unchallenged for long.

“This is the most ridiculous thing I have ever heard. Clearly, this signifies stable coronary disease and a trial of optimal medical therapy is indicated before thinking about putting in stents.” one non-interventinoal cardiologist citing the ORBITA trial results while shaking his head. An interventionalist

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WORLD 3-2 – It looks like the cumulative lifetime effect of punching bricks has finally caught up to our favorite plumber: In an attempt to find 1-Up mushrooms and bank some extra lives, Super Mario has shattered all 27 bones in his left hand.

“It’s not good, it feels like a bag of worms, a term that’s okay when you’re referring to varicoceles in a scrotum, but not a person’s hand,” said World 3-2 hand surgeon, Dr. Toad.  “Seriously.  He effed it up.  Like big time.  Not even an Invincibility Star can fix that.” 

Super Mario was found under a pile of bricks, screaming at the top of his lungs.  Game characters called for help. 

“Initially we thought it was his head and that we were going to need a neurosurgeon,” explained one of the nearby Koopa Troopas.  “Thankfully it was his hand.  Sure, his hand is a mess – I heard 27 bones broken? – but at least Mario’s brains aren’t splattered over Mushroom Kingdom.”

The Koopa Troopa alludes to a very common misconception among those in Mushroom Kingdom and videogamers alike: that Mario breaks the bricks with his head.

“Of course he’s not breaking bricks with his head, even if he did that once he’d have some sort of intraparenchymal bleed, a broken skull, and some cervical cord damage, and that would be the best-case scenario,” explained World 3-2 neurosurgeon Dr. Goomba.  “Just the thought of it sends shivers up my spine.” 

Though Super Mario wears white gloves, they’re not protective in any capacity.  They’re just plain, white latex gloves.  He wears them in case he needs to pause his quest to emergently unclog a toilet.  

Unfortunately for fans of the Super Mario francise, our beloved Mario will be out on FMLA for the indefinite future.

 

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POUGHKEEPSIE, NY – A groundbreaking new study conducted by CHOP (Children’s Hospital of Poughkeepsie) found that teenage males preferred access to the popular video game “Fortnite” over opioid analgesics for the management of acute pain. The randomized controlled trial compared two
populations of teenage boys with moderate to severe pain relating to acute appendicitis. The treatment group received at least 15 minutes of access to the online game, while the control population received standard pain management with opioids and supportive care.

Astoundingly, the researchers noted that all the boys in the treatment arm reported not only rapid and complete resolution of perceived pain, but significant reductions in perception of symptoms such as nausea, vomiting, and GI discomfort for the duration of access to the game.

By comparison, the control group reported significant but non-complete resolution of pain and discomfort relating to their appendicitis.
Not everyone was pleased with this development, local mother Tara Kemp was visibly agitated when she realized her son Braxtynn would be receiving therapeutic doses of Fortnite during his hospital course. “I can barely get him off the game as it is! Now you’re telling me you guys are
gonna let him play the game in the hospital?”

The manufacturer of Fortnite, Epic Games, has made several assurances that the game has limited addictive potential when compared to current opioid analgesics. The company also claimed the the free-to-play nature of the game combined with its demonstrated efficacy will make it the new standard of care for pain management in males aged 7-17 over the coming
decade.

The company dismissed early claims that withdrawal of the game led not only to significantly worsened self-reported pain scores when compared to pre-treatment, but severe game-seeking behavior lasting several weeks in nearly all the study participants. Several local emergency departments have reported an increase in requests for Fortnite prescriptions from young males. The Gomerblog team will update this article as the situation develops.

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YUKON TERRITORY, CANADA – Dispatches from the frozen north today report that a group of 40 brave Med-Peds physicians have set out into the Yukon territory in search for fabled Med-Peds Hospitalist jobs.

For many years, local Inuit legend has told of a vast cache of Med-Peds Hospitalist jobs in the northern tundra of the Yukon territory. Such jobs, consisting of 50% Pediatric hospitalist work and 50% internal medicine hospitalist work allegedly have been spotted in northern Canada according to fur traders. While such jobs are extraordinarily rare in North America, it is the collective hopes of this brave group that a large enough job depot can be discovered to satiate the large demand of Med-Peds graduates in the United States.

“All Med Peds trainees dream of this day” says Patrick Murphy, M.D. the lead Med-Peds explorer for the expedition. “You are stalking a fabled Med-Peds hospitalist job in the Tundra of the artic circle. You have it lined up in your sights. You know that if you can shoot it, that finally a Meds-Peds hospitalist job will be yours. They said it was impossible back home, but who’s laughing now.”

Critics of the expedition are quick to point out the overabundance of primary care Med Peds jobs indigenous to the continental United States. “Why risk life and limb searching for what may only be a rumor?” asks Chad Nedemeyer M.D., a Med-Peds graduate who actually practices primary care.

Reports also indicate that a sub expedition of Med-Peds explores will press on to the North Pole to search for an Adult Congenital Heart Disease job. Such jobs have long been extinct in North America. The last sighting of a small group of Adult Congenital Heart Disease Jobs indicated they may migrate into the deep artic around the summer solstice for the Northern Hemisphere.

“Why settle for primary care when you are Med-Peds?” Concluded Dr. Murphy. “Yes we know the overwhelming need for primary care in the US, but we train for these 50/50 hospitalist jobs, no one is better suited than us for this type of work.”

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A best practice alert, recently programmed by a highly competent collaboration between non-clinical quality and IT personnel, popped up today when Beth, RN was trying to write a quick note about post-mortem care on her recently deceased patient.

“Patient does not have documentation of a flu shot,” read the alert. The options to bypass the alert were to administer the vaccine or give a reason for the vaccine not being given: “crazy anti-vaxxer” or “contraindicated.” Wanting to quickly get back to her sick patient who was still alive, Beth
decided that being dead was a good contraindication and chose that option.

A new alert appeared: “Patient has no contraindications documented. Admitting provider must add addendum to history and physical that says this exact phrase including the misspelling “they got contradictions to the flu shot.” Any deviation of this phrase or documentation of this
phrase by any provider besides the admitting provider is a contraindication to the patient having contraindications.”

“Nope! no time for that” thought Beth as she quickly switched over and clicked “crazy anti-vaxxer.” “If the patient can’t consent because they are dead they technically refused!” she chuckled to herself, naively thinking that she may soon be able to get back to her living patient whose oxygen sensor is now beeping.

A new alert popped up: “Upload 30 minute video that shows vaccine education session with the patient including
their clear verbalization of a refusal in fluent English. Use Ken Burn effect.”

Now Beth’s living patient’s ventilator began to alarm. She could not review their chart until this alert was addressed. Beth grabbed the vaccine, scanned it and the deceased patient’s wristband, and injected the vaccine into their lifeless body. Only then was she able to bypass the alert, review her other patient’s chart, and deliver life-saving care.

At press time the chief quality officer was
seen laughing maniacally in the morgue as they administered flu shots and delivered rousing smoking cessation education to the sea of bodies.

Beth could not be reached for comment because she was being called into risk management to explain why she was spotted
creepily injecting substances into a deceased patient’s body.

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WASHINGTON, D.C. – Talk to any health care professional and they’ll tell you that self-treatment is not the best idea. However, for one D.C.-area neurosurgeon, he was convinced that self-treatment was absolutely the right call.

“The thing with my office is that I can’t ever get the temperature right,” complained neurosurgeon Dr. Arthur Desis. “I turn the thermostat a smidgen in one direction and it’s colder than the OR. Turn it a bit in the other direction and it’s an inferno.”

Desis had pestered every maintenance person in the building, but no one has been able to solve the problem. He decided “enough is enough” and took matters into his own hands.

“I was inspired by a cardiologist who stented his own blockage,” Desis continued, checking his head dressing for any drainage. “I might not be able to fix the office thermostat but I can certainly fix my own. They don’t call the hypothalamus the body’s thermostat for nothing. I honestly think this is some of my best work.”

We asked Desis why he removed the hypothalamus; it helped regulate the body’s temperature after all. If anything, removing the hypothalamus might make things worse. We asked him if perhaps he made a mistake?

No response.

Gomerblog will report on Desis’ answer to our questions when he snaps out of his stunned silence.

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(West Jersey, UK) – Around 90% of the patients in the ICU’s at West Jersey Regional Medical Center were on contact precautions last fiscal year, but adherence to the strict isolation policy was far lower than desired.

“We had doctors, nurses, technicians, all coming in and out of the room using various non-approved techniques of contact isolation including holding their nose, closing their eyes, holding their breath, and of course the classic just putting their hands behind their backs,” nurse manager Frank Reynolds stated. “This was completely unacceptable with our anticipated imminent health accreditation bureau inspection.”

Mr. Reynolds took swift action. He circulated a survey among hospital workers and found that 99.5% of the time, the reason these various staffers were not adhering to protocol was technical difficulties with getting into a contact isolation gown.

“We had many workers complaint they could not find the appropriate cart outside the room, or that the cart was empty, or that some people could not figure out how to get the gown on their body. Still others complained that they did not like the color of the gowns and refuse to wear them. One stated they would not wear anything but the Dior gown. She has since been let go.”

Mr. Reynolds thus devised a Quality Improvement plan. “I sat down with 351 of the hospitals top administrators, and demanded that we hire professionals to sit outside the rooms on contact isolation and help put on and remove the gowns for people. This would eliminate many of the problems and allow staff to comply with the contact precautions.”

I journeyed to the ICU to see Reynolds’ plan in action. The wardrobe consultants stand dutifully outside the patient rooms. Mostly younger, they range in age from around early 20s to late 30s and dress quite well. When any staffer approaches to enter a room, they politely ask if they’d like help putting on their contact gown. No matter the reply, they then begin to rather forcefully dress the staffer in a contact gown.

They have become quite proficient at it, and can gown the entire SICU rounding team (18 people if you include medical students) in under 90 seconds. To minimize cross-contamination, the consultants are each assigned to only one room, and take hourly hygiene breaks where they “hit the showers”.

The plan worked quite well. After only one QI cycle, compliance with contact precautions, as monitored by teams of newly-hired Contact Compliance Administrators, increased dramatically from 17% to 97%.

Their success was not without some drawbacks, of course. Mr Reynolds explains, “We had to fire several doctors and nurses, myself included, to pay for all these new personnel. But to keep JCAHO happy, any price is worth paying!”

“There’s no definitive evidence yet whether the patients receive higher-quality care as a result,” Reynolds concluded, “but let’s be honest, nothing matters as much as compliance.”

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