agosto 31, 2010

Que voy a extranar de Troncoso

Parecio una eternidad, pero hoy finalmente terminan los dos meses de rotacion por gineco en el sui generis Hospital General de Zona 2A 'Francisco del Paso y Troncoso'. Mas que nada fue un tiempo de explotacion encubierto con el titulo de ensenanza, aunque he de admitir que hay algunas cosas de este hospital que voy a extranar.

1.- A los de la guardia A, que se encargaron de alivianar esas largas noches de guardia.
2.- El cafe del comedor, nunca supimos bien el origen de esos tambos rellenos de cafe negro o leche endulzada con piloncillo, lo que si se es que a medianoche sabia a gloria.
3.- Hablando del comedor, si algo bonito tiene el hospital es la vista. Nada mejor para combatir con la depresion de la guardia que cenar admirando las luces de la ciudad por el ventanal.
4.- Las quesadillas de las tias y las hamburguesas de urgencias, desayuno, comida y cena de campeones.
5.- Y ya para terminar creo que voy a extranar la estancia en la Toco, el lugar en el que mas aprendi (y donde me di cuenta que no queria ser ginecologo).

Por ahora los dejo, ahi les cuento despues que tal el Pediatrico.
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agosto 30, 2010

The Art of Pimping

Me crucé por casualidad con esta joya publicada por el JAMA en 1989. En vista de que todos hemos vivido el pimping en carne propia y ahora los estudiantes que rotan conmigo me detestan por aplicarlo les comparto el siguiente texto:


by Frederick L. Brancati, MD, Department of Medicine, University of Pittsburgh.

From JAMA 262(1):89, July 7, 1989.

It's hard work becoming a revered attending physician in a university hospital. The task daunts the newly appointed junior attending as he strides down the corridor of his first ward with his first team. Oh, he's made some changes in anticipation of his new position. He's wearing a long coat now, an all-cotton coat with razor-sharp creases and knit buttons. The stained, shrunken polyester white pants and tennis shoes have given way to gray, light wool slacks with a cuff and polished loafers. Framed certificates bear testimony to his intelligence and determination. He should be ready to take the helm of his ward team, bu

t he's not. Something's missing, something important, something closer to art than to science. When physicians talk about the "art of medicine" they usually mean healing, or coping with uncertainty, or calculating their federal income taxes. But there's one art this new attending needs to learn before all others: the art of pimping.

Pimping occurs whenever an attending poses a series of very difficult questions to an intern or student. The earliest reference to pimping is attributed to Harvey in London in 1628. He laments his students' lack of enthusiasm for learning the circulation of the blood: "They know nothing of Natural Philosophy, these pin-heads. Drunkards, sloths, their bellies filled with Mead and Ale. O that I might see them pimped!"

In 1889, Koch recorded a series of "Puempfrage" or "pimp questions" he would later use on his rounds in Heidelberg. Unpublished notes made by Abraham Flexner on his visit to Johns Hopkins in 1916 yield the first American reference: "Rounded with Osler today. Riddles house officers with questions. Like a Gatling gun. Welch says students call it 'pimping.' Delightful."

On the surface, the aim of pimping appears to be Socratic instruction. The deeper motivation, however, is political. Proper pimping inculcates the intern with a profound and abiding respect for his attending physician while ridding the intern of needless self-esteem. Furthermore, after being pimped, he is drained of the desire to ask new questions -- questions that his attending may be unable to answer. In the heat of the pimp, the young intern is hammered and wrought into the framework of the ward team. Pimping welds the hierarchy of academics in place, so the edifice of medicine may be erected securely, generation upon generation. Of course, being hammered, wrought, and welded may, at times, be somewhat unpleasant for the intern. Still, he enjoys the attention and comes to equate his initial anguish with the aches and pains an athlete suffers during a period of intense conditioning.

Despite its long history and crucial importance in training, pimping as a medical art has received little attention from the educational establishment. A recent survey reveals that fewer than 1 in 20 attending physicians have had any formal training in pimping. In most American medical schools, pimping is covered haphazardly during the third-year medical clerkship or is relegated to a fourth-year elective. In a 1985 poll, over 95% of program directors admitted that the pimping skills of their trainees were "seriously inadequate." It comes as no surprise, then, that the newly appointed attending must teach himself how to pimp. It is to this most junior of attendings, therefore, that I offer the following brief guide to the art of pimping.

Pimp questions should come in rapid succession and should be essentially unanswerable. They may be grouped into five categories:

1. Arcane points of history. These facts are not taught in medical school and are irrelevant to patient care -- perfect for pimping. For example, who performed the first lumbar puncture? Or, how was syphilis named?

2. Teleology and metaphysics. These questions lie outside the realm of conventional scientific inquiry and have traditionally been addressed only by medieval philosophers and the editors of the National Enquirer. For instance, why are some organs paired?

3. Exceedingly broad questions. For example, what role do prostaglandins play in homeostasis? Or, what is the differential diagnosis of a fever of unknown origin? Even if the intern begins making good points, after 4 or 5 minutes he can be cut off and criticized for missing points he was about to mention. These questions are ideally posed in the final minutes of rounds while the team is charging down a noisy stairwell.

4. Eponyms. These questions are favored by many oldtimers who have assiduously avoided learning any new developments in medicine since the germ theory. For instance, where does one find the semilunar space of Traube? Or, whose name is given to the dancing uvula of aortic regurgitation?

5. Technical points of laboratory research. Even when general medical practice has become a dim and distant memory, the attending physician-investigator still knows the details of his research inside and out. For instance, how active are leukocyte-activated killer cells with or without interleukin 2 against sarcoma in the mouse model? Or, what base sequence does the restriction endonuclease EcoRI recognize?

Such pimping should do for the third-year student what the Senate hearings did for Robert Bork. The intern, in contrast, is a seasoned veteran and not so easily rattled. Years of relentless pimping have taught him two defenses: the dodge and the bluff.

Dodging avoids the question, wasting time as well as a valuable pimp question. The two most common forms of dodging are (1) to answer the question with a question and (2) to answer a different question. For example, the intern is asked to explain the pathophysiology of thrombosis secondary to the lupus anticoagulant. He first recites the clotting cascade, then recalls the details of a lupus case he admitted last month, and closes by asking whether pulse-dose steroids are indicated for lupus nephritis. The experienced attending immediately diagnoses this outpouring as a dodge, grabs the intern by the scruff of the neck, and rubs his nose back in the original pimp.

A bluff, unfortunately, is much more damaging than a dodge. Allowed to stand, a bluff promulgates a lie while undermining the academic hierarchy by suggesting that the intern has nothing more to learn from his attending. Bluffs weaken the very fabric of American medicine, threatening our livelihood and our way of life. Like outlaws in a Clint Eastwood movie, bluffs must be shot on sight -- no due process, no Miranda Act, no starry-eyed liberal notions of openness or dialogue -- just righteous retribution.

Bluffs fall into three readily discernible categories:

1. Hand waving. These bluffs are stock phrases that refer to hot topics in biomedicine without supplying detail or explanation. For example, "It's a membrane transport phenomenon" or "The effect is mediated by prostaglandins." In many institutions, they may evolve directly from the replies of Grand Rounds speakers to questions from the audience.

2. Feigned erudition. The intern's answer, though without substance, suggests an intimate understanding of the literature and a cautiousness born of experience. "Hmmm . . . to my knowledge, that question has not been examined in a prospective controlled fashion" is a common form. Frequently, the bluff is accompanied by three automatisms: clearing of the throat, rapid fluttering of the eyelids and tongue, and chewing on the temples of the eyeglasses. This triad, when full-blown, will make the intern bear a sudden resemblance to William Buckley and is virtually pathognomonic.

3. Higher authority. The intern attributes his answer to the teaching of a particular superior. When the answer is refuted, the blame of ignorance comes to rest on the higher authority, not on the obedient, accepting intern. The strength of the bluff depends on just whom is quoted. An intern quoting a junior resident about pathophysiology is every bit as cogent as Colonel Qaddafi quoting Ayatollah Khomeini about international law. An intern from an Ivy League medical school quoting the "training" he received on his medical clerkship goes over like Dan Quayle explaining the Bill of Rights at an ACLU convention. The shrewd intern, however, will quote his Chairman of Medicine or at least a division chief, pushing the nontenured attending to the brink of political calamity. Did the chairman actually say that? The attending is powerless to refute the statement until he is certain.

Indeed, a good bluff is hard to handle. Sometimes the intern's bluff sounds better to the ward team than the attending's correct answer. Sometimes it sounds better to the attending himself. Ultimately, the cunning intern is best discouraged from bluffing by aversive training. Specifically, each time he bluffs successfully, the attending should counter by inducing Sudden Intern Disgrace (SID). SID is induced in two ways:

1. Question the intern's ability to take a history. This technique depends on the phenomenon of historical drift. That is, a patient's story will reliably undergo a significant change in the 8- or 16-hour interval between admission and attending rounds. The attending need only go to the bedside and ask the same questions the intern did the night before. Now the entire case is seen in a light different than that cast by the intern's assessment. Yesterday's right upper quadrant cramping becomes right-sided pleuritic chest pain. Yesterday's ill-defined midepigastric "burning" becomes crushing substernal heaviness radiating to the arm and jaw. Suddenly, the intern is disgraced. He will never bluff again.

2. Question the intern's compulsiveness. In less rigorous programs, this is easy. Did the intern examine the peripheral blood smear and the urine sediment himself? If the intern does routinely examine body fluids, a more methodical approach is required. In this case, results of the following tests, procedures, and examinations may be requested in rapid succession: Hemoccult slide test, urine electrolytes, bedside cold agglutinins and serum viscosity, slit-lamp examination, Schiotz' tonometry, Gram's stain of the buffy coat, transtracheal aspiration, anoscopy, rigid sigmoidoscopy, and indirect laryngoscopy. Once the attending discovers a test or examination left unperformed, he asks the intern why this obviously crucial point was neglected. (The tension may be heightened at this point by frequent use of the word "cavalier.") The intern's response will generally revolve around time constraints and priorities in diagnostic evaluation. The attending's rejoinder: did the intern eat, sleep, or void last night? The scrupulous intern at once infers that he has placed his own needs before the needs of his patient. Suddenly, he is disgraced. He will never bluff again.

Clearly, pimping -- good pimping -- is an art. There are styles, approaches, and a few loose rules to guide the novice, but pimping is learned in practice, not theory. Despite its long and glorious history, pimping is in danger of becoming a lost art. Increased specialization, the rise of the HMO, and DRG-based financing are probably to blame, as they are for most problems. The burgeoning budget deficit, the changing demographic profile of the United States, the Carter Administration, inefficiency at the Pentagon, and intense competition from Japan have each played a role, though less directly. Against this mighty array of historical forces stands the beleaguered junior attending armed only with training, wit, and the determination to pimp. It won't be easy to turn back the clock and restore the art of pimping to its former grandeur. I only hope my guide will help.

agosto 10, 2010

Paso a paso por Fco. del Paso y Troncoso

El Hospital General de Zona 2A 'Francisco del Paso y Troncoso' del IMSS es ya una leyenda entre los MIPs de la UP. La rotacion por gineco-obstetricia es una de las mas temidas y odiadas de ese ano en el que los medicos en formacion comienzan realmente a vivir la vida intrahospitalaria.
En un esfuerzo por faciltarle la vida a los MIPs que vendran despues, y siguiendo el ejemplo de la MIP del Bollo les dejo la pequena Hitchhiker's guide to the Tronx.

Actividades Tronqueriles:

El MIP de gineco pasa por tres servicios durante su rotacion: hospitalizacion, consulta externa y la Unidad Tocoquirurgica (UTQ, o Toco). En todas ellas tiene que hacerle de sacachambas (tomar muestras, llenar solicitudes, hacer de mandadero con los laboratorios, etc.), convivir y cuidar a sus pacientes, y entre todo ello estudiar para el examen final de rotacion (OJO, el temario Troncoso y el UP son distintos).

- La Toco: Es el servicio de urgencias ginecologicas, el/la MIP tiene que vestirse con pijama quirurgica, gorro y botas (de preferencia lleven las suyas pq se acaban y luego hay que reciclar las del bote de basura). los internos se distribuyen en las labores A y B para desarrollar el fino arte de panzear (llenar el partograma, tomar foco fetal cada 30 min y hacer tactos vaginales cada hora en promedio) y aprender a atender partos (previo grito 'paciente a expulsion!' porque el camazo paga pastel). Es un servicio con mucho trabajo, aunque todo funciona mecanicamente: hacer ingreso y tomar muestras checar a la paciente, llenar las solicitudes de cirugia o analgesia segun se soliciten, ir al laboratorio por resultados, atender partos o entrar a quiforano para cesareas y salpingoclasias (OTBs). Todo el personal es muy atento y contestan tus dudas, los reganos son raros, y se dan mas que nada cuando no estan a tiempo los labs de una paciente grave (preeclampsia, sufrimiento fetal)
El ingreso: a toda paciente que llegue a la toco se le debe hacer una historia clinica ginecoobstetrica* al ingreso, tomarle BH, cruce (en tubos de tapa morada) y tiempos de coagulacion (tubos de tapa azul). si ingresa con diabetes o hipertension ademas se pide un perfil toxemico, osea una QS, PFHs, DHL y Ac. urico (en un tubo rojo) mas un EGO (en un tubo azul al que se le quito el tubo interno son anticoagulante*). Todas las pacientes deben firmar un consentimiento informado general y habiendo indicado si desean algun metodo de planificacion familiar (OTB o DIU).

- Despues del ingreso: Si la paciente esta embarazada se debera llenar el partograma, anotando cada 30 min la FCF y cada hora la dilatacion y numero de contracciones en 10 min. Esto es muy importante, pues es un documento con el que se ve la evolucion de la paciente y permite tomar decisiones, ademas de las implicaciones legales que le atanen en casos de demanda.
Las no embarazadas suelen llegar por abortos o sangrados anormales, y en su mayoria van a legrado, con ellas hay que estar revisando la intensidad del sangrado, que esten hemodinamicamente estables y procurar tener los laboratorios y el cruce listos lo mas pronto posible para que pasen al legrado.
Si la paciente pasa a quirofano, legrado o se le va a dar analgesia obstetrica debe llenarse una solicitud de cirugia. Las primeras dos deben ser entregadas a la jefa de enfermeras en cuanto el ginecologo solicite que la paciente pase a quirofano, la ultima se da a los residentes de anestesiologia hasta que la paciente ha superado los 6 o 7 cm de dilatacion.

- Consulta externa: Durante una semana (con suerte dos) los internos rotan por este servicio, en las consultas de ginecologia, embarazo de alto riesgo o mama. Es la rotacion mas tranquila, la entrada es a las 8 am y las actividades del MIP son explorar a las pacientes, llenar solicitudes de estudios y en caso de que haya estudiantes hacerles preguntas, explicarles y permitirles explorar pacientes. Los doctores son bastante tranquilos y responden a tus preguntas, aunque no se explayan mucho por el volumen de pacientes que se maneja.

- Piso: La rotacion mas aburrida de todas, los internos se dividen en el segundo piso norte (alojamiento conjunto), tercer piso norte (embarazo de alto riesgo) y tercer piso sur (ginecologia). La chamba varia un poco en cada uno, aunque en tienen cosas en comun.
A todos los ingresos se les debe completar el 'paqueteingreses' (juego de 4 hojas de las que conviene tener varios juegos de copias) y acomodar el expediente de acuerdo al 'estandar' del hospital. Se debe llenar una hoja frontal, una hoja de alta (con copia), la historia clinica y la hoja de alojamiento (solo en 2N). En todos los pisos se pasa visita entre 7 y 8 am, alrededor de las 3 pm y en 3N a las 8 pm.
En 3N solo se hacen ingresos, se pasa visita y se cumple con los pendientes, como labs, USG y PSS.
En 3S hay que tener listos laboratorios, cruces y valoraciones preoperatorios de quien va a quirofano, y hacer una nota SOAP a las pacientes que reingresan.
En 2N se recibe a las pacientes postparto y postcesarea. unicamente se hace el ingreso, se llena la hoja de alojamiento conjunto, se hace tacto vaginal y revision de episiotomia a quien tuvo parto y revision de herida quirurgica a las post-cesaria.
en caso de cualquier eventualidad, emergencia, duda o lapsus brutus siempre se puede recurrir al residente encargado de hospitalizacion, quien suele estar en el 3N y ademas es el guardian de las llaves de la maquina de PSS durante las guardias.

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agosto 01, 2010

In CPR, Less May Be Better

Fifty years have passed since Kouwenhoven, Jude, and Knickerbocker1 proposed external chest compression to provide circulation of blood to the brain and heart after cardiac arrest. Shortly thereafter, mouth-to-mouth rescue breathing was adopted as an essential addition to this lifesaving procedure. Since that time, there has been very little fundamental change in the method or manner of cardiopulmonary resuscitation (CPR). Decades of observational studies have shown that survival is improved if CPR is performed by bystanders rather than being provided only when emergency medical services (EMS) staff arrives. The use of automated external defibrillators by bystanders and the use of in-hospital hypothermia in comatose patients have also been found to improve outcomes in patients with cardiac arrest.

Only relatively recently, however, have the fundamentals of the initial resuscitation been investigated. Focused, impressive laboratory research has resulted in a surge of interest in these fundamentals. Most of the studies have involved pigs with electrically induced ventricular fibrillation and have resulted in two distinct conclusions. First, the interruption of chest compression results in a lower coronary perfusion pressure and presumably less myocardial blood flow during CPR.2 Second, an increased frequency of positive-pressure ventilation reduces the survival rate. The detrimental effect of this high frequency of ventilation is thought to result from both the interruption of compression2and the obstruction of venous return to the central circulation because of high intrathoracic pressure during ventilation.3

These data, along with observational EMS field studies suggesting that outcomes are better with continuous chest compression and no rescue breathing, led the American Heart Association to advocate “hands-only” CPR4 for bystanders not trained or competent in CPR with rescue breathing.

Two articles in this issue of the Journal — one by Rea and colleagues5 and the other by Svensson and colleagues6 — describe studies that took advantage of emergency medical dispatchers' instructing bystanders to administer CPR. In the studies, patients with out-of-hospital cardiac arrest were randomly assigned to undergo one of two types of CPR performed by a bystander: either continuous chest compression without any attempts at ventilation, or chest compression with interruptions for rescue breathing by bystanders (the current standard).

The straightforward conclusion from the primary analyses of these studies is that continuous chest compression without active ventilation, which is simpler to teach and perform, results in a survival rate similar to that with chest compression with rescue breathing. Equally straightforward is the message that advocating continuous chest compression without ventilation by a bystander should increase the frequency of bystanders' effectively performing CPR and therefore increase the chances of survival after cardiac arrest. Performance of mouth-to-mouth rescue breathing is far more difficult than proper chest compression, and rescue breathing may be viewed with distaste and raise concerns about risks associated with mouth-to-mouth contact. One suggestion made by Rea and associates in their discussion deserves some attention: that mouth-to-mouth ventilation is performed so poorly by bystanders that this periodic interruption for “ventilation” succeeds solely in diminishing coronary flow.2 Nonetheless, CPR courses should teach rescue breathing, since it is important in cases of cardiac arrest due to obvious respiratory failure, which include most cardiac arrests in children and some in adults.

There was a trend toward better survival with continuous chest compression among patients whose arrests were due to cardiac causes5 and among patients whose initial cardiac rhythm was ventricular tachycardia or fibrillation6 rather than asystole or electromechanical dissociation. This trend is consistent with the benefit of continuous compression in animal models, in which arrest is caused by induced ventricular tachycardia or fibrillation.2 In dogs, after the sudden interruption of blood flow by means of ventricular fibrillation, the predicted steep decline in arterial oxygen saturation does not occur until many minutes after the start of resuscitation. The volume of oxygen in the lungs is relatively great when arrest occurs suddenly.7

On the other hand, it might be detrimental not to provide rescue breathing in patients with other causes of cardiac arrest. Oxygenation may be more compromised over longer periods of declining circulation, such as when there is hypotension resulting in electromechanical disassociation or a prolonged period of bradycardia before asystole.

An even more radical suggestion is that in patients with sudden cardiac arrest caused by ventricular tachycardia or fibrillation, it may be beneficial to restore circulation with blood that is moderately unsaturated with oxygen rather than with well-oxygenated blood. Although in animal models of ventricular fibrillation, a prolonged period (i.e., 8 minutes) without ventilation is detrimental,8 recent observational clinical studies support the idea that hyperoxia during recovery from cardiac arrest is detrimental to patients.9 Studies of isolated cardiac-tissue specimens10 have raised the possibility that initial reperfusion with hypoxemic blood may result in fewer injurious oxygen free radicals and less reperfusion injury.

These are intriguing observations and hypotheses, but more research is needed. To my knowledge, definitive studies in animals of hypoxic reperfusion after ventricular fibrillation have not yet been performed. Although clinical observational studies support the relative benefit of compression-only CPR performed by EMS personnel on arrival, there is a need for a randomized study in this setting as well. Particular attention needs to be paid to whether the benefits of compression-only CPR are apparent primarily in cardiac arrest with initial ventricular tachycardia or fibrillation rather than arrest with other rhythms. It will also be important to study the subgroup of patients who undergo bystander-performed compression-only CPR followed by EMS-performed compression-only CPR. There is certainly a need for rescue breathing after a prolonged period of CPR; in such cases, should the rescue breathing be provided while continuous chest compression is performed or should compression be interrupted to provide greater ventilation? A large study might also address whether rescue breathing is of critical importance in patients whose cardiac arrest is not associated with ventricular tachycardia or fibrillation. The answers to these questions may be paradigm-shifting and will almost certainly be lifesaving.

Disclosure forms provided by the author are available with the full text of this article at


From the Department of Medicine, Johns Hopkins Medicine, Baltimore.

Myron L. Weisfeldt, M.D.

N Engl J Med 2010; 363:481-483July 29, 2010

Ganas de Chingar


Esta expresión puede acompañarse con las siguientes locuciones: ésas son, tengo unas, qué, ah pero qué, etcétera. Ésta es una frase que alude al deporte y gusto por chingar al otro. Uno puede tener ganas de chingar o simplemente nace con esa habilidad. A veces se pretende chingar con dolo y otras, sólo se hace por diversión o por costumbre.

<< - Lleva todo el día molestándome. De veras que ésas sí son ganas de chingar. >>

<< - Ah, qué ganas de chingar... Toma tu chicle y estate quieto de una vez.>>

<< - Dice que siempre no y que mejor cambies los dos ejemplos y, además, que lo ordenes alfabéticamente.

- Ah, pero ¡qué ganas de chingar!>>

Bueno con esto espero haberles robado una sonrisa, es un extracto que encontré en la revista Algarabía y que por alguna razón me recordó a la fauna que uno se encuentra en los hospitales.