MDCalc is fully international now, and you can now download it to your Pocket PC (Palm coming as soon as I can get my hands on one.)

Now featuring the CHADS2 score for Afib anticoagulation! Hell, here’s the whole list:

• A-a O ₂ Gradient
• Abs Neutrophil Count
• Abs Retic Count (Retic Index)
• Age
• Anion Gap (w/Delta Gap)
• Basal Energy Expenditure
• Bayes Sensitivty & Specificity
• Bicarb Deficit
• BMI/Surface Area
• Calcium Correction in Hypoalbuminemia
• Cockcroft-Gault GFR
• Cardiac Output (Fick)
• Corrected QT (QTc)
• Corrected Sodium
• CSF WBC Correction for RBCs
• Endotracheal Tube Size for Children
• FENa
• LDL (Calculated)
• Maddrey’s Discriminant Function
• Maintenance Fluids
• MDRD GFR
• Mean Arterial Pressure (MAP)
• Oxygenation Index
• Parkland Burns
• Pedi Ins & Outs
• Sodium Deficit
• Serum Osmolality
• Stool Osmolal Gap
• Water Deficit
• Winter’s Formula

• APGAR Score
• Cardiac Risk (Framingham)
• CHADS2 Score for Afib
• PORT Score / CAP Risk
• Glasgow Coma Score
• MELD Score
• Ranson’s Pancreatitis Mortality
• Strep Probability Score
• TIMI Score for UA/NSTEMI
• TIMI Score for STEMI
• Well’s Criteria for PE

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I guess I could’ve done this myself, but thanks to Kaiser for doing it. I’m starting to think, as our title states, that pretty much everyone should see this graph. It affects how people understand health care, health policy, the uninsured, Medicare, Medicaid, everything.

Ready?

Okay, I know it’s just a bar graph, but read it. Seriously. I’ll wait.

You’re not reading.

Okay fine. Look at that. The 5% sickest people in our country make up HALF of our costs. The HALF of us that are the healthiest make up 3.4% of our costs. And the sickest people aren’t generally people that you see and think “Wow, they look ill.” They’re 10 times sicker. They’re people that spend months–MONTHS–in an ICU. They get admitted for something serious, and then they get a hospital infection. Or they have something else bad happen to them. They’re incredibly, incredibly sick. They’re on 20+ medications. They’re probably at least 50, if not 60, 70, 80, or 90. They probably have diabetes, high blood pressure, high cholesterol.

So see? When all the Talking Heads talk about “Health Savings Accounts” and being in control of your health care dollars, they’re focusing on a leaking faucet when there’s a Niagara Falls right next door.

It has to make one question how we’re spending our healthcare dollars. We’re shooting ourselves in the foot. Instead of providing preventive care and basic primary care to people, we wait until they get so very sick that they end up in the Intensive Care Unit, on 20 drugs.

Instead of making sure they’re managing their diabetes (or preventing them from getting diabetes in the first place), we let them get sick.

And once they’re so sick that they’ll likely never recover, we can keep them alive almost indefinitely, with no quality to their lives, just so we can hope and pray that they’ll recover… instead of keeping them healthy.

Is this not quite possibly the worst way to run a health care system, or is it just me?

(Big thanks to Ezra Klein for pointing me to this .)

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So I’m doing research this year (specifically a chart review of VA patients with Afib, some of which have mental illness, and seeing if they’re less likely to receive warfarin, and so far, yes, it looks that way). It’s been a great experience thus far. My PI ( Private Principle Investigator) has essentially let me come up with my hypotheses, make the data collection sheet, and been an awesome mentor for the analysis process I’m finally doing. It’s low-stress, pretty simple stuff, and it’s been a real treat to actually have a life. So this is what my friends’ 20s feel like. Not bad.

But I miss medicine. I miss seeing patients. I miss the challenge of trying to figure out what’s wrong, what labs to order, all that. (I just don’t miss it 6 or 7 days a week.) I’m also amazed at how quickly I was losing my mad clinical skillz, but it makes sense, I guess–this early in the clinical medicine game, taking a year off will do that.

So I’ve been supplementing my knowledge with a weekly 8-hour ED shift. It’s a great immersion right into the thick of things, and just like a foreign language, everything has come back pretty quickly. I’m already learning new things, seeing new disease processes, and generally loving it (here I come, Emergency Medicine residency)!

The really, really nice thing about my setup is that I’m actually learning for learning’s sake, because I want to. OK, so I’ve always actually been that way, but I’m not getting the firehose sip-of-water. I can see my 5-6 patients, and any questions that I have about what I see I scribble down and read up when I get home. Percentage of kidney stone patients without blood in their urine? Learned it, ’cause it applied to my patient. Differential for scotomas, dizziness? Confirmed that I was on target (but forgot MS). How the hell does the pathophysiology go for hepatorenal syndrome? Read up on the theories.

In rotations, especially starting off, it’s a constant marathon. You work a 10-12 hour shift in the hospital, and then go home to read up on your patient and other diseases and treatments, because you have a big nasty test you have to pass. (And don’t forget your resident assigning you a topic to present to the team, or trying to bring in articles for the group to “show” people that you’re reading at night.) You can’t enjoy medicine at that speed–I don’t think you can enjoy anything at that speed. You’d get sick of it. (This was part of the reason I wanted to take time off, I was getting annoyed too easily and cynical or forgetting the patient is a person. That whole fun thing.)

I’ve also been trying to tackle a number of topics that I know I need to get down, but just didn’t have time during clerkships: advanced EKGs, radiology stuff, etc. So to wrap this guy up, here’s some good linkage if you want to brush up. (Also a final recommendation: if you can take a year off, do it! We’ll have plenty of years to be doctors!)

EKGs:

• The Web Brain for EKG Interp : Rocks. Dunno if it’s just that it’s the 10th time I’ve seen this stuff, but it finally makes sense now. Has all the different types of beats and complexes on one little strip, so you can easily compare them and see differences.
• EKG tests , a bunch more , and a bunch more . And no, wait, there’s more
• The ECG Library can show you pretty much any rhythm or block there is. Nice when you can’t remember what something looks like.

Rads:

• A new great site is radpod (Radiology Picture of the Day) –and yes, it’s rad. The author emailed me about it, and I’m a fan–already added it to the RSS feed. Has a nice Radiology image every day, with a short description. Coming soon: Arrows, so I know what I’m looking at.
• And I can’t praise Learning Radiology enough. Flash presentations on reading all types of films and scans, cases of the week. Totally rocks.

And don’t forget the Clinical Cases Blog , always a great resource. Enjoy!

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