The children’s hospital is not as bad as rumor painted it (although their computer system is strictly for the birds). There’s something to be said for having so many senior residents and fellows around that I am only responsible for floor patients – and I am by now very efficient at handling a large floor service.
It’s also fun to see entities which were previously the stuff of [textbook] legend showing up as large as life: gastroschisis, malrotation, intussusception, Meckel’s diverticulum – and lots of classic appendicitis. (Which is especially fun, because in pediatrics you try to avoid radiation as much as possible, so almost none of these kids get CT scans. Diagnosis and management are based on history and physical exam, with the occasional ultrasound. For a rarity, I got to book a patient for the OR simply on the basis of, “His abdomen is nearly rigid, and certainly requires urgent exploration.” No labs, no imagaing, just what my hands could tell me.)
For added fun, I stumbled across in the library (amazing how the books I like just pop up in front of me) an audio edition of Alison Weir’s Queen Isabella. Alison Weir is an English historian who writes detailed accounts of obscure medieval events, and manages to make them interesting. I first appreciated her for her defense of Richard III as innocent of the death of the Princes in the Tower (a private bias of my own; I always enjoy finding reputable evidence to support my romantic belief in Richard as hero). This book, while occupying 18 cds, and therefore valuable as promising to last for two months’s driving, seems a little biased. Admittedly, the story of Isabella (French princess, betrothed at 7, married at 12 to a homosexual 12 years older than her, she eventually ran away, took a lover, led an invasion of England, deposed (and allegedly murdered) her husband (Edward II), and ruled in her son’s name (Edward III) for years, till he came of age, killed her lover, and put her under house arrest till her death) lends itself to some feminist revision. However, the argument that we ought to regard Isabella in a better light, now that we can look back from the standpoint of modern sexual mores, seems a little weak. After all, Isabella did what she did in a society which certainly condemned adultery (especially by women, and regardless of excuses) and treason. The fact that 700 years later her behavior seems almost normal/rational/excusable doesn’t change the fact that it was wildly countercultural and dangerous at the time. Her choices were made in that setting, not under modern “enlightenment.” Nevertheless, I’m always up for a good story about international intrigue and the primal conflict between France and England (two nations that seem born to hate each other), and if Ms. Weir can stop mentioning male oppression in every other sentence (once a paragraph, perhaps?), this should be a fascinating book.
Cut On The Dotted Line 
December 7, 2008 at 10:55 pm
An ultrasound may indicate an appendicitis, but it can not rule it out.
December 17, 2008 at 12:37 am
It’s still possible to diagnose the vast majority of appys on the basis of H and P, and lab. Clearly, imaging is useful (but often non-definitive) in questionable situations, but I continue to feel imaging is over-used, for reasons of surgeon convenience (don’t call me till the CT is done) and medico-legal fears. I don’t deny, though, that making the diagnosis and acting on it absent imaging feels more and more like your are sticking it out there. But I persisted. WHen I felt the diagnosis was in the 90% range, I’d offer the patient imaging while explaining why I didn’t think it necessary. And I had the lowest negative appy rate in town. Call me old fashioned. And cost-effective.
December 7, 2009 at 1:13 am
I know this is an old post, but I found it while browsing through your book reviews, and… colour me bewildered. I’ve read Alison Weir’s ‘The Princes In The Tower’ and she comes out categorically as stating that the evidence is that Richard III *did* kill them. Unless you’re thinking of a different book altogether and confusing it with hers, I’m really baffled as to how you could conclude that she was saying the opposite.