Voltaire's Candide, medical students, and mentoring

In Voltaire's work, Candide, a young, naïve man, who has been taught that humans live in the best of all possible worlds, is thrust into the world only to find that this may not be so. He learns over time to balance his optimism with the skepticism he acquires through experience. While today's medical students are not naïve like the character Candide, they, nonetheless, carry an impression of the ideal medical practice, along with the expectation of a successful medical practice. Good mentors and role models are important to students in order to temper their optimism, control their skepticism, and to help them to be realistic, not only about their expectations of medical practice, but what society expects of them

The student and the ovum: The lack of autonomy and informed consent in trading genes for tuition

Rising tuition costs have forced university students to become creative in finding ways to fund their education. Some female university students have decided that ova donation may be an acceptable alternative in which to pay for their tuition. This alternative presents itself because of the insufficient number of ova available for assisted reproduction and emerging stem cell technologies. Young female university students are encouraged by Internet sources and respectable electronic and print media to donate their ova in the cause of assisted reproduction for monetary compensation. While university students generally exhibit autonomy, the constraining influence of their financial predicament compromises the elements of informed consent (voluntariness, competence, capacity, understanding, and disclosure) as to their making an autonomous decision in regard to egg donation. Thus, any moral possibility of giving informed consent is negated. Informed consent can only occur through autonomy. A female university student in need of financial resources to pay for her education cannot make an autonomous choice to trade her genes for tuition. Donated ova are not only needed for assisted reproduction, but for stem cell technologies. While the long-term health of women who donate their ova is of concern (a potential risk of cancer after long term use of ovulation induction), of equal concern is the possibility of a growth in the trade of ova targeting third world and Eastern European women where the precedence for autonomy and informed consent is not well established

Healthcare access as a right, not a privilege: a construct of Western thought

Over 45 million Americans are uninsured or underinsured. Those living in poverty exhibit the worst health status. Employment, education, income, and race are important factors in a person's ability to acquire healthcare access. Having established that there are people lacking healthcare access due to multi-factorial etiologies, the question arises as to whether the intervention necessary to assist them in obtaining such access should be considered a privilege, or a right. The right to healthcare access is examined from the perspective of Western thought. Specifically through the works of Aristotle, Immanuel Kant, Thomas Hobbes, Thomas Paine, Hannah Arendt, James Rawls, and Norman Daniels, which are accompanied by a contemporary example of intervention on behalf of the medically needy by the The Johns Hopkins Urban Health Institute. As human beings we are all valuable social entities whereby, through the force of morality, through implicitly forged covenants among us as individuals and between us and our governments, and through the natural rights we maintain as individuals and those we collectively surrender to the common good, it has been determined by nature, natural laws, and natural rights that human beings have the right, not the privilege, to healthcare access

Charles Dickens’ Hard Times and the Academic Health Center: A Tale of the Urban Working Poor and the Violation of a Covert Covenant, an American Perspective

Charles Dickens’ novel “Hard Times” focuses on the struggles of urban workers in 19th century England. The situations of workers in 21st century America are not dissimilar thus making Dickens’ commentary and characters applicable to the contemporary socioeconomic scene. The number of uninsured or underinsured poor in America is rising. AHCs must go beyond their traditional mission of patient care, education and research and embrace the local neighborhoods they serve. The urban location, technical expertise, and educational mission of many AHCs make them ideally suited to assist urban populations that are at great health risk. Many Academic Health Centers (AHCs) in America found their origins in working class neighborhoods, such as those described by Dickens, and today are surrounded by the urban poor. An argument is made that AHCs have a moral obligation to these neighborhoods; it is an implied, or covert, covenant that they are obliged to honor

Successful use of inhaled nitric oxide to decrease intracranial pressure in a patient with severe traumatic brain injury complicated by acute respiratory distress syndrome: a role for an anti-inflammatory mechanism?

Use of inhaled nitric oxide in humans with traumatic brain injury and acute respiratory distress syndrome has twice previously been reported to be beneficial. Here we report a third case. We propose that INO may decrease the inflammatory response in patients with increased intracranial pressure caused by traumatic brain injury accompanied by acute respiratory distress syndrome thereby contributing to improved outcomes

Labetalol infusion for refractory hypertension causing severe hypotension and bradycardia: an issue of patient safety

Incremental doses of intravenous labetalol are safe and effective and, at times, such therapy may need to be augmented by a continuous infusion of labetalol to control severe hypertension. Continuous infusions of labetalol may exceed the recommended maximum daily dose of 300 mg on occasion. We report a case in which hypertension occurring after an abdominal aortic aneurysm repair, initially responsive to intermittent intravenous beta-blockade, became resistant to this therapy leading to the choice of an intravenous labetalol infusion as the therapeutic option. The labetalol infusion resulted in a profound cardiovascular compromise in this postoperative critically ill patient. While infusions of labetalol have successfully been used, prolonged administration in the intensive care unit requires vigilance and the establishment of a therapeutic rationale/policy for interventions, such as the ready availability of glucagon, β-agonists, phosphodiesterase inhibitors, insulin, and vasopressin when severe cardiovascular depression occurs

Pulmonary bullet embolism – a safe treatment strategy of a potentially fatal injury: a case report

This is an Open Access article distributed under the terms of the Creative Commons Attribution Licens

Patient Safety Issues in Pathology: From Mislabeled Specimens to Interpretation Errors

Catastrophic breaches in patient safety often involve point-of-care settings such as the operating theater or intensive care unit, quite frequently without due consideration given to the elements leading up to such errors. Among such occurrences, wrong site procedures (WSPs) and diagnostic discrepancies continue to result in significant morbidity and mortality among patients. Addressing adverse events is difficult for all stakeholders involved. Furthermore, clinician familiarity with the workflow specific to particular disciplines or procedures may be poor, amplifying communication lapses that precede patient safety occurrences. The patient care paradigm has become increasingly multidisciplinary, and it is important to discuss, improve, and be more cognizant of measures required to achieve “zero defect” performance. Despite the rarity of “never events,” their consequences may damage patient and community trust, provider morale, and institutional reputation. This chapter aims to assess current preventive measures and risks in the context of errors involving surgical pathology in the setting of the operating theater utilizing the framework of clinical vignettes. The discussion below will further center on the practical and interpretative errors that occur in the pathological workflow, and the potential for compounding of such errors in the operating theater. Definitions concerning WSP and diagnostic discrepancies will be outlined to characterize potential outcomes of communication errors

Perniosis (chilblains) masquerading as CA-MRSA: a case report

Perniosis (chilblains) is a vasospastic, inflammatory disease that occurs when the skin is subjected to cold above the freezing point, under damp conditions. Erythematous (violaceous) blisters, ulcerations or pustules that sit on an edematous base, accompanied by pain, burning or itching, are usually evident. To the inexperienced clinician it may resemble community-associated methicillin-resistant Staphylococcus aureus and could lead to inappropriate treatment. Here we report such a case

Nonconvective Forces: A Critical and Often Ignored Component in the Echocardiographic Assessment of Transvalvular Pressure Gradients

Echocardiography is routinely used to assess ventricular and valvular function, particularly in patients with known or suspected cardiac disease and who have evidence of hemodynamic compromise. A cornerstone to the use of echocardiographic imaging is not only the qualitative assessment, but also the quantitative Doppler-derived velocity characteristics of intracardiac blood flow. While simplified equations, such as the modified Bernoulli equation, are used to estimate intracardiac pressure gradients based upon Doppler velocity data, these modified equations are based upon assumptions of the varying contributions of the different forces that contribute to blood flow. Unfortunately, the assumptions can result in significant miscalculations in determining a gradient if not completely understood or they are misapplied. We briefly summarize the principles of fluid dynamics that are used clinically with some of the inherent limitations of routine broad application of the simplified Bernoulli equation