Pain management

Hey, remember all the fun we had on Vioxx? It seems that, just yesterday, we were pain-free and guiaic-negative.

As you may have heard, Merck pulled Vioxx was pulled from the market today, after the APPROVe study showed long-term users of Vioxx were more likely to suffer heart attacks and strokes than patients on placebo.

Kevin MD is all over this. And Medpundit asks a good question -- could the increased risk of heart attack and stroke come from the lack of aspirin? The data's not published yet, but it seems like classmate Celebrex doesn't have these risks.

So, osteoarthritis patients will start switching, and public health will concomitantly improve. Or will it? On Wall Street today, Merck (NYSE: MRK) stock fell 27%. How many shareholder heart attacks did that cause?


Hey, remember all the fun we had on Tuesday?

Grand Rounds reached #11 on the Blogdex "most contagious" list. Many, many eyeballs flowed in from Instapundit and Roger L. Simon, for which I am much obliged. And from the sitemeter data, a fair number of the instalanchers stuck around, even browsed the archives. Let's hope they found some new medical blogs to enjoy, and that they come back for more.

Maybe the best part was seeing medical professionals, including many I'd never heard of before, come out of the woodwork to link to the site. I suspect Galen & co will have their hands full sorting through submissions next week. If the quality of the writing stays high, and we continue to get mainstream blog publicity, Grand Rounds will thrive.


As Gruntdoc noted (in the comments to this anecdote), not all drunk patients are polite. Still, my experience with intoxicated patients in the ED has been pretty benign, mostly because of kind staffs working to shield students from abuse.

Sometimes, though, students can learn from a distance. On an overnight shift, we had a drunk guy come in from from an assault. He was rude, vulgar, and demanding. Healthwise, he was quickly cleared, but he didn't want to leave Emergency because, as he loudly claimed, "I have nowhere to go! If I go home my mom's going to have me arrested!"

Every now and then he'd shout about his bizarre predicament to anyone passing by. As the hours wore on, the whole department became acutely aware of his situation.

Finally, at around 5 AM, he had a breakthrough. "I know where I can go! Hey, doc, it's ok now! I know where I can go!"

Everyone kept about their business, but a few of us cracked smiles. Stiffling a giggle, the resident turned to the attending, "So, uh... he knows where he can go."

The attending put to words what we were all thinking: "He can go to hell. And make sure to note that on the discharge paperwork."

Grand Rounds Archive & Upcoming Schedule

Grand Rounds is the weekly summary of the best healthcare writing online, featuring stories, opinion and analysis from doctors, nurses, patients, researchers and administrators, and journalists.

Each Tuesday, a different blogger takes the helm, publishing a new edition of Grand Rounds on their site. Each edition features the host’s picks for the ten best healthcare links of the week.

Add your name to the email subscriber’s list, to learn the location of each week’s edition.

Follow us on Twitter for links to GR editions, highlights and discussion led by each week’s host

Like us on Facebook for another convenient way to learn who’s hosting.

Promote GR on your blog, with our slick widget or a Grand Rounds button

Want to host Grand Rounds at your site? Drop us a line.

Future hosts of Grand Rounds can be found in the embedded Google Calendar below:

Previous hosts are listed below:

Week 1 09/28/04 hosted @ Blogborygmi
Week 2 10/05/04 hosted @ Galen's Log
Week 3 10/26/04 hosted @ Kevin, M.D.
Week 4 10/12/04 hosted @ EchoJournal
Week 5 10/19/04 hosted @ Code Blog: Tales of a Nurse
Week 6 11/02/04 hosted @ MedPundit(U.S. Election Day edition)
Week 7 11/09/04 hosted @ GruntDoc
Week 8 11/16/04 hosted @ MedRants
Week 9 11/23/04 hosted @ Shrinkette
Week 10 11/30/04 hosted @ DoctorMental
Week 11 12/07/04 hosted @ Doctor Charles (First Top-Ten list)
Week 12 12/14/04 hosted @ Parallel Universes (First International host)
Week 13 12/21/04 hosted @ Code Blue Blog
Week 14 12/28/04 hosted @ Code Blog: Tales of a Nurse ("Twenty Days of Grand Rounds" singalong)
Week 15 01/04/05 hosted @ Rangel, M.D. (Hospital Departments theme)
Week 16 01/11/05 hosted @ Medical Madhouse (Scut Hall theme)
Week 17 01/18/05 hosted @ Waking Up Costs (Medical Errors theme)
Week 18 01/25/05 hosted @ A Chance to Cut...
Week 19 02/01/05 hosted @ Daily Capsules
Week 20 02/08/05 hosted @ MedMusings
Week 21 02/15/05 hosted @ Sumer's Radiology Site
Week 22 02/22/05 hosted @ Catallarchy
Week 23 03/01/05 hosted @ Intueri (a la carte theme)
Week 24 03/08/05 hosted @ Hospice Blog (Hospice Care theme)
Week 25 03/15/05 hosted @ Respectful Insolence (TV Listings theme)
Week 26 03/22/05 hosted @ The Well-Timed Period
Week 27 03/29/05 hosted @ Grahamazon (Tabloids! theme)
Week 28 04/05/05 hosted @ Polite Dissent (comic book theme)
Week 29 04/12/05 hosted @ GruntDoc

Week 30 04/19/05 hosted @ GrrlScientist
Week 3104/26/05 hosted @ Dr. Tony
Week 3205/03/05 hosted @ Mudfud (A Day in the Life...)
Week 3305/10/05 hosted @ Azygos
Week 3405/17/05 hosted @ Galen's Log
Week 3505/24/05 hosted @ Iatremia: The Chaplin.News (Quotables theme)
Week 3605/31/05 hosted @ Dr. Sanity (Leonardo: Medicine & Art)
Week 3706/07/05 hosted @ Medgadget (Pomp & Circumstance theme)
Week 3806/14/05 hosted @ Red State Moron
Week 3906/21/05 hosted @ A Chance to Cut...
Week 4006/28/05 hosted @ Health Business Blog
Week 4107/05/05 hosted @ Medical Connectivity
Week 4207/12/05 hosted @ Shrinkette
Week 4307/19/05 hosted @ Aggravated DocSurg
Week 4407/26/05 hosted @ Pharyngula(Analysis of What Medbloggers Do)
Week 4508/02/05 hosted @ Alois, M.D.
Week 4608/09/05 hosted @ Dr. Emer
Week 4708/16/05 hosted @ Circadiana
Week 4808/23/05 hosted @ Straight From the Doc
Week 4908/30/05 hosted @ Healthy Concerns
Week 5009/6/05 hosted @ Corpus Callosum
Week 5109/13/05 hosted @ Sneezing Po(A Virtual Gallery)
Week 5209/20/05 hosted @
Volume 2, No. 109/27/05 hosted @ Docnotes
Vol. 2, No. 210/04/05 hosted @ The Haversian Canal
Vol. 2, No. 310/11/05 hosted @ Doulicia(Medicine & Law)
Vol. 2, No. 410/18/05 hosted @ Diabetes Mine(Hospital Departments theme)
Vol. 2, No. 510/25/05 hosted @ Hospital Impact(Letter from the House Staff)
Vol. 2, No. 611/1/05 hosted @ KidneyNotes
Vol. 2, No. 711/08/05 hosted @ MSSPNexus("Dammit, Jim" theme)
Vol. 2, No. 811/15/05 hosted @ Mr. Hassle's Long Underpants
Vol. 2, No. 911/22/05 hosted @ Code Blog: Tales of a Nurse
Vol. 2, No. 1011/29/05 hosted @ Over My Med Body(Thanksgiving theme)
Vol. 2, No. 1112/06/05 hosted @ The Examining Room of Dr. Charles
Vol. 2, No. 1212/13/05 hosted @ In the Pipeline
Vol. 2, No. 1312/20/05 hosted @ MedPundit
Vol. 2, No. 1412/27/05 hosted @ The Health Care Blog(best of 2005)
Vol. 2, No. 15 01/03/06 hosted @ Random Acts of Reality
Vol. 2, No. 1601/10/06 hosted @ Clinical Cases and Images - Blog
Vol. 2, No. 1701/17/06 hosted @ GruntDoc
Vol. 2, No. 1801/24/06 hosted @ Kevin, M.D.
Vol. 2, No. 1901/31/06 hosted @ Barbados Butterfly
Vol. 2, No. 2002/07/06 hosted @ Science & Politics
Vol. 2, No. 2102/14/06 hosted @ Intueri(Valentine's Personals)
Vol. 2, No. 2202/21/06 hosted @ Dr. Andy(Impressions of Spring)
Vol. 2, No. 2302/28/06 hosted @ A Chance to Cut...(Surgeon & Painter Joseph Wilder)
Vol. 2, No. 2403/07/06 hosted @ Emergiblog(GR in the ER)
Vol. 2, No. 2503/14/06 hosted @ GeekNurse
Vol. 2, No. 2603/21/06 hosted @ Healthy Concerns
Vol. 2, No. 2703/28/06 hosted @ NHS Blog Doctor(Cricket theme)
Vol. 2, No. 2804/04/06 hosted @ UroStream(History and Physical)
Vol. 2, No. 2904/11/06 hosted @ Anxiety, Addiction and Depression Treatments
Vol. 2, No. 3004/18/06 hosted @ Fat Doctor
Vol. 2, No. 3104/25/06 hosted @ Health Business Blog
Vol. 2, No. 3205/02/06 hosted @ Polite Dissent
Vol. 2, No. 3305/09/06 hosted @ Aetiology
Vol. 2, No. 3405/16/06 hosted @ Doc Around the Clock
Vol. 2, No. 3505/23/06 hosted @ Parallel Universes(Medical Journal theme)
Vol. 2, No. 3605/30/06 hosted @ KidneyNotes
Vol. 2, No. 3706/06/06 hosted @ The Medical Blog Network
Vol. 2, No. 3806/13/06 hosted @ The Haversian Canal
Vol. 2, No. 3906/20/06 hosted @ Psychological Perspectives(Movie theme)
Vol. 2, No. 4006/27/06 hosted @ MedViews
Vol. 2, No. 4107/04/06 hosted @ Rangel, M.D.(US health problems theme)
Vol. 2, No. 4207/11/06 hosted @ DonorCycle
Vol. 2, No. 4307/18/06 hosted @ ChronicBabe("It's all about the ladies" theme)
Vol. 2, No. 4407/25/06 hosted @ Medical Humanities(Garden metaphor)
Vol. 2, No. 4508/01/06 hosted @ Inside Surgery
Vol. 2, No. 4608/08/06 hosted @ Mexico Medical Student(Cultural and Musical Convergence)
Vol. 2, No. 4708/15/06 hosted @ Hospital Impact(Letter to a Newborn)
Vol. 2, No. 4808/22/06 hosted @ The Examining Room of Dr. Charles(100th edition)
Vol. 2, No. 4908/29/06 hosted @ Protect The Airway(GR in the ER)
Vol. 2, No. 5009/05/06 hosted @ Clinical Cases and Images - Blog(Medical Journal theme)
Vol. 2, No. 5109/12/06 hosted @ Diabetes Mine(Education theme)
Vol. 2, No. 5209/19/06 hosted @ Tundra Medicine Dreams
Vol. 3, No. 109/26/06 hosted @ Healthline / Enoch Choi(Anniversary Party theme)
Vol. 3, No. 210/03/06 hosted @ RDoctor Medical
Vol. 3, No. 310/10/06 hosted @ Unbounded Medicine
Vol. 3, No. 410/17/06 hosted @ EmergiBlog(Starbucks theme)
Vol. 3, No. 510/24/06 hosted @ Health Care Law Blog
Vol. 3, No. 610/31/06 hosted @ Dr. Hebert's Medical Gumbo(Halloween edition)
Vol. 3, No. 711/07/06 hosted @ MSSP Nexus(M*A*S*H theme)
Vol. 3, No. 811/14/06 hosted @ The Rumors Were True(The Holy Grail of GR)
Vol. 3, No. 911/21/06 hosted @ Doctor Anonymous
Vol. 3, No. 1011/28/06 hosted @ Dr. RW
Vol. 3, No. 1112/05/06 hosted @ The Antidote
Vol. 3, No. 1212/12/06 hosted @ Treatment Online
Vol. 3, No. 1312/19/06 hosted @ Nurse Ratched's Place(A Charlie Brown Grand Rounds)
Vol. 3, No. 1412/26/06 hosted @ Blogborygmi
Vol. 3, No. 1501/02/07 hosted @ Musings of a Distractible Mind(Explosions theme)
Vol. 3, No. 1601/09/07 hosted @ Dr. John La Puma(Diet and Food theme)
Vol. 3, No. 1701/16/07 hosted @ Six Until Me(A 'Real' Poem)
Vol. 3, No. 1801/23/07 hosted @ Signout(Evidence theme)
Vol. 3, No. 1901/30/07 hosted @ Envisioning 2.0(Consumer-Driven Healthcare theme)
Vol. 3, No. 2002/06/07 hosted @ Tales from the ER and beyond...(People Behind Medicine theme)
Vol. 3, No. 2102/13/07 hosted @ Chronic Babe(Give Me Some Sugar theme)
Vol. 3, No. 2202/20/07 hosted @ Pure Pedantry(Oscars theme)
Vol. 3, No. 2302/27/07 hosted @ Musings of a Dinosaur(Not Dead Yet theme)
Vol. 3, No. 2403/06/07 hosted @ Grunt Doc
Vol. 3, No. 2503/13/07 hosted @ Science Roll(Monty Python Medicine)
Vol. 3, No. 2603/20/07 hosted @ Blog, MD
Vol. 3, No. 2703/27/07 hosted @ MedViews
Vol. 3, No. 2804/03/07 hosted @ Urostream
Vol. 3, No. 2904/10/07 hosted @ Dr. Dork
Vol. 3, No. 3004/17/07 hosted @ Fat Doctor
Vol. 3, No. 3104/24/07 hosted @ Med Valley High(A Space Odyssey theme)
Vol. 3, No. 3205/01/07 hosted @ ShrinkRap(Bring Your Own Brain)
Vol. 3, No. 3305/08/07 hosted @ The Blog That Ate Manhattan
Vol. 3, No. 3405/15/07 hosted @ Medical Humanities Blog
Vol. 3, No. 3505/22/07 hosted @ ImpactED Nurse(Proudest theme)
Vol. 3, No. 3605/29/07 hosted @ From MedSkool
Vol. 3, No. 3706/05/07 hosted @ Inside Surgery
Vol. 3, No. 3806/12/07 hosted @ Dr. Val & the Voice of Reason
Vol. 3, No. 3906/19/07 hosted @ Code Blog: Tales of a Nurse(Advice Column theme)
Vol. 3, No. 4006/26/07 hosted @ Wandering Visitor (Inspirational theme)
Vol. 3, No. 4107/03/07 hosted @ Over My Med Body(American Independence theme)
Vol. 3, No. 4207/10/07 hosted @ Aetiology
Vol. 3, No. 4307/17/07 hosted @ Vitum Medicinus
Vol. 3, No. 4407/24/07 hosted @ Laurie Edwards
Vol. 3, No. 4507/31/07 hosted @ Health Business Blog
Vol. 3, No. 4608/07/07 hosted @ Eye On DNA(Beach House theme)
Vol. 3, No. 4708/14/07 hosted @ Med Journal Watch(Sudden Change theme)
Vol. 3, No. 4808/21/07 hosted @ Med Source(Back-to-School theme)
Vol. 3, No. 4908/28/07 hosted @ Rickety Contrivances of Doing Good
Vol. 3, No. 5009/04/07 hosted @ Parallel Universes
Vol. 3, No. 5109/11/07 hosted @ The Efficient MD(Health Innovations theme)
Vol. 3, No. 5209/18/07 hosted @ Six Until Me(Food Shopping theme)
Vol. 4, No. 109/25/07 hosted @ Kevin, MD
Vol. 4, No. 210/02/07 hosted @ Musings of a Distractible Mind(Dr. Seuss theme)
Vol. 4, No. 310/09/07 hosted @ Nurse Ratched's Place(Military medicine theme)
Vol. 4, No. 410/16/07 hosted @ NY Emergency Medicine(Emergency theme)
Vol. 4, No. 510/23/07 hosted @ PalliMed(Prognostication theme)
Vol. 4, No. 610/30/07 hosted @ Running a Hospital
Vol. 4, No. 711/06/07 hosted @ Counting Sheep
Vol. 4, No. 811/13/07 hosted @ Doctor Anonymous
Vol. 4, No. 911/20/07 hosted @ Mexico Medical Student(Thanksgiving theme
Vol. 4, No. 1011/27/07 hosted @ Prudence, MD
Vol. 4, No. 1112/04/07 hosted @ Enoch Choi's MedHelp Site
Vol. 4, No. 1212/11/07 hosted @ Odysseys of George(Diving theme)
Vol. 4, No. 1312/18/07 hosted @ Trick Cycling for Beginners(Haiku!)
Vol. 4, No. 1412/25/07 hosted @ Medgadget(Holidays in the Hospital theme)
Vol. 4, No. 1501/01/08 hosted @ Other Things Amanzi
Vol. 4, No. 1601/08/08 hosted @
Vol. 4, No. 1701/15/08 hosted @ Sharp Brains(Letter to next US President)
Vol. 4, No. 1801/22/08 hosted @
Vol. 4, No. 1901/29/08 hosted @ Emergiblog(Beatles theme)
Vol. 4, No. 2002/05/08 hosted @ DiabetesMine(The Health 2.0 Explosion)
Vol. 4, No. 2102/12/08 hosted @ Health Blawg(Valentine's Day theme)
Vol. 4, No. 2202/19/08 hosted @
Vol. 4, No. 2302/26/08 hosted @ ScienceRoll(The Future of Medicine theme)
Vol. 4, No. 2403/04/08 hosted @ Chronic Babe(New Beginnings theme)
Vol. 4, No. 2503/11/08 hosted @ Canadian Medicine
Vol. 4, No. 2603/18/08 hosted @ Polite Dissent("The Roundup" theme)
Vol. 4, No. 2703/25/08 hosted @ Monash Medical Student(Medical Missions theme)
Vol. 4, No. 2804/01/08 hosted @ Grand Rounds Fiasco(April First theme)
Vol. 4, No. 2904/08/08 hosted @ Dr. Wes(Cardiac theme)
Vol. 4, No. 3004/15/08 hosted @ Women's Health News
Vol. 4, No. 3104/22/08 hosted @ Dr. Val Jones & the Voice of Reason(Emotional theme)
Vol. 4, No. 3204/29/08 hosted @ Doc Gurley(Grand Rounds Smackdown)
Vol. 4, No. 3305/06/08 hosted @ Suture for a Living
Vol. 4, No. 3405/13/08 hosted @ Health Business Blog
Vol. 4, No. 3505/20/08 hosted @ Musings of a Dinosaur(Let There Be Grand Rounds theme)
Vol. 4, No. 3605/27/08 hosted @ Parallel Universes
Vol. 4, No. 3706/03/08 hosted @ Happy Hospitalist(Degrees of Separation theme)
Vol. 4, No. 3806/10/08 hosted @ NHS Blog Doctor
Vol. 4, No. 3906/17/08 hosted @ Marianas Eye Blog
Vol. 4, No. 4006/24/08 hosted @ Shrink Rap(iPhone theme)
Vol. 4, No. 4107/01/08 hosted @ Covert Rationing Blog(Independence theme)
Vol. 4, No. 4207/08/08 hosted @ The Blog that Ate Manhattan(Seinfeld theme)
Vol. 4, No. 4307/15/08 hosted @ Unprotected Text
Vol. 4, No. 4407/23/08 hosted @ Grunt Doc
Vol. 4, No. 4507/30/08 hosted @ Edwin Leap
Vol. 4, No. 4608/05/08 hosted @ Pure Pedantry
Vol. 4, No. 4708/12/08 hosted @ Medical Humanities Blog
Vol. 4, No. 4808/19/08 hosted @ Six Until Me
Vol. 4, No. 4908/26/08 hosted @ Rural Doctoring
Vol. 4, No. 5009/02/08 hosted @ A Chronic Dose
Vol. 4, No. 5109/09/08 hosted @ Apple Quack
Vol. 4, No. 5209/16/08 hosted @ Nurse Ratched's Place
Vol. 5, No. 109/23/08 hosted @ Dr. Val
Vol. 5, No. 209/30/08 hosted @ Monash Medical Student
Vol. 5, No. 310/07/08 hosted @ MDOD
Vol. 5, No. 410/14/08 hosted @ Notes of an Anesthesiologist
Vol. 5, No. 510/21/08 hosted @ Pallimed
Vol. 5, No. 610/28/08 hosted @ Emergiblog
Vol. 5, No. 711/4/08 hosted @ Nurse Ratched's Place
Vol. 5, No. 811/11/08 hosted @ Musings of a Distractible Mind
Vol. 5, No. 911/18/08 hosted @ Dr. Deb
Vol. 5, No. 1011/25/08 hosted @ Canadian Medicine
Vol. 5, No. 1212/09/08 hosted @ Sharp Brains
Vol. 5, No. 1312/16/08 hosted @ A Chronic Dose
Vol. 5, No. 1412/23/08 hosted @ Highlight Health
Vol. 5, No. 1512/30/08 hosted @ Monedeuloides

Grand Rounds

Welcome to the debut of Grand Rounds, the weekly summary of the best of the medical blogosphere. It's our hope that this new feature will introduce a wider audience to the expanding array of talented doctors, nurses, techs and students writing online today.

This week, we've got a roundup of new medical reports, opinions on current health topics, and a look into several medical specialties. Plus, some stories from caregivers to make you laugh, cry, or spur the contemplation of your mortality. On to the links...

New Studies:

Code Blue Blog interprets the recent findings about MRIs and breast cancer screening. Sure, the expensive MRI is more sensitive than mammography, but it has more false positives. His recommendation (and you might notice this trend with medibloggers): let individuals decide! (And pay.)

Did you ever wonder why dogs sniff fire hydrants? Would you believe they're screening for disease amongst their canine friends. Well, probably not. But Rob Thomas at AlmostMD explains the news that dogs can smell bladder cancer in our urine, and the implications for more ... refined detection.

Mighty Medpundit casts a skeptical eye on the recent hype about the Mediterranean diet. Is it olive it's cracked up to be? You'd feta take a look! (Sorry. I'm Greek.)

There's new controversy regarding teens taking antidepressants. Dr. James Baker, child psychiatrist, weighs in on the comparative risks.

Health Care Views:

Grahamazon's been busy studying pharmacology. Maybe that's where he learned about this lifesaving but unprofitable drug, which was discontinued until it found a new application in cosmetics. Because sometimes, people can be ugly.

Kevin, MD brings up a medical conversation that doesn't happen enough: Patients don't like to admit they can't afford their meds, or are taking them inconsistently. So doctors don't inform them of their options. Bad outcomes result.

Also writing on drug costs, Dr. Bob at MedRants proposes a free-market solution to for pharmaceuticals: Make pricing and transparent, and consistent, so patients can weigh cost along with dosing regimens and side effects. Which should work great, until double coupon day on Monday.

For a Kerry / Edwards supporter, Rangel, MD sure has problems with tort lawyers. He examines how tort reform in Texas has lowered medical insurance rates, and compares it to the hurricanes in Florida (in the analogy, I think the doctors are represented by beachfront property).

Dr. Bard-Parker, the surgeon at Cut-to-cure, carves up the latest report on deaths caused by hospital errors. Analysis: The report doesn't disclose all its methods, and makes mistakes. Kind of like hospitals! So I must warn: reading it could kill you.

Notes from the Front Lines:

"How much longer do I have, doc?" Short answer: It's difficult to say! But whatever your prognosis, the time will just fly by when you read the Cheerful Oncologist.

One of the blogging docs at EchoJournal puts to rest many of the misconceptions about anesthesiology. Get it? Put to rest? Anesthesia? It's not going to get better than that, people.

Cameron over at ThreeMD draws on all his medical student knowledge to make a rare diagnosis... Can you guess how this extraordinary insight will alter the patient's outcome? (hint: doctors are very lucky the body often heals itself)

Computers are making their way into the psychiatrist's office. It's there to make things run faster, but will it disrupt the doctor / patient rapport? I suspect the answer is no, unless Shrinkette starts blogging while her patient's on the couch.

If a picture is worth a thousand words, these scrap paper doodlings from a manic patient are worth... several thousand words... jumbled together. And now, you can imagine what mania might be like. Via Grunt Doc.

The surgery student at Vertical Mattress dwells on his various symptoms, but somehow elevates it from hypochondriasis to... literature! The beautiful Proust quote helps.

In a somewhat related post at our group blog, the Lingual Nerve, spacefan notes that this tendency for medical students to over-interpret their own symptoms gives way to a doctor's stubborn refusal to acknowledge them. My own untreated pain -- something I can look forward to.

Galen's developed a choose-your-own-adventure hospitalist simulator. See what it's like to run around the hospital, at the mercy of the specialists. Keep an eye on the clock, and remember that you're always one move away from a jury of your peers.

Case Reports

Azygos has a moving post about his dying patient, Harry.

Top-of-my-head is an ER nurse who submitted an old but instructive tale about a heart attack in a young man. I thought readers might like a story a little more racy.

Of course, that doesn't compare to EMT Tom Reynolds' tale of madness, violence, and sex (ambiguous as the sex might be).

That wraps up this week's highlights of the medical blogosphere. If you liked any of these blogs, keep visiting them! Tell the authors! Bookmark them! Because, as others have noted, medical information doesn't translate well to TV spots and blurbs. Why not skip the media, and find what the practitioners in the field think?

Be sure to tune in next Tuesday, when Grand Rounds will be hosted at Galen's Log.

Red Tape and Clear Taps

Galen's got a good post about bureaucracy and self-perpetuation, which quotes Max Gammon:

Note that bureaucracies are not about outputs. They are about process. And it's been known since Weber's time that bureaucracies take on lives of their own. They're like one-celled organisms. Their only objective is survival. And survival in a bureaucracy is not about output but about process.

He's writing about national health care, but it applies to other fields, as well. I'm reminded me of my classmate, who's been on a "research rotation" in radiology. But it took him weeks to set it up, get the clearances, sign the waivers, and get the permission to view the films. Two and a half weeks into the four-week rotation, he could finally get underway. Doc Shazam has blogged about a similar experience.

Contrast this to my elective, out-of-state ED rotation, which involved some minor paperwork and mailings a month beforehand. When the time came to start, I just walked into the hospital with my white coat, introduced myself, and asked if I could help. Someone handed me a long needle, and told me to get some spinal fluid from the patient in room 14. I was off and running within minutes! (though the screams still haunt me)

I'm grappling with a branch of the research bureacracy now. I've been trying to submit this case for publication, and the process of adapting my writeup to the journal's standards has been mind-numbing. There's actually a 17-part checklist with instructions like:

In the cover letter include (1) statement on authorship responsibility, (2) statement on financial disclosure, (3) 1 of the 2 statements on copyright or federal employment, and (4) a statement of acknowledgment. Each of the first 3 statements must be read and signed by all authors. The corresponding author must sign the acknowledgment statement. (See the form at the end of these Instructions.)

After I collect the signatures I'm required to snail-mail the journal a floppy, like our brave forefathers did in 1989. And don't get me started about the formatting of legends and figures, which must "be in a CMYK color space." It sounds like Dianetics.

Contributing to the scientific literature shouldn't be effortless, but it's not like this byzantine process eliminates fraud. Because the output of research rotations and case writeups isn't as easily quantified as the output from spinal taps, more emphasis is placed on bureaucratic "process" and administration.

With the proliferation of scientific journals, increased funding, and growing armies of administrators, it should be getting easier to conduct and publish research. But I've been doing this for ten years now and, if anything, it's gotten harder.

He shoots, he scores

Lileks, the accomplished columnist, blogger, and guest conductor, indulges himself (and closeted Star Trek fans everywhere) on the score for the "Doomday Machine" episode.

I think this will be the stupidest, most geeked-out thing I’ve ever written. I think I need an intervention: dude, it was one cheesy episide of one cheesy show. Give it up. But if you’ve ever spent 30 years looking for a particular piece of music – and found it! – then you might understand why I feel compelled to explain, once and for all...

When I first saw that episode, at around age five or six, it gave me an unhealthy fear of ice cream cones. And though I didn't recognize it at the time, it was the music that inspired those emotions (far more than the comical special effects).

Anyway, you can expect my post on the melancholy violins at the end of "Q Who" sometime around 2019.

Closing time

One overnight on trauma, I was suturing a long gash in a young man's leg. He was a passenger in a drunk driving accident, and was somewhat intoxicated himself. He kept apologizing profusely, though for what I wasn't sure.

Finally, he elaborated: "It's so late. I'm sorry to be keeping all the doctors here." Apparently, he thought our Level I Trauma Center would've shut its doors at 11 PM, if not for his thigh laceration. I informed him we're always open, and it was better for me to be working & learning than sitting on my hands for the whole shift.

He asked, "Nothing but emergencies, all day and all night?"

Yes. And I'm going to miss it next month.

Grand Rounds Submission Guidelines

Building from comments and questions from the earlier announcements, here's the comprehensive submission guidelines to next week's Grand Rounds.

  • submissions are due by 11:59 PM EST Monday night 9/27
  • Grand Rounds will posted on Tuesday 9/28 at 7 AM
  • Send nick -at- the link to your post, the title, and a brief description
  • One entry per blogger
  • Recent posts between 400 and 1000 words are preferred
  • Posts are to be written for a general audience (more on this below)

  • I'll be organizing the links into categories, based on what's submitted. Potential topics include:

  • Patient encounters -- something that made you laugh, cry, or gaze into the abyss
  • A profile of someone in medicine
  • Medical education -- experiences, insight, generalizations
  • Implications of a new basic science discovery
  • Commentary on a new study

    -- what it means for patients and practitioners
    -- why this new test / device / pill will save us / bankrupt us / kill us in our sleep

  • Commentary on health care delivery

    -- an experience you've had with a limitiation or success of the system
    -- your theories about what would improve access, outcomes
    -- something new and interesting about insurance, malpractice, regulations
    -- drug companies, and why they're so evil and / or saving lives
    -- why recent data about health care is all wrong / fine as is / not discouraging enough

  • Remember, the target audience here is NOT other medical bloggers, or people in the health care industry. It's the educated but nonmedical readers coming from general-interest blogs. So write for that audience, if only for this one post (even if your blog is about echocardiography). The idea is to introduce the wider world to the growing medical blogosphere -- the doctors, nurses, students, administrators, EMTs, techs, and patients who blog.

    More on style of the opinions pieces: I'm looking for informative, well-argued posts, from diverse political perspectives. One-sided screeds? Not so much (unless it's really entertaining).

    Two questions that are frequently asked:

    1. Is Grand Rounds just limited to bloggers in the health care field? No -- I'll look at any medical-related post. There are some patient-perspective blogs in particular that I hope submit links. But like I said, the point of Grand Rounds is to promote the nascent medical blogosphere, and submissions from health-related blogs will take priority.

    2. I'm a doctor / nurse / researcher / student / EMT / health care economist / patient who writes mostly about gardening / dating / reality television. Will you link to my post? Maybe. I'll certainly look at it, if it's medically related. And very few blogs are 100% medicine. But like I said, submissions from mostly health-focused blogs will take priority.

    It's the host's discretion as to what gets included. This week, that's me. In addition to linking to your posts, I'll be providing the groan-inducing puns, and snarky comments, that readers have come to expect and dread. It's nothing personal.

    If you're looking for more guidance, check out other linkfests such as Carnival of the Vanities. Grand Rounds was conceived as along those lines, like a Carnival of the Caregivers.

    If you've got more questions, email me or comment below! And we're looking for hosts for October 12, 19, and 26th. I look forward to your submissions!

    Groundswell for Grand Rounds

    The medical blogosphere continues to garner support and enthusiasm from other bloggers. Tech writer Jon Udell remarks:

    From the get-go, I knew that blogging was bound to disrupt information monopolies not only in IT and politics, but in other realms too. Now it appears that the medical blogosphere, something I've long expected, is finally emerging.

    ...In the long run there will be many more people hungry for informed analysis of medical issues than for informed analysis of tech issues.

    This looks like a great opportunity to watch the blogging meme replicate throughout another community of practice. I'll be fascinated to see how it changes, but also is changed by, that community.

    I hope he's watching next week! Regarding the upcoming first Grand Rounds, critical care nurse Alwin Hawkins writes

    ...I agree that there isn't an Instapundit of the medblog world, but that may change soon. Grand Rounds ... may be one of the breakthrough features that brings the medlog web to prominence.

    That's the plan.

    Conscience Objectors

    There was a solid discussion over at MetaFilter the other day, around this article about several "conscience clause" bills making their way through US legislatures. The article includes a tale from earlier this year, about a pharamacist who refused to prescribe emergency contraception to a rape victim. The MeFites responded by breaking down some arguments, extrapolating others, and everything in between.

    I find this debate interesting for a couple of reasons: first, because the chaos that would befall my hospital if the staff chose which patients to treat is a morbid fascination (and, fortunately, something likely to remain in the realm of imagination).

    Second, because the debate over pharmacists' rights, with respect to emergency contraceptions, forces some logical contortions: Suddenly, pro-life groups are asking to keep the law out of a private matter of conscience. Of course, these same people would jump at the chance to make abortion illegal, regardless of one's private feelings. Neat, huh? But everyone's got an agenda:

    Lourdes Rivera, who assists low-income patients as director of the Los Angeles-based National Health Law Program, worries that anti-abortion health providers are gaining too much leeway.

    "Yes, we need to respect individual freedom of religion. But at what point does it cross the line of not providing essential medical care? At what point is it malpractice?" she asked. "If someone's beliefs interfere with practicing their profession, perhaps they should do something else."

    This can be interpreted as inconsistent with pro-choice doctrine -- a woman has domain over her body, but pharmacists must do the bidding of the state. Yet Rivera's advice strikes me as exactly right, and exactly why these conflicts of service don't grind society to a halt: People tend to choose jobs that don't compromise their beliefs.

    But I think any job can ultimately put someone in such a position (the MeFites propose: Jewish sympathizers in the Nazi ranks, vegetarian waiters, and many more). ROU_Xenophobe writes:

    If you refuse to kill people, stop being a hit man. If you're no longer willing to employ the various shady tactics, stop selling used cars, or accept that you'll be fired when your sales drop.

    If you can negotiate a contract with your employer so that you're allowed to refuse to fill prescriptions, yay for you. So far, the pharmacies haven't been willing to do so, which seems reasonable to me given the possibility of lawsuits when they refuse to fill (or refer) prescriptions and people suffer as a result. I don't see any valid reason why the state should require them to accept pharmacists who refuse to fill valid prescriptions if they don't wish to.

    If the fired pharmacists want to band together to form Holiness Tabernacle Pharmacy or First Baptist Pharmacy, well, I wouldn't stop them, but I'd hope the market would.

    I'd like to think the market can show some people the folly of their ways, be it segregation or opposition to gay marriage (now raising state revenue in Massachusetts). But as Bashos_frog writes (and I'm not even trying to understand those screen names):

    ...I realize I am glad there were severe consequences for people like Rosa Parks, because it woke up more of society. What do you think would have happened if that one bus company had just changed its policy when Parks refused to move? Probably there would not have been much news, the company would have attracted more black business and less white business and a year later, instead of the laws changing, the buses would be segregated by company, insead of front/back.

    I guess it's possible things could've unfolded that way. And it suggests what might happen with pharmacies. Already, primary care docs know which drugstores around town don't carry oxycontin (for fear in burglaries) -- and they pass this information along to patients when precribing pain meds. Will the docs have to learn which pharmacists won't fill prescriptions for emergency contraception? For birth control? STD's? Addictions?

    Maybe. Of course, it'll be easy to remember to avoid the Christian Science Pharmacy (it's the one with all the empty shelves). But either we force druggists to honor prescriptions for all that's legal, or we memorize their morals, quirks, and biases.

    One can only hope patients don't get sicker as they race around town, trying to find someone who believes in treating them.

    Rash decisions

    So, as a blogger, I feel overwhelming pressure to comment on Rathergate, the forged national guard memos that CBS won't retract. I've been waiting for some kind of quasi-medical angle, and Andrew Sullivan has provided it:

    I think they so desperately wanted the documents to be legit that they rushed this story onto the air without taking the proper precautions. I know the feeling. I remember back when I was editing TNR, we were sent documents that seemed to prove that Senator Phil Gramm had once been in the KKK. Everything looked legit. And, of course, we were thrilled to have a big story about a politician most of us deeply disliked. But it's precisely the story that you want to be true that you have to be the most careful about. After many weeks of investigation, and much emotional investment in the story, the docs turned out to be fakes. Bummer, as far as we were concerned. The story never ran. I'm not bragging. It was self-interest that kept us from making an ass out of ourselves. And we were running a liberal opinion magazine, not a newspaper or "60 Minutes."

    Ok, it's a bit of a stretch, but -- are you ready? -- this reminds me of something I've seen in medicine. Something I've been guilty of, no less.

    Last week, I had a patient with a weeklong, worsening headache. Her neck was stiff, so triage had put her isolation (bacterial meningitis precautions). But when I pressed for associated symptoms, all she mentioned recent joint pain and malaise. Maybe a little fever a few days back. A few sniffles. On exam, however, I found an annular rash near her elbow. She said it'd been there for a year or so.

    I really, really wanted my patient's rash to indicate Lyme disease (scroll down for pic). It could explain all her symptoms, it'd be treatable, and I'd impress my attending with my find.

    Instead, the rash was ringworm. And the headache? a head CT showed... sinusitis. I ended up impressing the attending with a clean tap, she got some antibiotics and lamisil, and everyone went home happy.

    In conclusion, I'm learning to resist the temptation to overinterpret a finding, because the truth can still lead to lucrative procedures.

    But can it knock an anchor from his desk? And he said that irony is the shackles of youth. Uh huh.

    The journey is the (only) reward

    Galen deserves mad props for stretching the possibilities of medical blogging with his new Choose Your Own Adventure. And I hear Step III of the boards now has a section that resembles this. So now we can practice losing at work and at home!

    Giving love to scrubs

    On of the nice quirks of is when it hiccups up some old posts you've overlooked. [Is it a bug or a feature? -- ed.] Consider this gem from Vertical Mattress, on wearing scrubs:

    They're fashion classics, always appropriate, always stylish, accomodating all body types, ubiquitous but individual. In the hospital, washed-out blue is the new black. You can layer them over a t-shirt or wife-beater, under a white coat, and you can wear them home if you're feeling tired enough that you're willing to ignore how tacky it is to wear scrubs outside the hospital (so gauche).

    So true! (but a spirited rebuttal from Noah's "busty" sister appears here).

    Last month, I worked in many emergency department attendings requested shirt & tie for the men, citing studies that patient compliance, and physician authority, is enhanced with formal attire (this study is the closest proof I could find).

    This month, it's scrub city, baby! And damned if everyone doesn't look fabulous. Best variations: for men, light blue scrub top with khaki cargo pants. For women, blue scrub pants with tight black cotton top. Works great with or without white coat. Attendings whose scrubs reveal tattoos get bonus points.

    By the way, evidence is really lacking in the attire / respect / compliance debate. Consider this:

    Nearly 30% of patients incorrectly identified their doctor as wearing a necktie when no necktie was worn, and the perception of tie wearing was correlated with a positive impression of physician appearance. Wearing or not wearing a necktie did not significantly affect patients' impression of their physician or the care they received. However, patients seemingly preferred the appearance of physicians who were perceived to wear neckties.

    This suggests the old maxim, "the suit makes the man" isn't true! Instead, good male doctors can make patients percieve that they're wearing a tie, even when they're not. How's that for projecting authority?

    Meet the press

    Kevin's getting some attention lately, from old and new media alike. It's well-deserved, as his blog is an excellent distillation of relevant medical news. One media blogger remarks:

    The information the docs were offering was complex and many times serious. Trivializing it could have profound implications. It needed more time to be explained and understood than the 60 second special report on the news with dramatic music and MTV-like camera editing. And the 250 word story in the paper where your part got maybe 20 words didn't cut it, either. This is a very different community with a distinct culture that doesn't translate well in the media. I'm looking forward to reading their stuff. Unfiltered.

    I've expressed my frustration with big-media health reporting in the past. And I'm consistently impressed with the scholarship and analysis by many of the medical bloggers. Not to mention some of the illustrative cases and heart-rending stories.

    But how much of our writing is really reaching patients? It seems that for every comment or email from the 'lay audience,' I get three or four comments from colleagues in health care. Maybe it's because I'm still a student, or because I don't write as much about heart disease and diabetes. But I'd be curious to hear about the demographics of some of the physician bloggers.

    Grand Rounds on 9/28

    If you're a medical blogger (which so many of you are), and if you're interested in reaching more nonmedical readers, listen to this: I've received a lot of positive feedback about the idea for "Grand Rounds" (Carnival of the Caregivers) -- a series of "best-of-the-week" posts from around the medical blogosphere, with rotating hosts. I can vouch for the boost in traffic when these weekly linkfests are properly executed (thanks, Pete).

    I'd like to host the first Grand Rounds on Tuesday, September 28th. I'll be soliciting posts the week before that -- so get some good stuff ready. And if you have the ear of some of the blogging elite, let 'em know. Hopefully we'll be bringing a lot of new readers in to see our best posts on health care developments, new medical reports, drug companies, interesting cases and anecdotes, etc.

    After my week, hosting will rotate to another medical blogger, and we'll do it all over again. Stay tuned!

    Something old, something new

    I spoke recently with a bride about her wedding day -- today, September 11. She said picking that date wasn't an easy decision but, practicality aside, it was time to make positive associations with 9/11.

    Yes. We can continue to remember that awful day, while layering new memories. It's as inevitable as the growth of the babies born on 9/11/01 and subsequent anniversaries.

    I helped deliver one such baby last year. Time marches on. These kids will first associate that day with cake and presents and warmth, and only later realize their birthday signifies horrible events for countless others.

    You know what? They'll reconcile the two interpretations. Fitzgerald remarked that holding more than one perspective in one's mind was the mark of a first-rate intelligence. It also sounds like a good defense against the fundamentalist mindset.

    And it's not just our concept of 9/11 that can change. Maybe this sick child will give us the world a new association for Abu Ghraib. She was brought to the infamous prison by her Iraqi parents, who had exhausted treatment options in their country, and turned to the US for help.

    That they would do this is already a small wonder. But her health isn't secure yet. She's was born with cavernous hemangiomas, which usually enlarge before harmlessly involuting. But hers are already big enough to threaten her airway, and in she could die soon if she's not treated.

    As a result of Chief Wiggles' blogging on this situation, Dr. Marcelo Hochman has come forward to help. But more needs to be done to get this girl her surgery. Operation Give is on the case, soliciting donations via paypal. Readers can help.

    Something new can come from Abu Ghraib. Good things can be celebrated on 9/11. We can remember the horrors while taking postive steps forward. It's one of the best things about us.

    Thanks to Chai Tea Latte and ME and Ophelia for their writing on this matter. Cross-posted to the Lingual Nerve

    All docs are grunt docs

    I've heard military types sometimes compare the speed at which they can dismantle and reassemble their weapons.

    Maybe there's an equivalent for health care personnel.

    Today I reassembled my white coat after a vigorous washing (don't ask why). The pins, pens, pads, PDA, nametags, pen light, trauma scissors, spare gloves, gauze, tape, bactrim, lube, Maxwell's, Sanford's, quick-reference charts, eye chart, reflex hammer, pocket pharmacopia, and "pocket Tintinalli's" (which is large enough to use as a doorstop) all went in.

    38 seconds. Six pounds.

    I'm ready for battle.

    Future Stalk

    Last year, when blogborygmi was mostly just notes to myself, I filled a lot of posts with news on GPS miniturization and cell phone incorporation. Some of that research went into my last op-ed.

    So, I think it's safe to say people saw this coming:

    GLENDALE, Calif. (AP) - A 32-year-old man has been charged with stalking for allegedly attaching a cell phone and global positioning system to his ex-girlfriend's car to track her whereabouts, authorities said...

    ...Police said Gabrielyan, who ran a music and video shop, used the satellite tracking system to follow the unidentified 35-year-old woman and meet her unexpectedly at a book store, an airport, a cemetery and dozens of other places after she ended their relationship.

    "This is what I would consider stalking of the 21st century," said Lt. Jon Perkins of the Glendale Police Department.

    At least it's some comfort that this 21st-century technology dilemma was undone by a common 20th century one: the woman discovered how Gabrielyan was tracking her when she found him crawling under her car, trying to replace the cell phone's battery.

    Homeland scrutiny

    UMass Worcester grad student R---- is missing. He was last heard from this weekend, on the way to his uncle's home in Pennsylvania. Some faculty at the school are raising the possibility that foul play was invovled, because R---- works in an Infectious Disease lab affiliated with biodefense efforts.

    This is front-page, over-the-fold news in Worcester (subscription required). It seems to me, though, that Telegram & Gazette reporter Martin Lutrell has trumped up what's most likely a sad, sad car accident. The idea of terrorists ambushing or chasing this grad student hundreds of miles from home, to steal his ID and gain access to a Level 2 lab... it strains credulity.

    One of R----'s mentors, Dr. I----, was the one who raised specific concerns about his access to the lab, and the lack of an apparent vigorous search:

    "This could be a serious homeland security case. This isn't a joke," she added.

    Worcester police confirmed that a missing person report was filed over the weekend, and the detective bureau is handling it.

    But Ms. I----, a Ph.D. in her field, said police are not actively looking for Mr. R----.

    I wouldn't call myself an expert on these matters, but I do think the Ph.D. entitles her, literally, to be called "Doctor." I'm curious, though, why Dr. I----'s background and status give her any special insight into police operations (it's like saying I have insight into journalism, but I digress...) If this reporter was comfortable using her as a source on search procedures, he should press on, and explain how the Worcester Police Department might look for a missing adult lost somewhere between Connecticut and Pennsylvania.

    Buried in the middle of the story are the calming voices of reason:

    UMass Memorial Medical Center spokesman Michael Cohen said the FBI got a copy of the missing person report before it was understood that Mr. R---- lacked access to the Level 3 labs, which contain dangerous biological agents.

    "These are colleagues who are concerned about another colleague," Dr. A---- said. "I think they're worried and that they created some angles to help get things done. There would be no reason for anyone to target him."

    Dr. I---- is doing what she can to help find her student. I don't think what she did was appropriate, though I can certainly understand her motivation. I further doubt that raising these concerns about SARS, kidnapping, and homeland security to the press will help the effort to find R----. But she spoke to an experienced journalist who gathered dissenting opinions from other faculty. That reporter should've caught on to her attempt at manipulation, and responded by downplaying her unwarranted fears. Instead, he passed them along to the general public.

    This is not responsible behavior from the media, or from infectious disease researchers involved in biodefense. My thoughts today are where they should be: with the family, and classmates and colleagues close to R----.

    UPDATE: Just after posting this, it was publicized that R---- has been located, alive and recovering from an auto accident in a New Jersey hospital. He is well and expected to be discharged today.

    DIY Surgery

    You remember that hiker whose hand got caught under a massive boulder? His book is coming out this month. Outside magazine has an excerpt of Aron Ralston's Between a Rock and a Hard Place:

    Out of curiosity, I poke my thumb with my knife blade twice. On the second prodding, the blade punctures the epidermis, like it is dipping into a stick of room-temperature butter, and releases a telltale hissing. Escaping decomposition gases are not good; the rot has advanced more quickly than I guessed. Though the smell is faint to my desensitized nose, it is abjectly unpleasant, the stench of a far-off carcass.

    Hat tip: MeFi. Raltson's been making the rounds at Wilderness Medicine conferences. He seems like a good writer, and has a story with lessons for surgery, physiology, infectious disease, and appropriate outdoor preparedness.

    There is such a thing as overinterpretation, however. A little searching around on Ralston a led to this article, where an expert in Body Integrity Identity Disorder diagnoses Ralston as an apotemnophilic -- someone driven to amputation in order "feel themselves" again.

    Sheesh. Can't wait for the google searches on that term.

    Sans the S

    I don't want to make light of the disaster unfolding a thousand miles south. But I was surprisingly amused when I misread a headline on Hurricane Frances in today's paper:

    "France Slowly Creeps up on Florida"
    For a second I thought it was a story about plate tectonics (I hadn't had my coffee, ok?) But the fun didn't stop there:

    "Millions told to flee France"
    That's odd - I hear it's nice this time of year.

    "France cuts power to 2 million people in Florida"
    Their anti-Americanism has gone too far.

    France Slow, Fierce
    I thought that's how they described us.

    And finally: "Storm Carries Undercurrent of Angst"
    Mais bien sur! This is truly a storm the French existentialists would've found familiar.

    Building blocks

    I remember an education major telling me, ten or so years ago, about some findings on student learning. If I recall (and probably grossly oversimplify): people learn a subject best when taught exclusively for a shorter duration, rather than drawn out and interspersed with other material.

    In other words, the traditional college semester is less effective than, say, the approach employed by residents and clinical med students. Four or five classes spanning months is less effective than sequential one-month blocks of material.

    That seems right to me. I don't think I'd ever get comfortable prescribing seizure meds, for instance, if my neuro block was also spent covering colon cancer and pregnancy.

    Granted, this is all for the convenience of the teachers -- college professors couldn't sustain their careers (or their minds) teaching the same material every month, full-time. And hospitals couldn't staff the floors without a new supply of full-time students and residents.

    Whatever the source of the arrangement, I'm mostly glad for it. The constant variety is nice, and the prospect of "revisiting" each specialty down the road, and brushing up on those skills, is comforting.

    Right now, however, I'm glad to be starting my second consecutive month of Emergency Medicine. It's a different hospital -- a different state -- but the first time in a while that I haven't felt like a fish out of water. After spending the beginning of each rotation frantically trying to figure out how to function, I've been hitting my stride in the past few weeks. I want to continue operating at a level a little bit higher than 'newbie' -- for just a while longer.

    hypertext languages

    Helix and Lileks continue to inspire. Helix, because he's taken it upon himself to doggedly unearth new med student blogs like this one. It's that guy from Matchbox 20; I think he's becoming a doctor. I'll believe anything, now that Paul from the Wonder Years is a corporate lawyer.

    Lileks continues to express things that I really ought to be able to, and with breezy nonchalance, at that. For instance: I didn't mention it when the "Next Blog" button took me to this med student's site because 1) it wasn't particularly medical and 2) it wasn't particularly Enlgish.

    But when the great Lileks came across this strangely similar site, he met the challenge and aptly described it:

    [the site] makes me feel as though I am just having a shower of mini-strokes, because it makes sense and then it doesn’t, and then it does.

    I'm not even sure if it's the same language, or if Malaysians move in and out of written English as easily as my parents do for spoken English. It's just compelling to read, like a half-finished cryptoquote. And yes, for a moment it might feel like a TIA, or that Twilight Zone where the world's vocabulary shifts ... except for one poor guy who has to learn the new English the hard way.

    Enough. Lileks also points out this blogspot treasure, which is the first blog I've seen with automatic postings. I think it's designed to steer surfers-of-recently-updated-sites to a get rich quick scheme. In other words, blogspam is here. One expects it might get more sophisticated with time.