Blogging will be light until, um, 2005 or so. I'm now in Manhattan, and I'm rotating in a critical care unit. 'Nuff said?

Here are some exchanges from my first day that I will remember:

Resident: "Normally, the anesthesiology fellow would be guiding you around the ICU today. But, well, he was actually killed last week. Right over there."
Me: "What?"
Resident: "Yeah. Never forget to order restraints on patients who need them... or they'll remind you in the worst way."
Me: "He didn't die..."
Resident: "No, it's just the fellow's day off. But it's still a good lesson."

And later:

Me: "So, these room signs are not really helpful, and some of them are plain wrong."
Resident: "Yeah, actually, the guy in charge of signage here had a psychotic break a few months ago."
Me: "Come on, is this like that story with the fellow?"
Resident: "No, really, he's on leave now and everything. Some people were really surprised."
Me: "But not you?"
Resident, gesturing: "Just look all around..."
Me: "You caught the warning signs."


Go check out (it's the address and the title!). It's run by the AJOB editors, at Penn. It's informative, and a good deal more light-hearted than you might expect:

...bioethics clearly needs a good blog and we are trying to create it. That we happen to run bioethics' most-visited web site makes it much easier to do this. And since there are three of us, someone can always be sleeping.

Plus, they've got guest-blogging from Arthur Caplan (which totally trumps my plan to get Sanjay Gupta to fill-in for me during interviews.)

Uma, Oprah

Echojournal is collecting nominations for 2004 Medical Blog Awards. It should be interesting, because there are slightly fewer categories than medical bloggers.

I hope Dr. O goes all-out with this, Oscar-style: Excerpts from each nominee, Joan Rivers-style interviews, Lifetime Achievement awards, In Memoriam for defunct blogs... If he really wanted to, he could announce one winner every twenty minutes, dragging the proceedings well into the wee hours...

And how about a MTV-style version of the awards, with categories like Best Post or Best Flame War?

Jumping the Gun

Several bloggers (myself included) keep revisiting the the death of Victoria Snelgrove during the celebrations after the Red Sox victory over the Yankees. It's agreed that she was fired upon by a Boston Police officer with a "less lethal" pepperball gun. What happened after that is still very unclear, yet has ramifications for the future of crowd control in this country.

CodeBlueBlog has done admirable work (groundbreaking, really) on bringing his expertise to bear, and asking key questions that the mainstream media has so far been unable to answer. In one post he writes:

There is NO WAY that the ball itself could directly impact the brain tissue proper and kill her. Instead of proposing direct trauma, you have to ask HOW she died. If your brain gets contused, you don't die as a direct result of the contusion. I've seen people live with car stick shifts (to mention just one of many items seen) rammed through their foreheads into their brains and they lived.

THIS death was probably from hemorrhage of a lacerated carotid artery.

Despite the many unanswered questions surrounding this case, beat writers are coninuing to plagiarize, stereotype, and outright slander ...

Now, Dr. CBB seems to have a lot of experience in this field. I, on the other hand, have a lot of experience sitting at computers. And this week I finally had some spare time to indulge in some online research on this matter. My assessment?

CodeBlueBlog is probably right. BUT. I'd like to reopen the possibility that she died immediately, on the scene. Or at least, ask CBB how he interprets some of the following elements:

1) Eyewitness accounts that when she was fired upon, onlookers immediately thought she had died. Already, we're at a new level of severity from CBB's ocular trauma lit searches involving paintball guns. Granted, reports indicate that she "died hours later." But then there's this account on CBB's web site from a ED professional who claims:

I cared for this woman in the ED at Boston's Brigham and Womens Hospital... The plastic paint/pepperball penetrated her globe, then the orbit and entered her brain. The plastic, bone and pepper detrius was devastating. She never had a chance and we all new her brain damage was catastophic.. long before she went to the ICU. An unlikely injury, maybe, an unlucky one, yes indeed.

Now, the internet can be less than trustworthy, and there's not a lot to back this up. Except, if you google the guy's email handle, we learn 1) he does live near Boston and 2) he's got a hobby. Take it for what it's worth.

2) Accounts of the weapon's power. CodeBlueBlog summarizes his lit search thusly:

My search included ALL injuries to the globe including high pressure pneumatic glue and paint gun injuries, fish gun injuries, projectile injuries by:
Harpoon, Pencil, BB, Pellet, Bullet, Chopstick, Screwdriver, Pacifier, Pen, Arrow, Knife, Ninja star, Fern, Fencing wire... and NONE of these patients died.

It isn't the projectile that matters, it is THE GLOBE. It is just about impossible to kill someone by striking or impaling the globe with ANYTHING -- and that makes sense, doesn't it? The globe is rather exposed and mankind would have died out long ago if this were such a vulnerable spot...

I would argue that it's not the projectile itself, or the globe itself, but the kinetic energy. Obviously I could throw a bullet at someone's eye and they'd be alright (maybe a bit annoyed). But is CBB really arguing that a rifle-fired bullet through the eye can't kill? He's made his lit search available on his site; in doesn't include this:

Mahajna et al. Blunt and penetrating injuries caused by rubber bullets during the Israeli-Arab conflict in October, 2000: a retrospective study. Lancet. 2002 May 25;359(9320):1795-800.

BACKGROUND: Low-velocity rubber bullets were used by Israeli police to control riots by Israeli-Arabs in early October, 2000. We aimed to establish the factors that contribute to severity of blunt and penetrating injuries caused by these missiles. ... FINDINGS: 151 males and one female (age range 11-59 years) were included in the study, in whom 201 proven injuries by rubber bullets were detected. Injuries were distributed randomly over the body surface ... Severity of injury was dependent on ballistic features of the bullet, firing range, and anatomic site of impact. Two casualties died after a penetrating ocular injury into the brain and one died as a result of postoperative aspiration after a knee injury. INTERPRETATION: Resistance of the body surface at the site of impact (elastic limit) is the important factor that ascertains whether a blunt or penetrating injury is inflicted and its severity...

I know, it's Lancet. But still: the paper goes on to describe low-velocity as 130 m/s, a fair bit faster than the speed of the Boston Police FN303 pepperball gun.

Three people died of their injuries: one after a severe penetrating ocular injury into the sphenoid sinus; the second as a result of severe diffuse brain damage caused by penetrating ocular injury; and the third as a result of postoperative aspiration...

Now, the RCC-95 rubber bullets in question are far heavier than anything we're talking about (48 grams that splits into three components upon discharge -- 16g each?) and traveling at speeds faster than paintball guns and the FN303 missiles.

What was fired at Snelgrove? What I've heard reported is: it was a plastic-cased fin-stabilized pepperball with a mass of 8.5 grams.

Here's a table I made showing the relative energies of paintballs, pepperballs, and rubber and real bullets, with their guns (and I'm throwing in a 95 mph fastball for comparison):

weaponprojectile mass (grams)velocity (m/s)KE (J)
paintball gun38010

So, if the specs are true, the KE of the Boston Police's FN303 pepperball gun fall an order of magnitude short of a handgun bullet, and well short of a MLB fastball or potentially lethal rubber bullet. The FN 303 is, however, several times more energetic than the paintball guns CBB and others commonly compare them to.

I'd really like to reconcile the physics, however, with some of these eyewitness reports. We have one account that that a pepperball blew through someone's cheek. We have that sketchy comment on CBB's site from someone at the Brigham ED. And we have bystanders quoted as saying Snelgrove went down, motionless, immediately. Is any of this consistent with reports about paintball injuries, or projectiles with 35 joules of kinetic energy?

I'm forced to wonder if the Boston Police pepperball gun had a faster muzzle velocity than the FN303 advertised on the web.

On the Shoulders of Giants

Google Scholar is up.

Google Scholar enables you to search specifically for scholarly literature, including peer-reviewed papers, theses, books, preprints, abstracts and technical reports from all broad areas of research...

...Just as with Google Web Search, Google Scholar orders your search results by how relevant they are to your query, so the most useful references should appear at the top of the page. This relevance ranking takes into account the full text of each article as well as the article's author, the publication in which the article appeared and how often it has been cited in scholarly literature.

One advantage over pubmed, if there is one, is fewer clicks to get to a pdf of an article. Although I suspect their article rankings will be greeted with some skepticism, at least so long as their ranking algorithms are kept secret.

Back in June, I wrote about Google's usefulness to medicine:

I just met a toxicology student who, when confronted with a novel patient ingestion, has more luck with google than pubmed. And he's not the only scholar using Google results for urgent patient care...

Google is a private company, of course, and they provide a free service that works very well. But if the internet is becoming the central repository of human discourse, and Google is the indespensible guide to the internet, there should be more transparency about how it works. Why do some terms rise and fall, while others disappear and come back? The answers might be of trivial importance now, but someday it could be lifesaving...

...The bottom line is, will scientists and scholars remain content if their reference librarian pulls books and journals out of a black box and says, "trust me, this is what you want" ? Maybe... But only if they're always, always right.

We'll soon see. In the meantime, let the academic ego-jockeying begin! Are you really the top expert in your tiny little field?

Star Search

The new MSN search is out, and I'm disappointed. When you search "Dammit Jim", blogborygmi's not even in the top 50. But when you google the phrase, I'm still in the top 10.

What I infer from this is: Google will emphasize blog content more than MSN (after all, Google owns Blogger). And that makes it more useful to me.

Carnival of the Vanities #114

You probably think this post is about me.

But it's not! Contrary to Silflay's schedule, I'm not hosting next week. Mike at Interested-Participant is your host. Send your submissions to him at mjpechar / at /

We all co-pay

Every few weeks or so, it seems there's an explosion of commentary in an otherwise innocuous mediblog post. This time it's Kevin, and the back-and-forth is about insurance and society's values leading to inappropriate compensation.

All the commenters are anonymous, but I could swear I hear the voice of JB:

The only impediment to such a sensible system is that the American populace has sadly fallen victim to an entitlement culture-- in many spheres, but most notably in healthcare. They'd bristle at such a proposal. "What!? Me have to pay out of pocket up to $2500 per year!?", the single person earning $80K would say, totally oblivious to common sense. Yet these same people have no problem dropping $1200 on a TV, or $500 when they take their pet to the vet, or spending $150 per week to eat out at nice restaurants, or pay their mechanic $1000 when the coils blow on their car-- yet these same people, by and large, want to be able to walk into a physician's office-- a physician, who is the most competent, knowledgeable, and dedicated of professionals-- and hand them an insurance card and a $10 co-pay. That's not justice, and at some point, the American people should be spoken to in plain terms, just as I have here, and these realities should be made eminently clear to them.

...Realize this: NO OTHER PROFESSIONAL goes through as rigorous training, is more dedicated to their craft, and is more valuable than a physician. They deserve to be compensated accordingly; they currently are NOT being so compensated. Mean income for pediatricians, FP's and internists hovers around $140K now. Yeah, that's a lot of money, you may say, but think about what they have to do to get there, the nature of their profession, and also what we tolerate paying other professions such as lawyers, accountants, high level programmers, investment bankers and fund managers etc.

Have you seen some of these plasma TVs, though? The sharpness is really incredible.

Grand Rounds VIII

DB hosts Grand Rounds 8 over on MedRants. Go check out the latest and greatest in online medical writing this past week!

And be sure to stop by Shrinkette next week.

Upcoming Hosts:

11/23 Shrinkette
11/30 Doctor Mental
12/07 The Examining Room of Dr. Charles
12/14 Parallel Universes
12/21 Code Blue Blog

Taking stock

2005 will be the year of RFID -- radio frequency identification. Wal-mart will start requiring its suppliers to label products with it, so as to aid their inventory accounting. And now, Drudge has a siren blaring about how the FDA will require medicine bottle RFID. This NYTimes piece has more:

The labels are called radio-frequency identification. As in automated highway toll collection systems, they consist of computer chips embedded into stickers that emit numbers when prompted by a nearby radio signal. In a supermarket, they might enable a scanner to read every item in a shopping cart at once and spit out a bill in seconds, though the technology to do that is still some distance off.

For drug makers, radio labels hold the promise of cleaning up the wholesale distribution system, where most counterfeit drugs enter the supply chain, often through unscrupulous employees at the small wholesale companies that have proliferated in some states...

...Costs are still far too high for individual consumer goods, like the amber bottles that pharmacies use to dispense pills to individuals. But prices are expected to plunge once radio labels become popular, so drug makers represent an important set of early adopters.

Privacy-rights advocates have expressed reservations about radio labels, worrying that employers and others will be able to learn what medications people are carrying in their pockets. Civil-liberties groups have voiced similar concerns about ubiquitous use of the technology in the marketplace. But under the current initiatives, the technology would not be used at the retail level.

At first I didn't think counterfeiting was a big enough deal to warrant this intrusion. But then I recalled all the spam I get for Xanax and Vicodin... not to mention those phosphodiesterase-5 inhibitors.

Counterfeit drugs are still comparatively rare in the United States, but federal officials say the problem is growing. Throughout the 1990's, the F.D.A. pursued about five cases of counterfeit drugs every year. In each of the last several years, the number of cases has averaged about 20, but law-enforcement officials say that figure does not reflect the extent of the problem.

Last year, more than 200,000 bottles of counterfeit Lipitor made their way onto the market. In 2001, a Sunnyvale, Calif., pharmacist discovered that bottles of Neupogen, an expensive growth hormone prescribed for AIDS and cancer patients, were filled only with saltwater.

So, siren-watchers, your medicine cabinet won't start broadcasting your prescriptions to people passing by with RFID scanners. But the concept is a little less outlandish today than it was yesterday.

CSI Boston

CodeBlueBlog continues his investigation into the death of Red Sox fan Victoria Snelgrove. New information on the pepper-ball lets him speculate on the mechanism of death. Excellent stuff, but not for the squeamish.

Also, his excoriation of typical journalism in this investigation continues -- now he's got a list of questions the media should be asking (and, hopefully, the Boston DA will be answering).

I'm interested in this story for several reasons. First, as a Red Sox fan who was merrily celebrating in the streets that night, a few miles north of where Snelgrove was killed, I'm genuinely alarmed that this could occur.

Second, after hearing first-hand about the arrests and detentions during the RNC, I must wonder if police tactics have taken a disturbing turn. And finally, as a medical blogger and frequent media critic, I'm interested in getting the real details of the story, especially when mainstream journalism has dropped the ball.

I agree with Dr. BB at CodeBlueBlog that finding the mechanism of death is the first priority. I wonder if this new report of a video recording at the scene will influence his expert analysis:

The cheering, chanting crowd on Lansdowne Street had stilled to a dull, churning hum after police cleared the girders under the Green Monster seats and began pushing people toward Brookline Avenue. Smoldering material, some still flaming, littered the roughly 40-foot clearing where Milien stood, pointing a gun at shoulder height toward the receding revelers.

Four officers stood behind him, one on each side and two farther back on the Fenway Park sidewalk. None of the other officers was holding a weapon, and they were not engaging the crowd. They stood with their hands at their sides or clasped behind their back. Then, Milien began to walk forward. He took a step with his right foot and fired. Camera flashes reflected off white cross-straps on his chest as he stepped with his left foot.

A man in the crowd swore loudly.

Then a step with the right foot again. Bang -- a second shot in the same direction.

Within seconds, screams and expletives from the crowd are heard.

"Did you see that?" one voice said.

"What happened?" another asked.

"I don't know, but she's on the floor, and she's [expletive] dead," a voice said.

"It looks like they hurt her or something."

"You hit her in the eye."

"You [expletive] killed her."

"Look at her. She's like not even moving."

Or this new data on other victims:

Police have also not said who fired the pellet that tore through the cheek of 24-year-old Cambridge resident Paul Gately or a third pellet that pierced the forehead of Kapila Bhamidipati, a 19-year-old Boston University student. Both had climbed the girders underneath the left-field Green Monster seats...

The policy analysis can come after we have the facts (though I must have missed the town meeting where it was decided that climbing a fence is such a threat that targeting heads with projectiles is worth the risk).

As I hear more about the Boston Police's new weapons, they're sounding less "less than lethal" all the time. I appreciate and echo CodeBlueBlog's questions about what happened in the Brigham ER. But with these new reports, I think the emphasis of inquiry should shift to pre-hospital events.

"Code" blog

Technorati is showing another blog linking to me... with a reference to coding in the title.. but it's not CodeBlog or CodeBlueBlog or CodetheWebSocket. It's "Medical Billing and Medical Coding Outsourcing Industry News."

My first (almost heretical) thought: Blogging has gone too far.

My second thought: Actually, kind of interesting. Even to lay readers.

As a student, I know next to nothing about proper coding and billing. I seem to recall that if I don't review 5 of 9 systems, my preceptor can't bill for a Level 4 visit. Something like that. I think in the Emergency Department it's even more stringent, but exactly how is a mystery. I hope they teach us this in residency; in the meantime, I plan to stop by this new blog, now and then.


The Sox-blogging is winding down, I promise. A few more posts this weekend, maybe. But for now, if you're interested, here's a picture of Curt Schilling's ankle, showing how they relocated the peroneal tendon before Game 2 of the World Series.

Jayson Stark is saying there were 55 stitches. I don't know. I count three (to be fair, I heard there they needed four in ALCS Game 6). I didn't think there was additional suturing of the fascia under the skin, but maybe I'm wrong.

Stark also says: was able to obtain two photos of the fabled ankle in question, taken on the day of Schilling's Game 2 World Series start. And let's just say you don't need a framed med-school degree to notice this ankle doesn't resemble yours or ours -- not unless you're sitting in an orthopedic waiting room as you're reading this, anyway.

It always amazes us what athletes will do at times to play in the biggest games of their lives. But the more we look at this photo, the more we understand that what Curt Schilling did last month is one of the most amazing sports stories of the 21st century.

That, at least, is no exaggeration.

Gruntdoc hosts Grand Rounds 7

Allen is the first emergency attending to host a Grand Rounds, and I like what he's done with it, too. Quotes! Monty Python references! Go check out the latest and greatest from the medical bloggers this week.


For a while last week, Blogborygmi was the #1 search result for people typing "stupid personal sites" into Google. Welcome, new readers! Also, for some reason, I was #5 for the search term "anecdote" ... I'll try to keep that in mind.

Here's another in the series of jarring dialogues in which a medical student learns that integrating hospital experiences into one's personal life is an ongoing effort.

"So that's what they told me in the hospital. Congestive heart failure." He sighed and sank into his chair.

"You look good to me, though," I replied. "And that's not just wishful thinking."

"Terrible place, that hospital. They treated me like a baby. Don't become one of those doctors that talks down to people."

"No, no," I shook my head. "But, you know, you can be pretty stubborn. Sometimes that puts the team on the defensive, and makes them simplify things. What was that business about you refusing medication?"

"Too many pills! But that's not important... I have to get ready. My grandson is coming by to play some chess. He's getting very good. Going to get ready."

I smiled. "Do you remember when you taught me chess? And all those drills with the knight and the bishops?"

He leaned forward. "You were good, too. Do you still keep up?"

"I haven't played in a while," I admitted.

He began to push against the armrests. "Here, help me get up."

I rushed across the living room and grabbed his arms.

"Good job," I said. "There you go. Good job."

"That's exactly what I was saying about the hospital. Baby talk."

Purple Power

The election's over, and people are reflecting on the divisions in the country. One overplayed idea is that a huge cultural chasm is in place -- the Red States vs. the Blue States.

Joshua Glenn reprints Jeff Culver's map of America in today's Globe. I think this is worth harping on: it's not red states and blue states, it's not cities vs. suburbs... we're all living in a Purple America, with some areas a little redder and others a little more blue.

I like so many things about this map. First, it shows that the differences between us are relatively small (which might offend ubran sophisticates and rural good ol' boys, but nonetheless reassures me). Second, it suggests that any cultural divide is not imposed by geography, but by our own habits and circles.

Yes, we may be in small bubbles, but the remedy to this insularity doesn't involve a road trip to another part of the country. It means listening to your neighbors and coworkers, expanding your circle, reading different magazines, and surfing other blogs.

Although, to be honest, this map makes me smile, too.


I've really enjoyed browsing Malcom Gladwell's archives. Here's an article that struck me, about innovation and groupthink:

[Randall] Collins's point is not that innovation attracts groups but that innovation is found in groups: that it tends to arise out of social interaction—conversation, validation, the intimacy of proximity, and the look in your listener's eye that tells you you're onto something...

...[Jenny] Uglow's book reveals how simplistic our view of groups really is. We divide them into cults and clubs, and dismiss the former for their insularity and the latter for their banality. The cult is the place where, cut off from your peers, you become crazy. The club is the place where, surrounded by your peers, you become boring. Yet if you can combine the best of those two states —- the right kind of insularity with the right kind of homogeneity —- you create an environment both safe enough and stimulating enough to make great thoughts possible.

Uglow's book, "The Lunar Men", is about a group of friends that included Erasmus Darwin, James Watt, and Joseph Priestley. Gladwell compares them to another famous troupe, whose august members included Belushi, Aykroyd, and Radner. It's compelling reading.

And when Gladwell talks about stimulating but somewhat insular environments, I wonder if the medlogs regulars don't fit the bill.

Then again, it's good to have Dr. Charles remind us that the "Grand" in Grand Rounds doesn't mean grandiose.

Sydney Smith hosts Grand Rounds Six

Medpundit's hosting a special election-day edition of Grand Rounds. Go check out the latest and greatest from the medical blogosphere.

If you're a medical blogger interested in hosting on December 21st, December 28th, or January 4th -- please let me know (nick / at /

Ol' Blue Eyes

"Oh, I don't care much for doctors," she said, but not dismissively.

I leaned in a little, and gave my scotch a sip. "Why is that?"

"I just detest the way they size people up ... and pronounce their judgements. So arrogant..."

I sat quietly for a moment, trying to read her face. Something was off -- not quite right.

She conceded, "Maybe I had too many bad experiences, growing up. I saw a lot of them."

"Of course," I nodded. "Osteogenesis imperfecta! You know, I thought your eyes were really striking."

"See?" she recoiled. "That's exactly the kind of atrocious behavior I'm talking about."


On the wards, we see a lot of patients recovering from insults to the brain. As their mental status improves, I sometimes like to ask them who was president in 1975. I like this question because even sharp people stumble over it. Ford, you see, was never elected, and people tend to remember who they voted for.

For contrast, most everyone of appropriate age remembers who they voted for in 1980, or 1992. And they probably remember why.

I'm not so sure that will be the case when people look back on 2004. I'm hearing all kinds of interesting reasons to vote for the major candidates Tuesday. Most involve the same kind of convoluted thought process that's gone in to interpreting the OBL video.

Here are actual things people have written or told me in recent days:

I'm voting for Bush to send a message to trial lawyers.
I'm voting for Kerry because if he wins, Hillary won't run in 2008.
I'm voting for Bush to hasten the demise of the conservative movement.
I'm voting for Kerry to send a conciliatory signal to our estranged European allies.
I'm voting for Bush to send a belligerent signal to the terrorists.
I'm voting for Kerry because, even though he's an uninspiring fence-straddler, we need to win before anything can change.

They all have a certain logic. But sadly, none of the reasons are "this is the person I want to lead America."

I'm still of the opinion that it's good to vote your conscience. Am I being hopelessly naive? Or have many voters started pretending that their decision carries hefty strategic importance?

If the message of 2000 was that "every vote counts," the undercurrent of 2004 is that "every vote sends a clear signal to certain groups across the world." And people have become intoxicated with the notion that their vote, their demographic group, their neighborhood, is sending a nuanced message worthy of scrutiny and future study.

I disagree. I think, in the long run, the meaning behind your vote is more important to you than it is to the trial lawyers or terrorists or anyone else looking at exit polls.

Just think of it this way: when you're in a hospital bed in 2033 and some smartass medical student asks "Who was president in 2005?" -- you might recall voting for Kerry or Bush. But will you remember the reason? Will you remember that you were sending a signal to the Europeans, or trying to block Hillary Clinton's aspirations? Wouldn't it be nice to recall your convictions, your beliefs, your values?

If you're voting for Bush or Kerry because you line up well with one of them, good for you. But I suspect a lot of these convoluted voting strategies are imagined because people aren't really satisfied with the candidates. If neither Bush nor Kerry inspire you, or match your values, maybe you should keep looking.

Just don't try telling me that voting for a third-party candidate is wasting a vote, or throwing it to the other team. That kind of over-strategizing has lead to nominees as bland and flawed as the ones we have. And if you're voting for someone you don't believe in, you're throwing a lot more than your vote away.

Can't buy a Thrill

Kudos to antifaust for proposing the iSteth, a combination electronic stethoscope and iPod.

Electronic stethoscopes like this Littmann have been around for years, for amplifying, storing, and sending heartbeats. But adding MP3 playback will make them the choice for the rising generation of medical professionals. If you're ever unsure of a murmur, just cue up Huey Lewis' "Heart of Rock & Roll" for quick comparison.

Next up: an ophthalmoscope that plays DVDs!