Year Two is underway

First things first: Next week's Grand Rounds is being hosted by a medical student and Katrina evacuee, Neils Olson. The Tulane medical students are in the process of moving again -- from Texas A & M to Baylor for the rest of the semester. So do him a favor and get your submissions in early. His blog is called the Haversian Canal (a coincidence, I'm certain) and his email is haversian.canal -at- gmail.com

I must point out, one of Dr. Reider's major contributions to medblogging, besides practically strarting it, is the medlogs.com site. For the medbloggers who were peeved that GR was late this week, or they weren't included in the carnival -- try thinking of it this way: Jacob Reider has been linking to all of your posts, every day, for years.

Having said that, I expect Mr. Olson to be on time next week, hurricanes notwithstanding. (There are few things more certain than freshly-minted MDs demanding promptness and preparedness from medical students -- it's far more natural to us than, say, giving orders to nurses who've been working for a decade or two).

The City That Never Sleeps

There's nothing quite like the intense mood swings experienced during a night on call. The stress and fatigue, coupled with arbitrary setbacks and lucky breaks, can take me from dread to euphoria and back in a matter of minutes. And, as the night goes on, the likelihood of such swings rises...

And so I found myself on one call night last month, admitting patients and cross-covering the medical floors. Things finally quieted down at around 4 AM. My co-intern and I took the opportunity to follow-up on some radiology reports from earlier in the evening.

"Hey -- did the radiologist comment on Richardson's chest X-ray?" I asked, staring at the patient census, seated at the Team Room desk.

Jane, who was sitting at the computer, called up the report. "Yep, it's in here:"

"Portable chest X-ray, good inspiratory effort, the lungs are unremarkable with no infiltrates, effusion, or evidence of pneumothorax. The heart is within normal limits. New York is prominent and calcified."

I looked up from the lists. "What was that last part?"

"New York is prominent and calcified."

After we shared a few quizzical looks, we realized what had happened and started to smile, then giggle. Then came the full laughter, reserved for when the the absurdity of hospital work can't be denied any longer.

After about a minute, when our laughter subsided, Jane reasoned it out loud: "I guess the dictation machine interpreted 'aorta' as 'New York'..."

"Yeah, but..." The pendulum had swung, and I was getting serious again, maybe a little paranoid: "What if the dictation is right? What if this city really is..."

My words trailed off in the new, somber mood of the team room.

"It could be worse," Jane offered. "A lot of aortas are described as 'tortuous.'"

Snelgrove, Apres Mort

The Boston Globe is reporting the release of autopsy files and police documents surrounding the death of Victoria Snelgrove, a fan killed by a pepper-ball gun after the Red Sox beat the Yankees in the 2004 ALCS.

It's been nearly a year since this event, but we're finally moving closer to understanding how Snelgrove died -- and answering the questions incisively posed by Code Blue Blog immediately following the shooting.

In today's Globe:

...video evidence included with the transcript shows that Milien was the only officer in the vicinity with a pellet gun and that he fired two shots in quick succession in her direction, according to investigators.

Milien also said he had no idea that the FN303 pepper-pellet gun could kill someone. "Not in a million years," he said.

But the pepper-spray pellet pierced Snelgrove's left eye, opened a three-quarter-inch hole in the bone behind it, broke into nine pieces, and damaged the right side of her brain, according to an autopsy report. The 21-year-old Emerson College student was pronounced dead at 12:50 p.m. on Oct. 21, nearly 12 hours after she was shot.

The mainstream media is focusing on the police's judgment and use of force:

Conley announced last week that none of the officers will face criminal charges. On Friday, Police Commissioner Kathleen M. O'Toole demoted the overall commander that night, James M. Claiborne, from superintendent to captain; suspended two officers who shot fans; and issued written reprimands to two other officers who did not secure evidence after the shootings. Milien accepted a 45-day suspension without pay for using poor judgment and excessive force.

The Washington Post says the suspension is 90 days. The Boston Phoenix wonders why there isn't an inquiry into the coverup.

But I haven't seen an analysis of the mechanism of death. It's just facile for the Globe to say Snelgrove's skull had a hole, brain tissue was damaged, and she died twelve hours later -- there should be more, especially given the "nonlethal" billing of the pepperball gun, the literature on the these weapons, and what we know about traumatic brain injury.

CBB and I shared a spirited exchange on this subject last fall. His drew on his experience and knowledge of physiology. And some literature. I countered with my own lit review and some math.

We were the only ones asking these questions, let alone proposing answers.

Perhaps, from the public policy standpoint, the mechanism of death is now just an academic exercise. These "nonlethal" guns kill, and that ought to be the end of their use.

But the way Snelgrove died will undoubtedly come up in the Snelgrove's lawsuit against the makers of the FN-303 pepperball gun:

The letter sent to Falk by the Snelgroves' attorney, Patrick T. Jones, disputes that contention, saying that in its marketing material, FN Herstal suggested that the projectiles would break apart when they hit someone, which Jones argued led Boston police to believe the "projectiles are safe and contributed to an attitude by the shooters . . . that they could not cause any serious injury."

...After Snelgrove's death, the department pulled the weapons from service. Police Commissioner Kathleen M. O'Toole announced yesterday that the department will not use the guns again.

In his letter to FN Herstal, Jones alleges that the fact that pepper pellets fired from the guns penetrated the head of Snelgrove and two other victims proves that "fragmentation either does not always occur on impact or that the penetration of the skin can occur in some cases even with fragmentation."

..."As marketed, designed and sold, the product actually increased the likelihood of injury to innocent bystanders," Jones wrote. "As a result of these breaches, Victoria Snelgrove suffered severe injuries and death.

If the autopsy is, in fact, available, there might be some qualified medical reportage later week. We'll see -- in the meantime, eleven months have passed. Since Snelgrove's death, the FN303 has been barred from use by the Boston Police, and its future in US crowd control is very much in doubt.

Code Blue Blog's author, radiologist Thomas Boyle, MD, hasn't posted in five months. After the Snelgrove death, he went on to make increasingly bold but well-researched claims -- like that Ukrainian PM Yuschenko wasn't poisoned, or that Bill Clinton was sick. During the Terri Schiavo controversy, he criticized neurologists for over-interpreting individual head CT slices. Code Blue Blog became, briefly, the most heavily trafficked medical blog, and Boyle explained his views on TV and radio.

His conclusions and presentation style rubbed many the wrong way, but you had to do your homework before you disagreed with Code Blue Blog. And if reporters and interviewers took a cue from his pointed, reasonable questions, we'd enjoy a higher level of journalism in this country. Of all the voices in the media and blogosphere, his is one I'd like to listen to, again.

Grand Rounds #52

Dr. Kent Bottles of SoundPractice.net is hosting this week's Grand Rounds. It is a fine collection of the latest and greatest in medical blogging. His site is notable for many reasons, but the dearest to me is that he's making an effort to record the early history and motivations behind medical blogging, on his podcast interviews.

SoundPractice is one of the newest medical blogs -- it didn't exist when Grand Rounds started, a year ago. Next week, for the first anniversary edition, we turn to one of the oldest medical blogs: DocNotes, by Dr. Jacob Reider.

I was hoping by now to announce some major changes to Grand Rounds, to coincide with the start of Volume Two, but these hardball negotiation sessions with Manhattan mega-corporations are taking more time than I expected (these are offices with indoor waterfalls, people -- we have arrived).

And, truth be told, the proposed changes for Grand Rounds hosts and participants are minor: GR will always be a rotating carnival of health care bloggers. The only difference is, there'll be be an influx of new readers: web-using health professionals who aren't yet familiar with the world of blogging. Hosts won't have to carry ad banners for Lipitor or anything like that -- just a link-back to the new Grand Rounds archive and schedule (which should be a good deal spiffier than its current incarnation).

More to come...

Dispatches from New Orleans #1

There's a lot of accounts appearing online, from relief workers in New Orleans. I've received a few that have been cleared for posting. This came a few days ago, from a friend with a connection to an FDNY unit. It's from a blackberry, I think. I reformatted it a little:

8/30 I'm leaving this afternoon for New Orleans (or Missisippi, we're not sure whch) with my rescue crew. Apparently, things are VERY bad there. The New Orleans FD sent guys to help after 9/11, and we're sort of returning the favor.

8/30 I'm at the airport. We're going to New Orleans. FEMA says we'll be doing "vertical rescue", which means pulling people off roofs. And that we will probably be needed for......well, let's not think about that just now.

9/1 Haiti doesn't begin to be a metaphor. Hades is much closer. I'm not sure what the news is showing - we're virtually cut off from everything, including our command structure. We're completely on our own, just trying to do what we can and avoiding the maniacs as best we can. I'm not even sure if you'll get this. I'm trying to decide when to pull my guys out of here, because it's just too dangerous to stay. .

I have a hundred stories to tell you, and a hundred more I'll never be able to tell anyone. I've done this work for so long, but I never imagined any horror like this. And there's no end to it.

9/2 Morning. Thank God. We got a couple of hours of sleep in a looted store, figuring that nobody would bother it because there's nothing left in there to take. We're close to the French Quarter, where it's a little quieter. We've been advised to stay away from the convention center area, because things there have devolved to complete chaos. We came across a woman yesterday who was coming from there........you'll need to tell me how much of this you want to hear. It's beyond horrible. Telling the stories seems almost pornographic.

But there are good stories, too. Stories of amazing courage. We took a family off a roof - 4 kids and the mother, and there wasn't going to be room for the father. The woman didn't want to go, wanted to wait until somebody came with a bigger boat. The father whispered in my ear, "Go. Now. ". I looked at him, and he looked at me, both of us knowing that nobody else was probably going to show up. The NO cops talk about the "animals" they're trying to control. But here was this guy, probably one of the bravest guys I've ever seen. He had been on that roof for 4 days, and now he was going to be alone. I hope they're telling those stories on the news.

9/2 I don't know about the psychological and societal root causes of what's going on here. But I can tell you that the two overriding emotions I see are:

- terror. Lots of people are thinking they're going to die here. And lots of them are probably right.

- a sense that all rules have been dispensed with I saw a smaller version of this on 9-11, but this is on a far grander scale. This is Hobbesian in its magnitude.

I've become a looter myself, technically. In an effort to conserve our dwindling supply of MREs, we've been breaking into houses for canned food. I suspect we're being a little gentler than our looter brethren, and we try to secure the doors when we leave, but it's almost silly. Nobody's coming back to these houses for a long, long time.

We've also become an armed band. One of my guys "found" a shotgun. I didn't ask him where, but I feel better that he has it. I've fallen back on infantry tactics for travelling down the streets - stay close to the walls, don't bunch up - because there's lots of random gunfire. The good news is that there's a lot more National Guard around today, so maybe things will begin to stabilize.

I do need to tell you some of the stories.

There was a woman walking down the street carrying two plastic bags. She looked to be in shock, so we stopped her to see if we could treat her. She had two dead babies in the bags.

We didn't find out if they were her children. She was a 3 on the responsiveness scale (which goes 1-5) and wandered off before we got much out of her. There are a lot of walking dead here. In a lot of ways, they're the creepiest of all.

We walked around the corner and into a shootout between two cops and a guy carrying a rifle. One of the cops shot the guy in the head. And they got in their car and drove away.

We rescued a mom and two kids who had been on a roof since Tuesday with no food, no water and the body of their grandmother. How does a kid have a normal life after that? What kind of awfulness is being bred here?

And one more:

An old black guy had stayed in his barbershop all week, trying to protect it. As we went by, he came out and said "you boys need a shave." So I sat in a chair on Poydras Street while he shaved me with a brush, straightrazor and filthy water. I'm not sure which one of us felt better.

9/2 Just coordinated with a Nat Guard lieutenant ("New York??? " He said.). He said they're estimating 50,000 might still be trapped.


9/3 Things appear to be coming together, or maybe it's just that there are more personnel coming into the city, or maybe I'm just getting used to it. There are fires everywhere, and the FD can't do anything, because they have no water. Last night we were helping an engine company try to contain a huge fire, and all they had was the 700 gallons in their tank. The officer was in tears. It's those kinds of things that have affected me the most - people trying to do what they've always done in the midst of this horror. I saw a woman who was hanging clothes on a clothesline to dry.

We've connected with a NG unit, and they're going to use us as technical experts for rescues. I'm sending each of my guys with a squad of soldiers. I don't like breaking us up like that, but we'll give it a try.

And maybe I can get back to my regular role of being a boss, sitting down while somebody else does the work. I'm getting too old for this climbing stuff.

I think we'll be leaving Monday, if we can get out. We came as a "Rapid Response Team", and we were supposed to leave after 48 hours. But nothing's working like it's supposed to.

Dispatches from New Orleans #2

This letter is making the rounds on EM residency lists:

let me start by saying that i am safe and after a very rough first week
am now better rested and fed

out team was the first to arrive at the airport and set up our field
hospital. we watched our population grow from 30 dmat personal taking
care of 6 patients and 2 security guards well to around 10,000 people
in the first 15 hours. these people had had no food or water or
security for several days and were tired, furstrated, sick, wet, and
heart broken. people were brought in by trucks, busses, ambulances,
school busses, cars, and helicopters

we recieved patients from hospitals, schools, homes,
the entire remaining population of new orleans funneled through our
doors. our little civilian team along with a couple of other dmat
teams set up and ran THE biggest evacuation this country has ever seen

the numbers are absolutely staggering

in hind site its seems silly that a bunch of civilian yahoo's came in
and took over the airport and had it up and running exceeding its
normal operating load of passengers with an untrained skeleton crew and
generator partial power. but we did what we had to do and i think we
did it well

our team has been working the flight line off loading helo's.
overnight we turned new orleans airport into the busiest helicopter
base in the entire world. at any given time there were at least 8-10
helo's off loading on the tarmac, filled with 10-40 survivors at a
time, with 10 circling to land, it was a non-stop never ending process
24 hour a day operation. the cnn footage does not even begin to do it
justice. the roar of rotar blades, the smell of jet A and the
thousands of eyes looking at us for answers, for hope. our busiest day
we off loaded just under 15,000 patients by air and ground. at that
time we had about 30 medical providers and 100 ancillary staff. ALL we
could do was provide the barest ammount of comfort care. we watched
many, many people die. we practiced medical traige at its most basic,
black tagging the sickest people and culling them from the masses so
that they could die in a separate area. i can not even begin to
describe to transformation in my own sensibilities from my normal
practice of medicine to the reality of the operation here. we were SO
short on wheel chairs and litters we had to stack patients in airport
chairs and lay them on the floor. they reamined there for hours too
tired to be frigthened, too weak to be care about their urine and stool
soaked clothing, to desperate to even ask what was going to happend
next. imaging trading your single patient use latex gloves for a pair
of thick leather work gloves that never came off your hands and you can
begin to imagin what it was like.

we did not practice medicine

there was nothing sexy or glamerous or routine about what we did we
moved hundreds of patients an hour, thousands of patients a day off
the flight line and into the terminal and baggage area
patients were loaded onto baggage carts and trucked to the baggage
area, like, well, baggage. and there was no time to talk, no time to
cry, no time to think, because they kept on comming. our only
salvation was when the beurocratic washington machine was able to ramp
up and stream line the exodus of patients out of here

our team work a couple of shifts in the medcal tent as well. imagine
people so despeate, so sick, so like the 5-10 "true" emergencies you
may get on a shift comming through the door non stop that is all that
you take care of. no imagine having not beds, no O2, no nothing except
some nitro, aspirin and all the good intentions in the world. we did
everything from delivering babies to simply providing morphine and a
blanket to septic and critical patients and allowing them to die.

during the days that it took for that exodue to occur, we filled the
airport to its bursting point. there was a time when there were 16,000
angry, tired, frustrated people here, there were stabbings, rapes, and
people on the verge of mobbing. the flight line, lined with 2 parallel
rows of dauphins, sea kings, hueys, chinooks and every other kind of
helocopter imanigable, was a dangerous place. but we were much more
frightened when ever we entered the sea of displaced humanity that had
filled every nook and cranny of the airport. only now that the
thousands of survivors had been evacuated, and the floors soaked in
bleach, the putrid air allowed to exchange for fresh, the number or
soldiers allowed to outnumber the patients, that we feel safe

i have meet so many people while down here. people who were at ground
zero at 9-11, people who have done tusanmi relief, tours in iraq and
every one of them has said this is the worst thing they have ever
seen. its unaminous and these are some battle worn veterans of every
kind of disaster you can imagine.

watching the new reports trickle back to us has been frustrating and
heart braking. there is NOTHING anyone could have done to prepare for
this. it was TOO huge, even now its so big its almost impossible to
comprehend. the leaders needed to see first hand the damage but did
not because their safety could be guarenteed. its a war zone in new
orleans. it is covered in raw sewage with no infrastructure. every
engineer i have spoken with believes that most of the city will have to
be plowed into fields and that rebuilding what is left will take
decades. it will NEVER be the same. never. ever.

for those of you who want to help the next step is to help those who
arrive in your local area. the only real medcial care these survivors
will recieve is once they land in safe, clean area far from here. for
the 50,000 people we ran through this airport over the last couple of
days, if they were able to survive and make it somewhere else, their
care will begin only when providers in dallas and houston and chicago
and baton rouge (etc) volunteer at the shelters and provide care. and
yes there are many, many more on their way

many of the sickest simply died while here at the airport, many have
been stressed beyond measure and will die shortly even though they were
evacuated. if you are not medcial then go the shelters, hold hands,
give hugs and prayers. if nothing else it will remind you how much you
have and how grateful we all should be. these people have nothing.
not only have they lost their material posessions and homes, many have
lost their children, spouses, parents, arms, legs, vision, everything
that is important.

talk to these survivors, hear their stories and what they have been
through, look into their eyes

you will never think of america the same way
you will never look at your family the same way
you will never look at your home the same way
and i promise it will forever change the way you practice medicine

It's signed by Hemant Vankawala, MD, who has spoken to the press about the airport experience.

L

Grand Rounds #50 is up at Corpus Callosum. Go check out the best of the medical blogosphere, hosted this week by an Ann Arbor psychiatrist.

Tune in next week, when Sneezing Po takes the reins.

And watch this space for news and developments about Grand Rounds, Volume Two -- just a few weeks away.