After a month without television, I've done some catching up since Christmas. And I've seen TV do some catching up with current events.
The Indian Ocean tsunami disaster was something I heard about first as an afterthought during afternoon football games, and placed at low priority on the local nightly news (a snowstorm was settling in, and the post-holiday mall blitz was underway). But the initial report of 7000 dead, with assorted clips of foreign harbors, seemed absurdly out of place sandwiched between sports highlights and snowfall totals. It was anomalous, and I'd think about it later.
Now the number they're throwing around is 60,000. I try to imagine my town being wiped off the map, or a dozen 9/11's, but nothing really registers. Yet the disaster has gone from a neatly compartmentalized, abstract story, to something I can't stop thinking about.
The TV's coverage has reflected this change -- they've gone to full-court press. Is it because the networks finally got correspondents in place? Did they underestimate the story's traction? Or did they, too, have a hard time processing this far-away disaster? For all the suddenness of the tsunami, it seems to have taken a few days to realize this might be the most widespread catastrophe in our experience.
If it helps to think of the concrete, there's a second crisis looming as the disrupted water systems in 11 countries succumb to contamination. This time, at least, there's some warning, and an opportunity to intervene. It's at least something to do.
Taxi Cab Confessions
I was running late to an interview (meaning that, I wasn't certain I'd be 15 minutes early), so I decided to skip the subway in favor of a cab. I flagged one right outside my apartment and asked the driver to take me to a place we'll call Hospital X.
I try to take things in stride, really. And I try to be conscious of prejudice with mental illness. I read Shrinkette, dammit. But I can't deny my general state of alarm, as visions of "Taxi Driver" danced through my head. So I turned to my trusty smalltalk skills, and asked him why he didn't like the psychiatry at Hospital Y, often reputed to be the best.
OK, I thought. And a nice epitaph, to boot. I'm calming down. But then:
A finer endorsement, I cannot imagine. The traffic quickly cleared, and as we zoomed along the edge of Manhattan, I knew I could handle the upcoming interviews.
"Hospital X? I love that place. You work there?" he said, eyeing my suit.
"No, just interviewing," I replied. "So what's so great about Hospital X?" I figured I might get some first-hand insight into the operations of the emergency room, or an off-service department like ortho or surgery.
The cabbie replied, "It's the best psychiatry unit in the city. I've been there many times. I love it when they take me there."
I try to take things in stride, really. And I try to be conscious of prejudice with mental illness. I read Shrinkette, dammit. But I can't deny my general state of alarm, as visions of "Taxi Driver" danced through my head. So I turned to my trusty smalltalk skills, and asked him why he didn't like the psychiatry at Hospital Y, often reputed to be the best.
"Last time I was there, they had me next to these murderers from Riker's Island. I don't need that. I'm not a criminal, I just get confused sometimes."
OK, I thought. And a nice epitaph, to boot. I'm calming down. But then:
At the conclusion of his tirade, I realized I had stopped breathing. I forced some air out to say "Ha," weakly, as I tried to smile.
"Aww, look at THIS! Traffic on the FDR at this time of day? Of all the @%#(&#(*$&# luck to *#%($#(*# me upside the #$%@#* in the *$&##$*%. It kills me when we're in traffic. I make #@%&*!* money. It KILLS me. I oughtta drop you off RIGHT HERE for getting me into this *(#%&(*#%."
"Just kidding, buddy. Don't worry, I'm on seroquel."
A finer endorsement, I cannot imagine. The traffic quickly cleared, and as we zoomed along the edge of Manhattan, I knew I could handle the upcoming interviews.
Bring a Torch
REM's latest single notes that leaving New York is never easy. You might think they're talking about giving up on a relationship, moving on. In fact, they're singing about the Port Authority Bus Terminal at Christmastime. The ten o'clock riot at Gate 83 was more harrowing than anything I dealt with in the SICU.
A happier memory from New York came from a week earlier, when I attended a poetry reading to hear an accomplished medical student. Good stuff! And I'm sure we'll be seeing more of it in print, soon.
After the readings, there was an audience-participation haiku contest based on this story:
So inspired, I jotted down the following:
Alas, I lost the haiku competition. I can't recall the winning entry, other than it contained the term "glory hole." Tough crowd. Almost as tough as those holiday bus passengers.
Maybe next year.
A happier memory from New York came from a week earlier, when I attended a poetry reading to hear an accomplished medical student. Good stuff! And I'm sure we'll be seeing more of it in print, soon.
After the readings, there was an audience-participation haiku contest based on this story:
A 74-year-old Georgia woman is in serious condition after a man dressed as Santa Claus hit her in the face and head with a large piece of wood for no apparent reason, according to Local 6 News.
Police in Atlanta, Ga., said Elkin Donnie Clarke, 49, attacked Annie Ruth Nelson, 74, with a two-by-four piece of wood as she walked down a downtown street this weekend.
So inspired, I jotted down the following:
Santa rearranged
Old St. Nick with a yule log
could it be ... Satan?
Alas, I lost the haiku competition. I can't recall the winning entry, other than it contained the term "glory hole." Tough crowd. Almost as tough as those holiday bus passengers.
Maybe next year.
Metaphase
CodeBlueBlog is hosting this week's Grand Rounds. He advances the notion that the growth of medical blogging isn't simply geometric, but rather...
Well said. But then later he dubs me the progenitor, which probably has more to do with my name than anything else. The first medical weblogger is Dr. Jacob Reider, who continues to advance the field with his academic approach to blogging, and his useful medlogs.com aggregator. Medical blogging would simply not be where it is today without him, and his colleague David Ross.
As for where it's going, well, beats me. The weekly linkfest continues to feature a nice mix of established writers and newbies, with interesting and different perspectives. Compared to automated aggregators, or year-end Web awards, I think the format of Grand Rounds -- with its rotating host / editors -- is most likely to bring good writing to the attention of regular readers.
But I might be biased.
Tune in next week when Codeblog: Tales of A Nurse gets a turn.
...A sort of medical blog meiosis that assures the mixing of information, the distribution of characteristics, and the spontaneity provided by point mutations.
There are not just clones budding throughout the medical blogosphere; rather, we are watching unique individuals produced with information crossed, passed, and punctuated by individuals who live all throughout the map of modern healthcare.
Well said. But then later he dubs me the progenitor, which probably has more to do with my name than anything else. The first medical weblogger is Dr. Jacob Reider, who continues to advance the field with his academic approach to blogging, and his useful medlogs.com aggregator. Medical blogging would simply not be where it is today without him, and his colleague David Ross.
As for where it's going, well, beats me. The weekly linkfest continues to feature a nice mix of established writers and newbies, with interesting and different perspectives. Compared to automated aggregators, or year-end Web awards, I think the format of Grand Rounds -- with its rotating host / editors -- is most likely to bring good writing to the attention of regular readers.
But I might be biased.
Tune in next week when Codeblog: Tales of A Nurse gets a turn.
Over there
I sometimes wonder if this blog should devote itself exclusively to the writings of surgeon Atul Gawande. The big concern is that I wouldn't be able to keep up (I already missed the boat covering his latest New Yorker piece).
In last week's NEJM, Gawande wrote on combat medicine, providing some blockbuster statistics in his usual understated, enlightening manner:
He goes on to discuss the transformation of front-line trauma care since Vietnam, and some of the remarkable people behind it. One comes away with a greater appreciation of what the tiny number of army physicians and surgeons have accomplished in Iraq. There are implications for our civilian trauma management, as well (lengthy stabilization in the field or community hospital may not be in the patient's best interest).
I understand there was some controversy over how his article was presented, because he's not a trauma surgeon and is not involved with the war. But to me, his points are so clear and salient, I can't see how readers are disserviced. Plus, as becomes obvious from his reporting, the doctors in Iraq don't currently have the time to write.
In last week's NEJM, Gawande wrote on combat medicine, providing some blockbuster statistics in his usual understated, enlightening manner:
When U.S. combat deaths in Iraq reached the 1000 mark in September, the event captured worldwide attention. Combat deaths are seen as a measure of the magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is — and not just the enemy's weaponry — in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period.2 The difference appears to be our trauma care system: mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.
We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In World War II, 30 percent of the Americans injured in combat died.3 In Vietnam, the proportion dropped to 24 percent. In the war in Iraq and Afghanistan, about 10 percent of those injured have died. At least as many U.S. soldiers have been injured in combat in this war as in the Revolutionary War, the War of 1812, or the first five years of the Vietnam conflict, from 1961 through 1965 (see table). This can no longer be described as a small or contained conflict. But a far larger proportion of soldiers are surviving their injuries.
He goes on to discuss the transformation of front-line trauma care since Vietnam, and some of the remarkable people behind it. One comes away with a greater appreciation of what the tiny number of army physicians and surgeons have accomplished in Iraq. There are implications for our civilian trauma management, as well (lengthy stabilization in the field or community hospital may not be in the patient's best interest).
I understand there was some controversy over how his article was presented, because he's not a trauma surgeon and is not involved with the war. But to me, his points are so clear and salient, I can't see how readers are disserviced. Plus, as becomes obvious from his reporting, the doctors in Iraq don't currently have the time to write.
Sports Medicine
For years, the Boston Red Sox received care from UMass Medical (despite the fact that the campus is not particularly close to Fenway Park). After team physician Arthur Pappas* retired, Sox care fell to Dr. Bill Morgan. He made a lucrative deal with St. Elizabeth's in Brighton, and sent the Sox players to his new sports medicine center there. Then, a few years ago, Beth Israel-Deaconness became the Sox care center, though Bill Morgan stayed on as team physician.
Now, the winds of change are blowing again:
These maneuvers are big business, even here in New York (where Sox cap sightings currently outnumber Yankees caps 3:1). NYU Med Center apparently paid the Mets a lot to be the caretakers of New York's other baseball team. And even though they advertise it prominently, even this relationship isn't clear cut:
Obviously sports teams want the best physicians and resources to get their injured athletes back on the field. And obviously hospitals want to show people that they've got such physicians in their ranks.
I only bring this up because, at some level, the privilege of caring for sports figures amounts to hired celebrity endorsements for hospitals. There are many ways to attract patients to a particular hospital, but this method isn't particularly grounded in the patient's best interests. Why not tout improved outcomes or other evidence-based data? Wouldn't you rather have surgery at a place with the lowest complication rates, instead of just going where Pedro goes? Wouldn't your answer be influenced if Pedro's team was reimbursed for the chance to care for him?
People routinely criticize pharmaceutical companies for vague direct-to-consumer advertising. They say it's wasteful spending and gives patients false impressions. I have yet to hear these people, however, speak out against hospitals involved in a similar practice. This issue will only grow larger as more hospitals seek, and advertise, relationships with sports teams and celebrities.
*Full disclosure: I once rode in an elevator with Dr. Arthur Pappas.
Now, the winds of change are blowing again:
The Red Sox are reportedly negotiating with Massachusetts General Hospital and Beth Israel Hospital for the care of their players. Morgan is employed in Brighton at St. Elizabeth's Hospital, which is also believed to be bidding to care for Sox players.
Though the Sox established a relationship with Beth Israel shortly after the current ownership took control of the team, recent indications suggest Sox players will end up under the care of doctors at Mass. General.
These maneuvers are big business, even here in New York (where Sox cap sightings currently outnumber Yankees caps 3:1). NYU Med Center apparently paid the Mets a lot to be the caretakers of New York's other baseball team. And even though they advertise it prominently, even this relationship isn't clear cut:
The widely respected Altcheck, who is associated with the Hospital for Special Surgery, was replaced in 2001 when NYU and the Hospital for Joint Diseases paid the Mets for the right to provide the team physicians.
In a carefully worded release, the Mets claimed the two sides amicably ended their association. But the Mets were a medical mess last season.
Obviously sports teams want the best physicians and resources to get their injured athletes back on the field. And obviously hospitals want to show people that they've got such physicians in their ranks.
I only bring this up because, at some level, the privilege of caring for sports figures amounts to hired celebrity endorsements for hospitals. There are many ways to attract patients to a particular hospital, but this method isn't particularly grounded in the patient's best interests. Why not tout improved outcomes or other evidence-based data? Wouldn't you rather have surgery at a place with the lowest complication rates, instead of just going where Pedro goes? Wouldn't your answer be influenced if Pedro's team was reimbursed for the chance to care for him?
People routinely criticize pharmaceutical companies for vague direct-to-consumer advertising. They say it's wasteful spending and gives patients false impressions. I have yet to hear these people, however, speak out against hospitals involved in a similar practice. This issue will only grow larger as more hospitals seek, and advertise, relationships with sports teams and celebrities.
*Full disclosure: I once rode in an elevator with Dr. Arthur Pappas.
The next generation
Here's something I noticed about my team a few weeks back:
Everyone was either a child of a physician... or a child of immigrants. One guy was both.
I suppose that says something about the pools that medicine draws from. Assume that, if you go into medicine, you have to think you'll love it. That expectation seems to come from either growing up around doctors, or from a residual old-country respect for physicians.
These are deep-seated influences, to be sure. And it's encouraging to think that future physicians are inspired by a familiarity with, or notion of, the importance of doctoring.
But maybe carrying these notions with us is the only way to get through the process of becoming a doctor. No other motivation seems to be doing the trick as reliably.
Everyone was either a child of a physician... or a child of immigrants. One guy was both.
I suppose that says something about the pools that medicine draws from. Assume that, if you go into medicine, you have to think you'll love it. That expectation seems to come from either growing up around doctors, or from a residual old-country respect for physicians.
These are deep-seated influences, to be sure. And it's encouraging to think that future physicians are inspired by a familiarity with, or notion of, the importance of doctoring.
But maybe carrying these notions with us is the only way to get through the process of becoming a doctor. No other motivation seems to be doing the trick as reliably.
Housekeeping
Head on over to Dr. Emer's Parallel Universes to see this week's Grand Rounds. He's done a great job organizing the best posts from the growing number of medical blogs.
Thanks to all for the comments and emails after my last post, about future Grand Round hosting. Sorry if I haven't gotten back to you all. The time I'm spending on interviews, the SICU, and the diversions of this island has really cut into blog-related activities. And sleep. Suffice to say, we've got a lot of new interested participants and I hope to be contacting them and making up the schedule soon.
Be sure to check out CodeBlueBlog next week, for Grand Rounds #13.
Thanks to all for the comments and emails after my last post, about future Grand Round hosting. Sorry if I haven't gotten back to you all. The time I'm spending on interviews, the SICU, and the diversions of this island has really cut into blog-related activities. And sleep. Suffice to say, we've got a lot of new interested participants and I hope to be contacting them and making up the schedule soon.
Be sure to check out CodeBlueBlog next week, for Grand Rounds #13.
An Evening in the Examining Room
Dr. Charles hosts this week's edition of Grand Rounds. What can I say? He makes me want to read my post over again.
I count 26 entries, which is a record. Also, seven entries come from blogs I've never heard of before. But they're good, so go check it out! And the Carnival of the Caregivers marches on. Here are the upcoming hosts for Grand Rounds:
12/14/04 Parallel Universes
12/21/04 Code Blue Blog
12/28/04 CodeBlog: Tales of a Nurse
1/4/05 Rangel, MD
1/11/05 Chronicles of a Medical Madhouse
Parallel Universes will be our first international host; Dr. Emeritus hails from the Philippines.
CodeBlueBlog, in addition to distinguishing himself as the master medical sleuth of the blogosphere, will be our first host who's involved with Tangled Bank, the Carnival of the Scientists.
Geena from CodeBlog will be our first repeat host, for several reasons. Her first gig was spectacular yet received no Instalanche (the Professor was on vacation). Also, she was willing to host right smack in the middle of the holidays. These nurses, they're saints (and if Instapundit is on vacation again, well, I'm just going to hit Refresh on my browser a few thousand times).
If you want to host Grand Rounds, drop me a line. I've tried to favor bloggers who write mostly about medicine, who've been around a while, and who post at least weekly. There are more such medical blogs that I've been meaning to solicit, but not many more.
I've received hosting offers from political blogs that happen to be written by health care professionals, from spankin' new blogs, and from blogs that are infrequently updated. I'm more reluctant to give them the spotlight of hosting Grand Rounds, but at the same time, I'd like to see what some of these writers come up with. And I'm not quite ready to cycle through the original hosts again. Any thoughts on this matter? Let me know.
I count 26 entries, which is a record. Also, seven entries come from blogs I've never heard of before. But they're good, so go check it out! And the Carnival of the Caregivers marches on. Here are the upcoming hosts for Grand Rounds:
12/14/04 Parallel Universes
12/21/04 Code Blue Blog
12/28/04 CodeBlog: Tales of a Nurse
1/4/05 Rangel, MD
1/11/05 Chronicles of a Medical Madhouse
Parallel Universes will be our first international host; Dr. Emeritus hails from the Philippines.
CodeBlueBlog, in addition to distinguishing himself as the master medical sleuth of the blogosphere, will be our first host who's involved with Tangled Bank, the Carnival of the Scientists.
Geena from CodeBlog will be our first repeat host, for several reasons. Her first gig was spectacular yet received no Instalanche (the Professor was on vacation). Also, she was willing to host right smack in the middle of the holidays. These nurses, they're saints (and if Instapundit is on vacation again, well, I'm just going to hit Refresh on my browser a few thousand times).
If you want to host Grand Rounds, drop me a line. I've tried to favor bloggers who write mostly about medicine, who've been around a while, and who post at least weekly. There are more such medical blogs that I've been meaning to solicit, but not many more.
I've received hosting offers from political blogs that happen to be written by health care professionals, from spankin' new blogs, and from blogs that are infrequently updated. I'm more reluctant to give them the spotlight of hosting Grand Rounds, but at the same time, I'd like to see what some of these writers come up with. And I'm not quite ready to cycle through the original hosts again. Any thoughts on this matter? Let me know.
Sponge Count Squareness
Atul Gawande has a new book coming about that most egregious operating room mishap: when a sponge or clamp is left behind. I wrote about his last book, Complications, back in February (twice). Now Douglas Starr of the Boston Globe Magazine has interview with the author of When One Is Missing:
Anesthesia was the first field to institutionalize this viewpoint, and it led to a dramatic decrease in dosing mistakes. Now that kind of systems approach is coming to surgery (and other fields) with all its obviousness. As Gawande remarks in the article:
Some common-sense solutions, and neat statistics, are found within the paper. Read the whole thing.
"Anytime you hear that someone has left a 12-inch retractor in a patient, you think, `What kind of idiot did that?'"
But what if the surgeon wasn't an idiot - in the same way that not every pilot in a plane crash is an incompetent? That's the question that has medical experts beginning to take an engineer's view of hospitals. Rather than see them as warrens of individual doctors and nurses, the new view posits them as complicated human and mechanical systems with small, undetected flaws that can make mistakes inevitable. To borrow the airline industry's language, it isn't pilot error that causes most mistakes, but subtle system problems instead. Gawande's simulation conforms to a growing interest in finding new ways to reduce medical errors - not by punishing doctors after the fact, but by building more safeguards into the system.
Anesthesia was the first field to institutionalize this viewpoint, and it led to a dramatic decrease in dosing mistakes. Now that kind of systems approach is coming to surgery (and other fields) with all its obviousness. As Gawande remarks in the article:
"For God's sake," he says, "you can't walk out of a bookstore without an alarm going off. How can a patient leave an OR with an instrument inside him?"
Some common-sense solutions, and neat statistics, are found within the paper. Read the whole thing.
Touching Me, Touching You
In New York right now there's news about one family's attempt at receiving a kidney donation. After 10 months renal failure following a rare cancer, the sister of Neil Diamond (not the singer) placed an add on Craig's List on his behalf.
Here is one early report of the effort, and I've since found two new pleas for kidneys. The story has been picked up by mainstream New York media.
(Aside note: Not to make light of their situation, but if Diamond's eventual donor is named Caroline, I think you'd have to call it poetic justice).
This Craigslist post is a new wrinkle in the method employed by Todd Krampitz this past August. Krampitz caused outrage when he bought billboard space and took out ads, all asking for a liver. Some feared we were heading toward a system where the wealthy could publicize their need for an organ, but the poor would suffer in anonymity.
Yet the Diamond family has achieved at least the publicity that Todd Krampitz did, even though posting to Craig's List is free. I suspect, however, the "me-too" posters are less fortunate.
There's lots of potential stories here:
I was fortunate to recieve some informed commentary from a Gift of Hope coordinator. He has written before on the details of organ recovery (pdf, page 6).
He wrote a lot to blogborygmi, but Haloscan cut it off. Also, it was the comments to an unrelated post. So I'm reprinting what I can here, because his expertise deserves at least as much space as my armchair meanderings or the Daily News' sensationalism (emphases mine):
Looking at the statistics, I'm inclined to think the transplant situation in the US can't get much worse, or at least, these "outside-the-system" efforts won't hurt it. Also, I'm heartened that the UNOS people seem interested in what polling Americans on what they prefer, and try to get the public to understand the donation.
I think it's pretty clear what allocation system the Diamond and Krampitz families prefer, if UNOS is polling them. And really, whose voices matter most in these situations: those of the patients and donors, or those of the masses, who UNOS can't seem to educate anyway?
But my few encounters with the transplant process pale in comparison to what the UNOS people endure every day. I just hope their frustrations aren't blinding them to radical but promising solutions.
Here is one early report of the effort, and I've since found two new pleas for kidneys. The story has been picked up by mainstream New York media.
(Aside note: Not to make light of their situation, but if Diamond's eventual donor is named Caroline, I think you'd have to call it poetic justice).
This Craigslist post is a new wrinkle in the method employed by Todd Krampitz this past August. Krampitz caused outrage when he bought billboard space and took out ads, all asking for a liver. Some feared we were heading toward a system where the wealthy could publicize their need for an organ, but the poor would suffer in anonymity.
Yet the Diamond family has achieved at least the publicity that Todd Krampitz did, even though posting to Craig's List is free. I suspect, however, the "me-too" posters are less fortunate.
There's lots of potential stories here:
1) the New York Daily News editor replacing "ailing" with the misleading "dying" in the front-page story (Diamond's condition is managable).
2) the fact that Krampitz, as far as we know, has a malignant tumor that will likely claim his new liver in time. Did the donors know? Do people lining up from Diamond know he's not dying (see #1)
3) Dave Winer tried something similar on his blog last year, for friend Dave Jacobs. The attempt failed to catch on and Jacobs is still waiting for a donor. Is online solicitation really the way of the future, or simply a case of using the right publicity at the right time?
4) Will any of these public cries for help raise awareness about the shortage of organs? Or, better yet, lead to any improvements in organ recovery?
I was fortunate to recieve some informed commentary from a Gift of Hope coordinator. He has written before on the details of organ recovery (pdf, page 6).
He wrote a lot to blogborygmi, but Haloscan cut it off. Also, it was the comments to an unrelated post. So I'm reprinting what I can here, because his expertise deserves at least as much space as my armchair meanderings or the Daily News' sensationalism (emphases mine):
Private publicity campaings since they are cheap, and at least in the case of Mr. Krampitz effective are here to stay, but they shouldn't be dismissed as being without consequence.
The current UNOS policy on "directed donations" allow a donor family to name an individual to receive a specific organ. If the organ is not a medically suitable match it is then allocated according to UNOS allocation policy. (A family cannot btw discriminate based on age, sex, race, religion etc., nor can they demand that a class of patients such as those with HIV or alcoholic cirrhosis be excluded as a possible match).
There is no requirement that the donor or their family have any pre-existing relationship with the potential recipient.
The donation/transplanatation community is in an difficult position, because we need publicity to raise awareness of the need for families to consent to donation, and there are few effective options for touching the hearts and minds of the public beyond attaching a real individual's face and story to a faceless group of 87000 people. Private publicity campaigns certainly raise awareness.
To further complicate mattters, each cadaveric donor, on average donates 3 or 4 organs (up to 8 are possible) and many more benefit from tissues recovered from such a donor. Aside from the "directed donation" of a single organ, many more can benefit from the donor's gift. So while one organ may be allocated "outside the system", several more would be used for those determined to have the greatest need.
It is possible (though hopefully unlikely) that creating a policy denying the family the option of "directed donoation" to someone they have no relationship with could cause them to refuse donation altogether, which helps nobody.
If things are left as they stand, there is a good chance that public pleas for a directed donation will become so commonplace that they will fade into the noise of the information age and lose their impact. Another outcome is that such pleas may cause the American public to lose faith in the allocation system altogether.
We have reached a point in the shortage of donor organs where transplanting the entire waiting list of 87000 is a mathematical impossiblility. Our only hope is to continue to refine the system to prevent death on the waiting list by transplanting those with the most urgent medical need first. Poll after poll of the American public confirms that this is the way they want the allocation to be done. By circumventing the allocation system through directed donations on a large enough scale, this barely feasible goal will become impossible.
The policy on directed donations must change, sooner than later, before either scenario can come to fruition. But we can't seem to get across even the most basic of messages in many cases, and trying to get the public to understand that such a change is for the greater good would be difficult indeed.
Looking at the statistics, I'm inclined to think the transplant situation in the US can't get much worse, or at least, these "outside-the-system" efforts won't hurt it. Also, I'm heartened that the UNOS people seem interested in what polling Americans on what they prefer, and try to get the public to understand the donation.
I think it's pretty clear what allocation system the Diamond and Krampitz families prefer, if UNOS is polling them. And really, whose voices matter most in these situations: those of the patients and donors, or those of the masses, who UNOS can't seem to educate anyway?
But my few encounters with the transplant process pale in comparison to what the UNOS people endure every day. I just hope their frustrations aren't blinding them to radical but promising solutions.
Vocal Folds
I began writing a song last night in the ICU. It's called "Midnight Bronchoscopy." It's blues, based on the alarms of the mechanical ventilator. I'm particularly fond of the alarm progression that, when you let your mind go, almost sounds like the machine is saying, "I-am-not-breath-ing." If anyone with skills can get an mp3 sample of this alarm, I'll cut you in on royalties.
All I know so far is that the song begins, "Midnight bronchoscopy / what have you done to me?" I'm not sure if it's told from the patient's perspective, or that of the sputum-covered student. I think the song should end on an upbeat note, too, with some improved breathing, some samples for micro, and the promise of a portable chest film ruling out bronchopleural fistula.
All I know so far is that the song begins, "Midnight bronchoscopy / what have you done to me?" I'm not sure if it's told from the patient's perspective, or that of the sputum-covered student. I think the song should end on an upbeat note, too, with some improved breathing, some samples for micro, and the promise of a portable chest film ruling out bronchopleural fistula.
The Hand of Spector
Jonathan Spector is many things to many people. Now, he's developed a relationship with the good folks from Passion of the Present.
When you combine his ground experience and Passion's, well, passion for raising awareness, I hope good things could finally happen for Sudan.
And if that doesn't work, they're re-recording "Do They Know It's Christmas?" This version will feature Keane, Snow Patrol, The Darkness, Dido, and Radiohead's Thom Yorke. Bono returns with his piercing lyric, "Tonight thank God it's them instead of you." Blur's Damon Alban was on hand but did not sing.
Hat tips: Ingrid.
When you combine his ground experience and Passion's, well, passion for raising awareness, I hope good things could finally happen for Sudan.
And if that doesn't work, they're re-recording "Do They Know It's Christmas?" This version will feature Keane, Snow Patrol, The Darkness, Dido, and Radiohead's Thom Yorke. Bono returns with his piercing lyric, "Tonight thank God it's them instead of you." Blur's Damon Alban was on hand but did not sing.
Hat tips: Ingrid.
Shattered
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:
And later:
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."
Beneficent
Go check out blog.bioethics.net (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:
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.)
...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?
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:
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:
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:
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:
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.
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):
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.
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):
| weapon | projectile mass (grams) | velocity (m/s) | KE (J) |
| paintball gun | 3 | 80 | 10 |
| FN303 | 8.5 | 90 | 35 |
| handgun | 7-10 | 300 | 330 |
| RCC-95 | 16? | 130 | 135? |
| fastball | 145 | 42 | 128 |
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.
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