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.

"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:

"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 *(#%&(*#%."
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.

"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:

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.


CodeBlueBlog is hosting this week's Grand Rounds. He advances the notion that the growth of medical blogging isn't simply geometric, but rather...

...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:

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:

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.


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.

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.

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:

"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:

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.

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.


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 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:

...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 / yahoo.com

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:

ESPN.com 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 / blogborygmi.com).

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!

All Saints' Day

The Dean's Letter goes out to residency programs tomorrow, November 1st. Our applications are complete at that time, and there's nothing left to do but sit and wait for more interview offers.

The Dean's letter, also called the Medical Student Performance Evaluation, is an overview of all our clerkship grades and evals. Most of the comments doctors and residents gave us in the past year find their way into this document. At our school, students are given a chance to correct grammatical mistakes and errors. It's a good thing, too -- I spotted one evaluator's comment that read:

Clearly, Nick was one of the students this past year.

I really hope an adjective was missing.

But in talking with my peers, many who are usually well-balanced and easy-going, we have discussions that George Orwell and Garrison Keillor could both enjoy. It's because we've become adept at reading between the lines of evaluations.

"Outstanding" is the best adjective to describe your candidacy for residency. It's nice to have it mentioned as often as possible, in fact: next to your people skills, your initiative, your knowledge base. "Excellent", by contrast, is really a let-down. It's the second-best adjective. Only in medical school can someone dread being called "excellent," but it happens. And don't get me started on "Very Strong" or "Very Good". That's damning by faint praise, as far as I'm concerned.

Maybe it's different at other schools, but I thought this was the code all program directors used. Actually, it's discouraging to think some of my graders might employ real English, and some are using eval-speak.

Fall classic

I slept for a long time last night, catching up on a deficit spent on the ALCS, the World Series, Halloween parties, and pediatrics call. This morning, I experienced the pleasant gift of an unearned extra hour.

I wrote about Daylight Saving in the spring. But it's a topic whose time has come again.


There's so much love in New England right now. Last night, for instance, I saw strangers share many a weepy embrace. Families strolled the eclipse-lit streets at midnight. I myself high-fived over two hundred people.

We took pictures with the man wearing a functional replica of the Fenway scoreboard. We cheered the cops and taxi drivers as they slowly rode by. There was even a guy handing out Baby Ruth candy bars in Central Square. It was perfect: don't just beat the curse -- eat it.

Yes, there's a spirit of magnanimity in the air, a generousity that comes naturally from a land that has produced this year's NFL and MLB champions.

With this in mind, here's a big thank you to my readers. October will break blogborygmi traffic records, which is kind of unexpected because 1) I think I'm posting less and 2) the Grand Rounds instalanche was back in September. But this has been a month of pleasant surprises...

Also, I have to thank the commenters, who have made so many posts more interesting and enjoyable by sharing their thoughts.

The mark of courage

Did I mention how great my readers are? Erin writes:

I'm desperately seeking a photo of the FrankenSchilling
sutures, due to a bargain I made with god/satan/whoever
regarding the World Series.

I can't find a picture anywhere, but I'm wondering
if any of you, with your expertise, could hazard a
guess as to what that must have looked like?
Vertical or horizontal? Above or below the ankle
bone? I promised the ghost of Babe Ruth that if
the Sox won this series, I'd tattoo those sutures
to my ankle.

First, take the time to get this right. Everyone will be talking about this magical month for the rest of their lives, but you'll have something to point to. Make sure it's accurate. Ask a surgeon blogger, or someone who's named his blog after a stitching technique. Or, hey, try asking Curt Schilling himself -- he posts to Sons of Sam Horn...

Failing that, at least print out a picture of a dislocated peroneal tendon and show it to your artist.

But from what I've gathered (and from Noah's input) I think you'll have four stitches total. They'll be in pairs over the outside knob of the right ankle (lateral malleolus). On each side of the forward-displaced tendon, two stiches, running lengthwise and parallel to the tendon, made a new groove for it to slide in.

I also heard Schilling had four sutures in Game 6 of the Yankees series, but Dr. Bill Morgan and company used only three in Game 2 of the World Series.

Good luck!

Calling a Code

Geena's the first nurse to host Grand Rounds, over at CodeBlog.* Go check out the latest and greatest in the medical blogosphere.

*(Not to be confused with CodeBlueBlog, cited below.)

A tale of two mobs

Bravo to CodeBlueBlog for asking a question that's somehow slipped everyone's mind:

How, exactly, did Victoria Snelgrove die?

This 21-year old fan took to the streets with thousands of others after the Red Sox beat the Yankees in Game 7 early Thursday morning. The police were called in, armed with new weapons purchased (but not used) for crowd control at the Democratic National Convention. Some poorly trained officers sprayed pepper-bullets into the mob. Snelgrove was struck in the eye and died hours later.

CodeBlueBlog is right to criticize the media's coverage of this sad event. At this point, no one in the press actually digging up facts anymore. The ratio of commentary to real news is so out of whack, you have to wade through hundreds of "me too" articles on Google News just to find out the smallest wrinkle in the story. The press has become just as unruly and misguided as the drunken revelers they're criticizing. The key questions -- mechanism of death, coroner's report, past medical history -- are not even being asked, as far as I can tell.

So, props to Code Blue for raising these questions. He performed an armchair literature survey of similar accidents -- above and beyond anything unearthed in the mainstream media. His findings? Among the hundreds of cases of paintball-to-eyeball injuries recorded, none resulted in death. Something's fishy here, and the truth may illuminate some of the polarized policy discussion now underway (Bostonians are being asked to either reinstate Prohibition or submit to the stormtroopers).

It's interesting though, that CodeBlue thinks the media's rush to commentary has led to an anti-police bias. I think the Boston press has been unconscionably pro-police, at a time when even the cops are admitting a major error. Either way, this debate needs more data, and journalists are failing us.

It's a sad coincidence that Snelgrove herself was a journalism student. I like to think she still has a story to tell -- if only her peers were asking the right questions.


Malcolm Gladwell writes with an outsider's clarity and wit, which has served him well in such books as the Tipping Point, an excellent and readable introduction to phenomena in sociology and marketing. Hell, he can even make ketchup compelling.

But he's now tackling drug prices, and while he makes some excellent points, I wonder if his final conclusion isn't off the mark.

It is accurate to say only that the United States has a different pricing system from that of other countries. Americans pay more for drugs when they first come out and less as the drugs get older, while the rest of the world pays less in the beginning and more later. Whose pricing system is cheaper? It depends...

In fact, drug expenditures are rising rapidly in the United States not so much because we’re being charged more for prescription drugs but because more people are taking more medications in more expensive combinations. It’s not price that matters; it’s volume.

So true, and not emphasized enough. But then Gladwell focuses on a significant problem in prescription drugs: new meds with side-benefits that aren't cost effective or particularly efficacious. An example he gives is pravachol (one of many "me too" cholesterol-lowering drugs), which was shown to lower strokes in a small, select population but actually raises stroke incidence in a bigger, more vulnerable population.

He doesn't squarely blame the drug companies for advertizing these benefits, and he doesn't exclusively blame doctors for overlooking the caveats buried in the scientific literature. Instead, he implicates a new target: medical journal editors, for not doing their jobs and properly highlighting the advantages and drawbacks to new drugs. This criticism is all the more damning, since a powerful former editor, Marcia Angell of the NEJM, has just written a book about Big Pharm's duplicity (and, um, dropped the ball on pravachol).

I've edited some manuscripts myself (for publications with substantially smaller impact than the New England Journal of Medicine), but can still vouch for its difficulty. Clarifying the results and conclusions of some scientist-authors can be like herding cats. And even after I've done a spiffy job, I still can't be sure which section of the paper, which figure or conclusion, will be seized upon by other authors. Some data that I considered superfluous might be the puzzle piece that allows another lab to move forward.

I don't think it's different for clinical publications on drug efficacy. I'd bet that, no matter what results an author uncovers, and no matter how skillfully these results are arranged and highlighted by an editor, drug company marketers will still find material to work with. They'll always be able to find obscure, questionable benefits to justify new drug prescriptions over less-profitable generics. These results will make their way into Big Pharma handouts and presentations, where they'll be repeated ad naseum for years. They've got more money, and they've got more interest. The editors can't compete.

Via Medrants.

Social services

Kevin highlights a BMJ article about a male nursing home resident with a pressing need:

It seemed that Mr Cooper had persistently been asking female members of staff to have sex with him. The problems seemed to have begun when Mr Cooper's regular visits from an elderly female friend had ceased.

Although rather deaf and undoubtedly frail Mr Cooper did not have significant cognitive impairment. He volunteered that his visitor had been providing him with paid sexual services, and that since this was no longer possible he wanted to hire another prostitute. He said his deafness and poor vision had now made it difficult for him to do this for himself, and he had consequently sought help from the staff. He had been firmly refused. I gathered that after a stalemate of many months he could think of nothing to do other than proposition the staff.

As usual, Europeans have a very sophisticated approach to these matters. I recall a story earlier this year in which an unemployed German man asked his government to finance his sexual activities, since his wife was couldn't return to his country.

This case also reminds me of the uproar when health plans started covering Viagra but continued to exclude birth control pills. Why is restoring intercourse considered a medical necessity, but preventing its consequences is considered a lifestyle choice?

I never had a good answer, until I read of the havoc caused by this libidinous nursing home patient:

His situation deteriorated. An extra male staff member was hired, devoted solely to following him around all day to prevent him from making improper suggestions. Both the staff member and Mr Cooper found this constant observation trying.

Later, staff at the residential home obtained the telephone numbers of prostitutes, and one agreed to meet Mr Cooper at a neutral venue. The staff were still divided, although the man who had followed Mr Cooper's every tottering step for many weeks was reported to be relieved.

Read the whole thing.

Uncharted territory

So, um, the Sox beat the Yankees.

Here's a simple guide to peroneal tendon dislocations, like the kind that used to bother Sox ace Curt Schilling. Judging by his bloody red socks, and this Bill Morgan transcript, it seems the tendon was anchored out of its anatomical location, to a site anterior to the lateral malleolus:

JD: “I’m still not sure I understand how you create a wall, what did you attach the sutures to? Skin to skin and that created what, a barrier? Is that the deal?”

Dr.M: “Well the tendon is out of position and out in front of the bone and the problem is that it would slip back again to where it was supposed to be and then slip out again. And it was really just to create a barrier between the skin and the underlying tissue which is called facia so that there wasn’t let’s say a tunnel subcutaneously underneath the skin, it just kind of anchored the skin through the underlying tissue so it would stick the tendon where it was supposed… where it was, so it couldn’t sublux at all."

JD: “If I understand you correctly, you sewed this in a position with the tendon not where it eventually will be when it’s repaired, it’s out of position for the entire game last night?”

Dr.M: “Just for last night. Those sutures are out now.”

GC: “And you assure us he’ll be ready for the World Series correct? You’ll do this again and have him ready for the World Series…”

I think they should change the Red Sox logo to reflect this groundbreaking procedure. Can we get a photoshop on this?

And I expect anatomical gift programs in the Boston area will experience a boom when fans learn how cadavers were used to guide the Sox to victory:

Epstein spoke of how [Sox doctor Bill] Morgan practiced the procedure on cadavers (a common exercise for orthopedists) before using it on Schilling. After applying the anesthetic Marcaine to the area, Morgan sewed in three stitches directly through the skin and attached them to both ligament and deep connective tissue located next to the ankle bone itself. Schilling was satisfied that the procedure had worked during a light throwing session before Monday's Game 5. On Tuesday night, he was proven right.

They'll try it again before Game 2, apparently.

Stitched together

I'm going to continue these late-night ramblings because, as has been the case all week, the Red Sox Are Facing Elimination and in 24 hours I might be too depressed to share.

Bill Simmons, the Boston Sports Guy, pulls off the difficult job of relating the Fenway experience to both die-hard fans and perplexed outsiders:

For two straight days, I watched my beloved Red Sox stave off elimination against the Yanks, needing 26 innings over 27 hours to stay alive for Game 6 in New York. These weren't just baseball games. They were life experiences. They broke you down in sections. They made you question God, the meaning of life, whether sports should possibly mean this much. On Sunday night, I stewed in my seat vowing never to raise my kids as Sox fans. On Monday night, I skipped out of Fenway wondering if any other team could possibly mean this much to a group of people.

...Game 4 ended a little after 1:30 a.m. Fifteen hours later, I was sitting in my same seats in section 116 with my father, glancing around and wondering if we ever actually left. Apparently we did. There was only one major difference between the two nights: in Game 4, the fans were waiting for the Yankees to win the game. In Game 5, the fans were waiting for the Red Sox to come through. Now everyone in New England is pinning their hopes to the greatest comeback in baseball history. It happens that fast.

Emphases mine. Some of the best writing on the Red Sox is coming up at Surviving Grady. Start at the bottom and work your way up from the despair of the early Yankees drubbings, to the whiff of respectability when we won one, to the glimmer of hope Tuesday morning. Now? Chest-thumping and a dare to dream. On the ankle-sutured heroics of Curt Shilling, Red says:

The absolute fantastic-ness of this event is impossible to overstate. Two days ago, he was a gimp. A horrific footnote [pardon the pun] to the 2004 season. A million dollar horse that went tits-up when we needed him most.

But then the balls took over. And he was literally a one-legged guy at an ass-kicking contest. And his cleat did find ample ass to strike. And he turned in a one-run-over-seven-innings performance with blood soaking through his socks and sweat coating his back.

It was simply the gutsiest thing MLB has witnessed all year.

On the flipside, we had A-Rod resorting to schoolboy tactics, blatantly knocking the ball from Arroyo's glove on a close play at first, then whining incessantly when he was called out for it.

Maybe God's finally paying attention. Maybe he sees what's up.

Yeah, a little boisterous, but everyone who's up and blogging about this right now is drunk on something. Read the comments to those posts, as well, because the fans are writing poetry.

Penetrating Trauma

I'm writing this Red Sox story now, because I can't predict my emotional state this time tomorrow. After the Sox momentum these past few days, the tale feels distant, and receding, but I suspect it can never be too far from our thoughts...

Last year, during Game 7 of the epic 2003 American League Championship Series matchup between the Yankees and Red Sox, I was on call. Admitting patients. To the Surgery team. Every day was a long slog but call days especially so; this one was bearable only though occasional dispatches from the nurse's lounge: "Sox up 5-2!" "Pedro's looking strong!"

By the eighth inning, I was on the floor, admitting a middle-aged guy with alcoholic pancreatitis. Volume depletion is a big problem with pancreatitis -- we needed to know how much urine this guy was making. Precision required a foley catheter.

I tried to inform the patient of this as he looked over my shoulder, at his wall-mounted TV. He was watching our tired ace, Pedro Martinez, give up one hit after another.

Me: "So, uh, you're going to need a foley."
Patient: "Why is he still in the game? He's done!"
Me: "A tube will go through your penis."
Patient: "Whatever. Take Pedro out of the game!"

I slowly set up my foley kit (in retrospect, this was probably my second or third career catheterization). I glanced over my shoulder a few times, seeing Pedro give up a run and manager Grady Little come out to the mound.

Me: "Looks like Pedro's out."
Patient: "No! They're leaving him in!"

Pedro then gave up a ground rule double to Hideki Matsui -- there were two on with one out in the eighth. The score was 5-3, Red Sox. Jorge Posada came up to bat. I tuned everything out as I inserted the foley.

As the tube went in, I glanced up at the patient's face and saw an expression of abject horror and revolting pain. I will never forget that look, and I never want to see it again. I assumed at this point I had just obliterated the man's prostate.

Me: "What is it?! What is it?!"
Patient: "Posada doubled! The game's tied."

I looked up at the TV and saw the real damage. Pedro was pulled after that -- two hitters too late. The Yankees went on to win the game and move on to the World Series. The Red Sox manager was fired shortly thereafter.

The 2004 season brought a new set of memories and frustrations to the Sox/Yankees rivalry, but never doubt that the sting from that Game 7 lingers in the hearts of New Englanders. All I have to do is remember that face, and a pain far worse than any foley.


The best and brightest in research, engineering, and medicine have been working nonstop to solve one of the most pressing problems facing the nation.

Of course, I speak of Red Sox Nation, and the problem of stabilizing Curt Shilling's right achilles tendon.

Reebok has built a custom high-top cleat to do the job. I expect to hear much more on this miracle of science soon, now that Game 6 has gone from "extremely hypothetical" to "Tuesday". For now, this story from the Globe will do:

The suspense surrounding Curt Schilling's possible return to the mound in the American League Championship Series intensified yesterday as the Red Sox indicated Schilling has found the footwear that would enable him to pitch if his injured right ankle permits it.

Manager Terry Francona said Schilling was experiencing normal soreness in his ankle the day after he tested a customized high-top cleat in his first bullpen session since his injury-shortened start in Game 1. The only problem was the shoe, built by Reebok, was too small and hurt Schilling's toes. He received a new pair of cleats yesterday.

"I think he's real comfortable with that high-top as long as he gets the right size," Francona said, indicating Schilling could pitch without an additional brace. "That was Plan A going out to the bullpen, and I think it worked pretty successfully."

The only remaining question was whether the footwear and a dose of the anesthetic Marcaine would permit Schilling to pitch effectively with a dislocated peroneal tendon. The tendon, whose protective sheath ruptured Sept. 26, runs around the back of his ankle.

"I think he kind of feels like we do, that the door isn't closed," Francona said. "Until it does [close], you keep the hope and faith, and try to work hard and do what you're supposed to do. We'll kind of see how it goes."

That attitude is slowly bringing us back from the brink, one game at a time. On a more personal note, residency matching has taken on an added dimension...

Vaccine fever

The flu vaccine shortage of 2004 has indirectly caused its first death:

LAFAYETTE, Calif. (AP) -- A 79-year-old woman who stood in line more than five hours for a flu shot collapsed and died after striking her head.

Marie Franklin and her husband, Robert, had been standing with hundreds of other seniors outside a Safeway supermarket on Wednesday when she became pale and weak. She collapsed as she walked toward shade.

Franklin, an award-winning local artist, died from those injuries Thursday. The Contra Costa County coroner's office ruled the death an accident.

"We see it as a fluke accident and choose not to blame anyone," said the Franklins' daughter, Ginni Poulos of Portland, Ore., who flew to her parents' home in the San Francisco Bay area city of Orinda. "We do think it could have been better organized. People wouldn't have had to wait so long if they had more workers or created a better system."

The daughter is exhibiting a fair and expansive attitude in a difficult time.

I wonder if the next victims' families will be so reasonable. Remember, you can't spell "fluke accident" without some of the letters in "flu vaccine shortage" (and when you have vulnerable patients waiting in lines overnights in October, you're bound to have more morbidity).

Why are patients being forced into this bizarre distribution system, anyway? If you're healthy enough to camp in line outside all night, you should be rewarded with concert tickets, not potentially lifesaving meds. At our pediatrics clinic, docs are making sure the infants with a history of lung disease get the influenza vaccine -- the most vulnerable, first. We're not having the kids arm-wrestle each other for it. So why are the elderly subjected to endurance tests?

Skin deep

Symtym's back with a spiffy new look. The custom skinning was implemented by Moxie. And that logo! A neat use of the icons behind medicine and law.

Anyway, he's got the goods on the VeriChip, the implantable RFID developed by Applied Digital Solutions and recently approved by the FDA. A transmissable past medical history would make my job in the emergency department a lot quicker... but maybe at a price (and I don't mean granulation tissue).

Spheres of influence

Galen's got some commentary on my post about influence and bias in journalism and medicine. And although he graciously identifies his political bent, he stays mum on his stance re: NoFreeLunch.

But hey, I'm staying quiet, too. I've got interviews coming up, and don't want to stake any positions more inflammatory than "the media could do a better job". (If a residency director ever quotes blogborygmi back to me in an interview, I will either rank that program #1 or claim someone has chosen my name as a pseudonym).

Anyway, I came across two interesting quotes about bias in journalism, and the state of the media:

"I think what happened to the media is ambition and stardom have overwhelmed purpose. People always talk about how there's a liberal bias and a conservative bias. But the main bias of the news is personal ambition, because a lot of choices are made based on not burning this source or not causing a conflict in an area that is your ladder upward.... the media is utilized purely as a strategy by people in power."

"Former CBS News-man Bernard Goldberg has written a best- selling book called Bias, in which he maintains that the real problem with the media is not a bias based on liberal vs. conservative or Republican vs. Democrat. It is a bias based on the sameness of worldview caused by social, intellectual, educational and professional inbreeding. These are folks who travel in the same circles, go to the same parties, talk to the same people, compare their ideas to people with the same ideas, and develop a standard view on issues that makes any deviation from them seem somehow marginal, or even weird."

The first quote is by Jon Stewart, host of the Daily Show, as told to Rolling Stone (sadly, the excerpt is only in the print version). The second quote comes from Pat Sajak.

In this era of celebrity journalists and fake news, we're lucky to have some entertainers with the insight and courage to call journalists to task.

Can I bring this back to medicine? Lemme try: Is there a medical equivalent to what Jon Stewart and Pat Sajak have done? Not unless the cast of ER starts giving interviews about the selfishness of doctors.

I don't think that's happened. The task of reigning in drug marketing's influence on doctors has been taken up by... doctors. And it's something to be proud of.

Update: Jon Stewart just went grapeshit on Crossfire today. Via metafilter. Some of the CNN transcript:

STEWART: What you do is not honest. What you do is partisan hackery. And I will tell you why I know it.
CARLSON: You had John Kerry on your show and you sniff his throne and you're accusing us of partisan hackery?
STEWART: Absolutely.
CARLSON: You've got to be kidding me. He comes on and you...
STEWART: You're on *CNN*. The show that leads into mine is puppets making crank phone calls. What is wrong with you?

and later:

STEWART: [after the presidential debates] you go to spin alley, the place called spin alley. Now, don't you think that, for people watching at home, that's kind of a drag, that you're literally walking to a place called deception lane? ...
BEGALA: ... They actually believe what they're saying. They want to persuade you. That's what they're trying to do by spinning. But I don't doubt for a minute these people who work for President Bush, who I disagree with on everything, they believe that stuff, Jon. This is not a lie or a deception at all. They believe in him, just like I believe in my guy.
STEWART: I think they believe President Bush would do a better job. And I believe the Kerry guys believe President Kerry would do a better job. But what I believe is, they're not making honest arguments. So what they're doing is, in their mind, the ends justify the means...
CARLSON: I do think you're more fun on your show. Just my opinion.
STEWART: You know what's interesting, though? You're as big a dick on your show as you are on any show.

And one point Stewart asks them to stop, stop, stop broadcasting, because they're hurting America. It's really something. The clip is available at Media Matters.


Over at Kill As Few Patients as Possible, Dr. Bradley and I have been going back and forth about embryonic stem cells, the public's perception of the issue, and how much Kerry should be castigated for a misstatement in the second debate.

I think we're coming to an agreement on the following:

1. Kerry's position is contorted
2. The media could do a better job
3. We're going to stay away from the 'is it murder' question

But you know, when I put it like that, it's sounds bland. Getting there is where the interest lies -- so go check it out.


Back in July I asked, "Where are the Med Students?" -- specifically, why are there so few medical student bloggers compared to law students?

One quote I used came from Mary, a law student who brought up this subject in March.

Now the topic is revived again, thanks to some deep digging from Izzy. Check out his perspective on the question, and some of the comments it generated (including a fun cameo by the aforementioned Mary).

I do look forward to the time when people stop asking, "where are the med student bloggers?" -- because soon I hope they'll be ubiquitous. Until then, consider visiting some of the student sites collected on my sidebar.

Round 3 goes to Kevin

Kevin, MD is bringing us this week's Grand Rounds. He's done a great job rounding up the best posts from medical bloggers. Check it out!

Here's the schedule for upcoming editions of Grand Rounds:

October 19 Echo Journal
October 26 Code Blog
November 2 Medpundit
November 9 Grunt Doc
November 16 DB's MedRants
November 23 Shrinkette

Are you a medical blogger? Want to host? Drop me a line: nick -at- blogborygmi.com

Influence peddling

There's no shortage of opinions amongst medical professionals about the influence of drug companies on prescriptions and patient health. Some of my mentors and colleagues have made compelling arguments against accepting gifts from Big Pharm. Others have invited me to extravagant 'information sessions' at expensive restaurants and hotels.

Some examples of pharm influence are outrageous, while most are comparatively benign. And while there's evidence that free lunches and other perks that drug companies provide influence prescription-writing, I've argued in the past that no studies show these perks lead to actual harm to patients (yet).

I've wondered what studies have been done on bias in other fields -- say, the media. Because there's no shortage of opinions on liberal bias, or Fox News bashing, but precious little data. More underpowered contentions were made this weekend. The Ombudsman for the New York Times, Daniel Okrent, concluded after months of analyzing the Old Gray Lady's presidential coverage there is no systematic bias toward either candidate:

If there's a commissariat at The Times ordering up coverage to help or hurt a specific candidate, it's doing a lousy job; close reading shows bruises administered to each (and free passes handed out) in a pattern adapted from Jackson Pollock. Many people want to know why the other guy's position is in the first paragraph of a story, and their side doesn't weigh in until the sixth; they don't notice when it's the other way around. Sherrie Sutton of Manhattan, who describes herself as "the only possible Bush vote on the Upper West Side," asked why Times headlines consistently use "attack" when Republicans criticize Democrats, but not when Democrats criticize Republicans. Intrigued, my associate, Arthur Bovino, determined that in the past year, headlined Republicans attacked Democrats 12 times and Democrats attacked Republicans 22 times. Ms. Sutton replied: "Statistics don't lie, and you've got 'em. Interesting, that in the face of facts, I could still feel unsatisfied that campaign coverage by the NYTimes is balanced."

This is something, but hardly the in-depth analysis many bloggers were calling for. Okrent goes on to make a broadside against fact-checking blogs that urge readers to complain to the Times (the examples he picks of eggregious complaints, however, are effectively breathtaking).

Blogger Mickey Kaus counters:

Okrent denies that "because charges of bias come from both liberals and conservatives, the paper must therefore be doing things right"--but that doesn't stop him from using complaints from left and right to balance each other out and conclude the Times isn't "systematically biased toward either candidate." Might there be other large systemic biases, or biases within various departments?

There are some broader, systematic studies out there. A Yale group report on media bias was made available earlier this year. It's summarized nicely in the Rocky Mountain News:

Two researchers have ... come up with a measure of media bias that doesn't depend on journalists' own perceptions of where they fit on the political spectrum, or on subjective judgments about the philosophical orientation of think tanks. Tim Groseclose, of UCLA and Stanford, and Jeff Milyo of the University of Chicago used data comparing which think tanks various politicians liked to quote and which think tanks various media outlets liked to quote in their news stories to estimate two ADA scores for each media outlet in the study, one based on the number of times a think tank was cited, and the other on the length of the citation...

...The predominance of liberals (however identified) in major media is well-documented, but there remains a great deal of controversy over how much that fact influences news reporting (this analysis looks only at news reports, not editorials, reviews or letters to the editor). Most journalists I know say they work hard to keep their personal views out of their news reporting (again, excepting people like me who are supposed to be expressing opinions). And most of them, I'm sure, sincerely believe they succeed. This is evidence that what they succeed best at is sounding like Democrats.

Obviously there are problems with this method, and the authors address some of them. Other criticisms are discussed here. But the point was to develop an objective measure of ideological bias, which is not easy. Most people knows bias when they see it (triggering an involuntary roll of the eyes after a particular phrase or quote from Fox News or the NYTimes). But how to quantify it, and compare to some standard (in this case, Congress)? It's a start.

But comparing journalists' attitude toward bias to that of physicians is instructive The bias of reporters, left or right, isn't really financially motivated. It's about perception from colleagues, maintaining access to sources, and promoting a specific worldview. It's also partly about reader expectations, though polls suggest readers expect less and less.

Doctors, on the other hand, have a lot to lose by giving up pharmaceutical perks. You can count the value of free meals, conference fees, office supplies, etc. Plus, the doctor loses out on new drug developments (slanted as that might be, docs are usually good enough to read between the lines, and the reps can't outright lie). Finally, the doctor's patient pool stands to lose, as many clinics have an in-house pharmacy made up of free drug company samples.

So that's what each professional group -- doctors and reporters -- stands to gain or lose from their conflicts of interest. From that, you'd think it'd be straightforward to guess which group is acting responsibly, reflecting on what goes on, asking the tough questions, and proposing action on behalf of their consituents.

But the truth is surprising. Journalists, with less to lose, tend to deny bias. Medical professionals, with so much more at stake, are leading the charge against the influence of pharmaceuticals.

Sure, the problem of media bias is less likely to kill people (at least, not directly), and solutions aren't as easy to imagine (a "fair and balanced" review board?). But biased reporters are as repugnant to the code of journalism as corrupt doctors are to the oath of Hippocrates.

I just find it gratifying that doctors are trying to protect their patients from the possibility of bias, at their own measurable expense, while many journalists continue to insist they're not biased at all.