Unforgettable patients

This past month, I saw two cases of transient global amnesia. It's a remarkable malady -- the patient is unable to lay down new memories for a brief period. Old memories are untouched, personality is unchanged, and there are usually no other associated symptoms. After a few hours, they get better. Most face no futher complications, and in most cases no satisfying etiology is uncovered.

Since we saw both cases within a few days, and since my neurology attending has only seen five or six in her career, I found it reasonable to assume we were at the beginning of an epidemic. I imagined some virus would soon render us all amnestic for a day, but then we'd spontaneously get better, and no one would be the wiser.

My first patient was an athletic 68 year old woman who had already recovered by the time I saw her. The medical team was just looking for an explanation for her reported confusion the day prior. She remembered waking up, fixing up a bagel and coffee, and nothing else for about ten hours. What's amazing is she had plans to meet friends for brunch, and followed through on those plans. She got in her car, drove half an hour (following printed directions) to a place she'd never been, and joined her friends for a meal. One of the friends remarked that she was acting odd, confusedly repeating remarks and questions. But apparently she was not so odd that they stopped eating, or cancelled a leisurely bike ride across the countryside. It was only at the end of the day's activities that someone was concerned enough to take her to the hospital. But after a few hours in the ER, her ability to lay down new memories returned. She felt fine, except for the disappointment of "missing" the brunch and bike ride.

My other patient was a similarly active 70 year old woman. Her amnesia was in progress, and it was terrifying. Her working memory was no longer than ten or fifteen seconds -- you could literally ask the same question, over and over, with her showing no hint of recognition that she kept supplying the same answer.

Her family was a wreck. The husband was stricken with guilt that he took his wife gardening in the hot sun, figuring she'd had some kind of heat stroke. The daughter was afraid she'd lost her closest confidante forever. It was a tremendous relief to them when I said, with some confidence, "This is something we've seen before -- I expect she'll get better in a matter of hours."

What's amazing about these cases is how well the patients can function with little or no short term memory. My first patient was able to follow pre-printed directions to a new place, and when there, managed to "go with the flow" well enough to avoid causing too much concern. My second patient was notable in that she was surrounded by family, all day, yet no one was really sure when her symptoms started. Her husband sheepishly admitted that he might never have learned anything was wrong -- it was only with the daughter's complex, detail-oriented conversation that the patient's deficit became apparent.

After these cases, I dug up some TGA research, and consulted Adam Sandler's romatic comedy 50 First Dates. The closest my patients come to anything in the movie is "10-second Tom" -- but he was provocative about his impairment, whereas my patients were docile and agreeable. Nor were they confabulatory like this patient with viral encephalitis, whose short term memory lasted several minutes.

In cases like this, personality and outlook are not affected. But maybe that's obvious -- if nothing registers, there's nothing to get angry or sad about, and people are free to be themselves.

One wonders if the incidence of transient global amnesia is much higher -- but the nature of the disease, and subsequent lack of initiative, prevents solitary people from noticing or doing anything about it. Then, the patients get better -- and wonder where the day went.

Cross-posted to LingualNerve.com

Late in the day

It is a matter of some irony that two immodest researchers wrote one of the most beautiful understatements in the history of science:

"This structure has novel features of considerable biological interest... It has not escaped our attention that the specific pairing we have postulated immediately suggests a possible copying mechanism for the genetic material."
-- Watson J. D., Crick F. H. (1953) Molecular structure of nucleic acids: a structure for deoxyribose nucleic acid. Nature 171: 737-738.

It was an achievement that changed our perception of ourselves, which prompted more bemused understatement:

"What is the secret of life?" I asked.
"I forget," said Sandra.
"Protein," the bartender declared. "They found out something about protein."
"Yeah," said Sandra, "that's it."
-- Cat's Cradle, Kurt Vonnegut

And, naturally, some professional jealousy:
"That ... such giant shadows are cast by such pygmies only shows
how late in the day it has become."
-- Edwin Chargaff, speaking of Watson & Crick

Pygmy or giant, Francis Crick gave shape to our essence. Now he's gone, and we're poorer for the loss.

Conventional Wisdom

Blogging from the Democratic National Convention went from novelty to cliche in short order, amidst a blaze of self-promotion and navel-gazing. But since those activities make up a big chunk of my free time, there was no doubt I'd be making the trek down the Pike. Wednesday night, a group of us descended on Boston to take in the experience, and the beer. Some observations from around the FleetCenter:

  • The Hardball tent was pretty neat. You could hear Chris Matthews barking comments to his staff while off-mic. A friend remarked, "that's really just the way he talks, I guess." Noted historian Doris Kearns-Goodwin was wearing leather and stripes; from behind, I thought Matthews was interviewing another rock star.

    A librarian from my school said she saw our group at around 9. We were mostly just staring at the monitor; I was chatting up a malpractice trial lawyer. But that's a post for another time!

  • The free-speech zone really was creepy. Chain link, barbed wire, and the monstrous steel remains of the old central artery gave the area a Big Government feel, back when Big Government meant forced internment. More is discussed at mefi:

    It's a shame that nobody's making use of the cage, though. Think of how compelling and poignant the images would be if there were a lone protester, holding up their sign, in the middle of the cage.

    When we saw this, it was not so much compelling & poignant, just pathetic. The site was pretty much deserted, so anyone could step up to the podium and heckle the passing delegates. Maybe I'll get a picture up.

  • There was a man in a furry donkey mask, walking around and shouting into a megaphone: "It has come to my attention that John Kerry has not released his dental records. What is Kerry trying to hide?"

  • The LaRouche people were everywhere. One of them was following around rich-looking delegates and telling them their money would be worthless in the new order. Another was wandering around, shouting, "A vote for Kerry is a vote for Edwards." No argument here.

  • Celebrity sightings: one friend claimed he saw Rudy Guiliani entering a restaurant at Faneuil Hall. Another sighted Larry David. I saw no one, unless you count one of the rickshaw drivers from that episode of "the Apprentice" (we had a beer and waxed Omarosa).

  • Two lines that didn't work:
    1. "You know, the Greeks invented democracy. And conventions."

    2. "Did I mention I ... have a blog?" (adapted from a Lovitz skit. Bad idea)

    The lines that do work are, um, going to stay secret... in case I make it down to the RNC. But as others have noted, there's a lot of social climbing at these events. If you don't have something official dangling from your neck, you're not going to have long conversations with those who do (I'm particularly referring to those two volunteers from Holland, and a sizeable chunk of the Arizona delegation.)

  • The big revelation this week is that I have hobnobbed with the literati, I just didn't know it at the time. Back in college, Duncan Black used to date my friend, and hang out in our house. Years later, he assumed the secret identity of Atrios, the prominent liberal blogger who recently revealed himself this week in Boston. But I'll always remember him as "Dunkers" ... or on a bad day, "Clunkers" ...
  • Standards of Care

    You have the enormous responsibility for safeguarding lives. You're not sure how to proceed in a particular case, so you (grudgingly) ask for a consult. The consultant team is widely regarded as fair and impartial. They end up recommending an urgent, costly plan. What's more, they don't promise the plan will guarantee success, and they candidly admit you might get by without following the plan.

    Still, the vast majority of physicians would follow such a consultant's recommendations. For one, an expert's opinion is usually what's best for your patient. And two, it covers the doctor's ass if something does go wrong.

    But say I'm not talking about medicine -- I'm talking about government. And the consultant is the National Committee on Terrorist Attacks Upon the United States. Their urgent and expensive recommendations are freely available.

    A physician doesn't think twice about following tough recommendations, if it's remotely possible the plan will save lives. On the other hand, when the 9/11 Committee report was first released, the Congress, and the President, were not even considering whether to return from vacation.

    Now hear this

    A musician / future ophthalmologist brought Sonocytology to my attention. At their website, Pelling and Gimzewski describe the use of atomic force microscopes to sample cell membrane vibrations:

    While the tip rests on top of some types of cells, we observe an oscillatory motion with amplitudes less than 5 nm. By Fourier transforming the oscillatory signal we find that the signal has a frequency in the kHz range...

    ... Human hearing ranges from about 20 Hz to about 20,000 Hz. The frequencies observed in the study described above are well within the range of human hearing. Inspired by this finding, we have developed a way to convert the motion data into sound, allowing us to listen to the cells...

    ... The process of “feeling” a cell with the AFM and interpreting its motion as sound is the basis of Sonocytology. Observing the motion of cells in different situations, i.e. cells under stress, generates different sounds. In fact the state of a cell, if it is healthy or cancerous, can be distinguished by listening to its sound. Sonocytology is a diagnostic tool similar to listening to a beating heart. A doctor can diagnose heart conditions by listening to a person’s heart and comparing its sound with the sound of a healthy heart.

    However, not all cells display motions that are oscillatory. We have found that cancer cells display a very noisy motion with no particular oscillations. In turn, the resulting sounds are also quite noisy. In the future we hope to bring our research in sonocytology to the point at which it can be integrated into medical disciplines such as cancer research. “Listening to cells” would allow a fast diagnosis of cancer without the use of drugs and/or surgery. Sonocytology might also make cancer detection possible before a tumor forms, and for this detection only one single cell would be needed....

    Atomic force microscopy keeps blowing me away. This latest use, though, strikes me more for its value as a research tool, than for its clinical uses. Would it really be cost-effective to set up an AFM in every path lab, to identify those cancers for which there's no probe, no stain, no histological pattern, already? Then again, this NEJM article suggests some tumors influence endothelial cells in surprising ways -- maybe an AFM can help pin down where the transformations end.

    Since any change in membrane properties will likely change the cell's pitch, this process could be useful for studying things beyond cancer, like cholesterol metabolism, viral replication, alcohol absorption, or cytoskeletal remodelling. And more and more researchers are using AFMs.

    Sometimes I miss the lab. It would have been nice to hear my chondrocytes sing.

    Where you're coming from

    One of the many secret rewards of blogging is that I can peruse the search engine results that direct readers to my site.

    Some recent gems:

  • class action lawsuit +boston +hepatitis a +quiznos
    (I've been getting searches for Quiznos since February, but queries took a disturbing turn during the recent Hep A outbreak around Boston. Now, it looks like the exposed are fighting back. Did the plaintiffs just tip their hand?)

  • "man in wheelchair hit by train"
    (doo-dah, doo-dah. A classic headline.)

  • is a nasogastric tube more uncomfortable than an ercp
    (it is, the way I do it)

  • acecdotes about plastic surgery
    (I haven't written about this, but the query reminds me about this guy who got pretty much his entire hand cut off by a circular saw. The ulnar nerve was severed. The ulnar head was sawed off. He cut his median nerve, and 11 of the 12 flexors. All he really had going for him was an intact radial artery. I helped the attending and the plastics fellow in the OR for six hours, using little flags to mark the tendons. Best anatomy lesson ever, and still the coolest surgery I've seen. And the patient, by the way, regained motor control very quickly, and on follow up months later, I heard he had some sensation back, too.)

    (I really ought to set up some kind of fact sheet or something. People are desperate!)

  • "I pursued and she withdrew" gonorrhea
    (I once quoted the Seinfeld episode featuring Kramer's stint as a standardized patient. People love that episode, with a passion that still burns...)

  • it kills 300 americans every day "300 AMERICANS"
    (I don't know what it is, but it's got me scared. Actually, enough people have searched for this that I suspect it's part of some trivia challenge.)

  • "Dammit, jim"
    (six searches in a week must mean I'm #1 again. Or is someone just googling this because blogborygmi is too hard to spell?)

  • songs about work
    (An oldie, but a goodie. And a good opportunity to open submissions for my epic forthcoming post: Songs About Doctors, Nurses, and Hospitals)

    (to quote another writer from my hometown: "Yup, these are my readers")

  • The new gumshoes

    Yesterday's news (which I'm just getting to today) highlights how bloggers are making the transition from news commentary to actual reporting:

  • Stanford blogger Clinton Taylor spent some time on the phone, and on Google, and quickly cracked that chilling airline drama from last month.

  • Myrick , a blogger in Singapore, wrapped some documents in his socks to test a theory about former Clinton advisor Sandy Berger. Berger is under fire for sneaking confidential documents out of the National Archives. Can socks be used in this way? Quoth Myrick:

    "With the Drezner-Farrell study my sock started to slip immediately. It had slid about three-inches after about 40 steps on a flat surface. I doubt I could have walked any considerable distance without a complete loss of the report... I didn't test how far I could have walked, however, as I got a paper cut on my ankle."

    This kind of reporting doesn't require vast resources or cultivated insider connections. It's fun to read, yet provides obviously relevant angles to these stories. So why didn't it come from Big Journalism?

    Maybe they're all busy gearing up for the DNC.
  • Open-ended question

    The Wall Street Journal's James Taranto cites a story about four learning-disabled students who are suing AAMC, the group that administers the Medical College Admissions test (MCAT). They're suing for extra time to take the exam.

    Taranto echoes my thought on the Florida ballot initiative: It's in the best interests of trial lawyers to promote bad doctoring.

    I'm not jumping to his conclusion that these students will generate malpractice cases. In fact, I hope they succeed in their lawsuit. Maybe later in their careers, they'll sue Medicare, paving the way for doctors to spend more time with patients.

    Disposable Art

    In psychiatry, patients are sometimes asked to abstract -- to complete a maxim, explain what it means, etc. Those who can't are "concrete" and may be suffering from an organic brain disorder, or schizophrenia.

    One common test of abstraction is to explain what this means: "people in glass houses shouldn't throw stones."

    I've heard answers ranging from "it's like shooting yourself in the foot" ... to "you'll break the walls" ... to "people are watching me!"

    I just hope a paranoid patient never walks into this structure.

    Sheesh, I have a hard enough time going when there's someone in the adjacent room.

    somewhat appropriately, this tip comes from The Proximal Tubule

    Sunshine state

    What a day. SIX neuro consults! None of them straightforward! One of them in Greek !

    I remember the time, a few months ago, when doing three consults in a day would give me cerebral edema. Now I just have numbness and essential tremor! This MD thing is really happening.

    In that vein, let's indulge in some sarcastic snarkiness. Kevin, M.D. links to the story of the dueling Florida ballot initiatives, pitting doctor against lawyer:

    Trial lawyers want to open up records detailing patients harmed in hospitals, limit what doctors can charge for services and strip the license of any medical doctor found to have committed three or more cases of medical malpractice.

    The doctors want to limit how much lawyers can make.

    People give lawyers such a bad rap. Sure, trial lawyers' salaries continue to rise, as physicians' salaries fall and medical costs spiral out of control due to "defensive medicine." Sure, lawyers use emotional manipulation to turn juries against scientific and statistical principles.

    But you can't deny they're doing the public a big favor here, by taking negligent doctors off the wards. Removing physicians with three suits against them is not even in the lawyers' best interests -- they're selflessly depriving themselves of future clients! But if you liked defensive medicine before, wait until you see how many diagnostic tests are ordered by a doc with two strikes.

    Maybe the trial lawyers heard that, in many specialties, the average doctor is sued two or three times over the course of a career. So if voters pass the new ballot initiative, all surviving docs will be above average (or, fresh out of residency).

    As for that crusade to cap doctors' reimbursements, well, that's precious. Think how much money the patients will save when doctors have no financial incentive to spend time with them. It does makes me wonder, though, why the lawyers are trying to fight the physician inititive to cap attorney fees. Aren't we all just looking out for the patients? Haven't they suffered enough?

    I guess the big difference between physicians and lawyers is: lawyers aren't afraid to use their legal expertise to help themselves and hurt doctors. Most doctors, on the other hand, recoil at the thought of withholding care for attorneys. Or, you know, going Shakespearean.

    At least now it's the in voters' hands. And things always work out swell when Floridians go to the polls!

    Respected authority

    After sitting through a grandiose but underpowered medical student research presentation, a prominent faculty investigator voiced an axiom I've since taken to heart:

    "The role of the physician is to express confidence. The job of the scientist is to express doubt."

    (The investigator tactfully predicted the presenter had a bright future in healthcare).

    This distinction between medical types and research types is already apparent from the start of classes. At my school, the first-year lecturers are often researchers, and these biochemist or genetics PhDs pull double-duty by lecturing to the graduate school, as well.

    As a mudphud student, I've seen the lecturers get perplexed by the different audiences. Grad students try to pick apart presentations -- challenging weak spots, and offering alternative explanations for conclusions. The professors usually find the exercise stimulating, and rise to the occasion.

    On the other hand, the med students often either passively record and memorize, or try to extrapolate for patient care. Too many times, an hour-long lecture ends with the presenter awkwardly asking for questions. "None? Not one? Really? Anybody?"

    Cheer up, professor. Their silence doesn't mean they weren't listening. Rather, take it to mean the med students trusted your authoritative tone. It's something they're trying to cultivate in themselves: you spoke with confidence.

    Cross-posted to LingualNerve.com

    The Joy of Cola

    Here's what we know:

  • A middle-aged white woman was in her usual state of health a week before admission, with no significant past medical history other than high cholesterol, for which she takes lipitor.
  • She then noted progressive weakness of her arms and legs, more each day. She woke up on the day of admission, essentially unable to move.
  • In the ER, they found she was hypokalemic and gave her potassium.
  • She wasted it. When she got to the floor, they gave her K, and more, and finally some of her strength returned.
  • Her thyroid was fine. Thus, her demogaphics are not good for either hypokalemic periodic paralysis (first onset usually in adolescence) or thyrotoxic periodic paralysis (she's not Asian, and her thyroid appeared fine).
  • She drinks A LOT of cola. About three liters a day. Caffeinated. And not diet.

  • Other lab results excluded other causes of muscle weakness. We saw she had CPK's at around 1000 (a sign of muscle damage). Her metabolic panel, ABG, and potassium wasting led us to suspect she had type I renal tubular acidosis. But what brought on this RTA? Could it have been triggered by statin-induced muscle damage, or cola-induced muscle damage... or both?

    The literature reveals that high-dose cola by itself (ok, with the help of a fetus) can cause a hypokalemic paralysis.

    Whatever the cause, she lost potassium and was transiently paralyzed. We held her lipitor and her soda. She got better over the course of a few days.

    But what the heck actually happened? And could it happen again?

    Where are the medical students?

    Reading Lingual Nerve's recent posts about medical school, I started thinking again about the lack of medical student blogs. It's particularly notable relative to the number of law student blogs. I've discussed this disparity with some (disinterested) classmates, as well as distinguished faculty from other schools. And this issue has been noted elsewhere, too:

    Try googling "law student blog," just for kicks. You'll get about 276,000 results. Try "blawg" and get 51,900. "Graduate student blog"? 72,200. "Med student blog"? A scant 16,000. There must be something unique about the law school experience, and the law in general, that makes people just want to TALK about it so much. And people do talk...

    ...Maybe it's because law school is just so goddamn all-consuming complicated, and expensive. But that's med school too, isn't it? Maybe it's because the study of the law changes your life in such profound ways that it's best to talk about it, to get everyone's perspective out in the open before people get into it so they know what they're getting into.

    I object! Sure, law school changes lives in "profound ways" -- but any one period in young adulthood is going to be significant. Try delivering babies, diagnosing cancer, or telling someone your age that he's not going to walk much longer. You'd think it'd make for gripping reading, and cathartic writing. So where are they? Maybe med students don't need talk therapy -- we need meds.

    I can accept that law students, are, as a group, more inclined to interact through the written word. Medical students are looking for meaningful personal interactions -- just look at how many instinctively rule out specialties like radiology, pathology, or anesthesia.

    But can this alone explain the med student's reluctance to sit down and type what they learned in school today? What they saw on the wards? No, I think the reason more law students blog is: blogging is more conducive to success in law school. Postings on court cases lend themselves well to hypertext linking, to thoughtful discussion, to constructing arguments and backing them up. New legislation, or trial decisions, are immediately relevant to students and nonstudents, and the consequences can be constructively debated. I haven't seen too many law school exams, but I suspect that law students blogging about their classwork are synthesizing material in a beneficial way.

    What medical students write about their experiences can be enlightening, challenging, and fun, but it's probably not going to boost board scores. Even "Guess the diagnosis" vignettes that pop up occasionally are too low-yield to really help (I could go through a CD-ROM full of X-Rays before the answer is posted to a blog).

    This is not to say medical students aren't good at critical reading, or formulating arguments, or summarizing cases... it's just that honing these skills takes time away from studying. Patients don't need doctors who make brilliant arguments, or are up to date on the latest national health care proposals. They need physicians who cast a broad differential, make good pick-ups, and employ evidence-based treatments. We work at this by reading, sitting through lectures, and trial-and-error (with supervision!) on the wards. Internet conversation doesn't play a large role.

    If it did, med student blogging would've taken off by now. Instead, I'm aware of only about 15-20 med student blogs, and a good fraction of those either focus on personal events or health policy. This is a paltry number, considering there are 50,000 med students in the US alone.

    Med students on the net migrate to 'old-fashioned' web sites, mailing lists, and discussion boards. Questions (mostly technical or career-oriented) are answered faster, resources and helpful links are centrally located, and time doesn't get wasted addressing comments and updating the blogroll.

    Something is lost this way, but if the med students need to talk about what they've seen, they talk about it -- with family, friends, fellow classmates and faculty. Our school provides enough opportunity for this, and so far no one else has felt the need to extend it to the blogosphere, risking HIPAA violations and lost hours.

    Fortunately, there are a few med students writing because they want to. I thoroughly enjoy their posts, and deep down, I have a feeling blogging might improve my practice of medicine, too. It's just not something I can defend in an argument.

    Cross-posted to LingualNerve.com

    Will to power

    Sometimes a headline catches your eye:


    I'm happily joining others in welcoming our new Cyborg Monkey Overlords. Did I mention I know a nice local juice bar? With bananas? Oh, that's right. I didn't need to mention it; my thoughts are yours. Here, I'll drive.

    Actually, this headline isn't too far from the truth. I've noted earlier studies, where computers mapped monkey brain activity and used it help them guide robot arms with their thoughts. But these Caltech scientists distinguish their their breakthrough: "It's the difference between thinking "I want to move my hand to the right" and "I want to reach for the water".

    Andersen's team recorded the neural activity during the monkeys' thinking phase and identified certain electrical signals that related to planned movement. They then used powerful algorithms to recognise these signals and translate them into the movement of a cursor on the screen. Within a day, the monkeys had learned that thinking about their plan yielded a reward, when the cursor touched the flash of light, and they stopped touching the computer screen.

    The team then altered the task to include a variety of reward types, sizes and frequencies. The researchers found they were able to predict what each monkey expected to get in return for thinking about the task.

    "It's an exciting study," says John Donoghue, chief scientific officer of Cyberkinetics in Foxborough, Massachusetts, who is developing similar technology for human use. "They know what the monkey is going to do before it even does it."

    Taking a quick look at Anderson's article in Science, it seems that these higher-level "cognitive-based" movement plans require weeks of training before computer recognition (compared to the earlier, "trajectory based" systems, which IIRC took days). Monkeys needed 250-1100 training trials before the computer could accurately read their planned reach. Motivated humans with more organized thoughts might do better, of course. And we'll find out soon:

    Cyberkinetics recently obtained Food and Drug Administration approval to implant chips in the motor cortex region of five quadriplegic patients to give them mouse control and computer access. Results will be available next year.

    Implanting chips in the parietal cortex might yield unexpected side-effects, cautions Donoghue. Suppose you planned to shake your boss's hand, but thought transiently about slapping him in the face. The slap could happen.

    Andersen believes that training would soon rule out unwanted responses. And the ideal brain-chip would tap into many different brain regions, coordinating planned actions with instructions for movement.

    Obviously I'm enthusiastic about this, almost enough to consider specializing in neurology. But it seems to me it will take another order-of-magnitude leap in either computing power, or training time, before computers can recognize complex thoughts and movement plans. The authors opine:

    Moreover, this research suggests that all kinds of cognitive signals can be decoded from patients. For instance, recording thoughts from speech areas could alleviate the use of more cumbersome letter boards and time-consuming spelling programs, or recordings from emotion centers could provide an online indication of a patient's emotional state.

    The cognitive-based prosthetic concept is not restricted for use to a particular brain area, as can be seen by the finding that PRR and PMd activity could both provide goal information. However, some areas will no doubt be better than others depending on the cognitive control signals that are required...

    This system, as is, could probably decode "thank you" and "the juice bar is on South Quinsigamond Ave" but not, say, "What a piece of work is man" -- unless retrieving Hamlet is a well-marked path in one's mind. And, to take Anderson's analogy further, could you train the computer to respond, not to "reach for the water" but to "quench my thirst" ? Maybe, but only if the command relied on pre-programmed subroutines.

    Just like complex motions are based upon lots of trajectory-based thoughts, complex ideas are made up of smaller concepts and discrete words. If you're willing to take the time to train the computers, thought-projected movement and speech will soon be possible.

    Hurry up and wait

    The ER at Boston Medical Center is in many ways the ultimate in place to do a rotation: the most traumas, the most indigent population, and the most turnover in Boston. In Thursday's front-page story by Scott Allen in the Boston Globe, we see that through systems management, BMC is moving patients through faster:

    The secret lies in a radical idea for medicine, but one that has guided airport managers and restaurant hostesses for years: Keep the customers moving.

    ...The hospital's changes since last fall have reduced the typical ER stay by 30 minutes, to 3 hours and 45 minutes. That's still half an hour above the US average, but impressive considering Boston Medical Center's heavy patient volume and difficult caseload.

    Patients receiving treatment yesterday said the emergency staff is attentive and aggressive and has reasurred them that they won't be forgotten.

    Alexis Morales, 36, said doctors went to work on him moments after he arrived with breathing problems from an asthma attack, giving him epinephrine and other medications to open constricted airways so that he wouldn't need a breathing tube. An hour after he arrived, still wearing his landscaping boots, Morales was breathing on his own in an ER bed, praising BMC's care.

    "When I first started working here, not a lot of people said 'thank you,' " said Morales's nurse, Bree Sullivan, who has worked in the ER for 2 years.

    Likewise, Caryn Hibbard, 32, said she was impressed by how quickly doctors ordered a CAT scan after she told them that doctors at another hospital had failed to find the cause of abdominal pain that had begun several days earlier.

    Other interviewees (and bloggers) are also enthusiastic about these changes. The reporter gets a revealing quote:

    "I won't be surprised if five years from now, this is the biggest change in healthcare," said Dr. Donald Berwick, president of the Institute for Healthcare Improvement of Boston, an influential think tank that last week hosted a session on BMC's reforms for hospital officials from around the country. "We have to bring the science [of management] back into healthcare in a way that we haven't in a very long time."

    Berwick is talking about hospital efficiency, of course, but he forgets that the "science of management" was brought to bear on healthcare, big-time, in the last decade. HMO's, provider networks, copays, preferred drug lists... all this management kept health care costs stable through the 90's, despite growing dissatisfaction from patients about lack of choice, lack of access, and a time crunch.

    In an emergency, however, the time crunch is desirable, and patients ("customers", now) may not mind being shuffled around anonymously. After all, when you're sick, it feels good to know someone's doing something.

    But this is why I'm somewhat pessimistic the changes at BMC are going to last. First, there's the lesson from highway engineers: adding extra lanes doesn't cut traffic, it just attracts more cars.

    On the individual level, making ER stays less time-consuming and unpleasant will make patients less likely to go to through their overbooked primary care physician (if they have one) and more likely to present at the local ER.

    On a larger scale, what will happen if efficiency rises in the top regional ERs? Small community emergency departments are under enormous financial pressure as it is, and this could tip them over, causing a commensurate rise in traffic at the regional centers.

    The second reason these gains may not last is the bottome line. The Globe article reveals that consultants and accreditation agencies are trying to spread the success of the BMC initiatives to other ERs. But they're motivated by patient safety and satisfaction, which didn't count for much during the HMO revolution. It's not obvious to me that higher turnover translates to higher profits in Emergency medicine (even if it seems to be the case in primary care). Also, any cost savings will wipe themselves out when the speedy care leads to more frequent ER visits from those least able to pay.

    If hospitals and insurance agencies find that improving efficiency doesn't improve their bottom line, these positive changes will be resisted. Don't hold your breath waiting for them at your local ER.

    Peristalsis and the Tsunami

    Kevin MD asks a good question: healthwise, what's going to happen to this guy?

    He's referring to "the Tsunami" Takeru Kobayashi, who dominates his sport like Tiger Woods and Michael Jordan dominate(d) theirs. His sport, however, is competitive eating, particularly hot dogs. From CNN:

    For serious hot dog eaters, technique can be pivotal. Kobayashi swears by the "Solomon approach" -- he breaks his wieners and buns in half before shoving them mouthward. "It saves me half the chewing effort," he said.

    Kobayashi, who weighs 155 pounds, says competitive eating requires a special brand of bodybuilding.

    "You have to gradually build up your gut by eating larger and larger amounts of food, and then be sure to work it all off so body fat doesn't put a squeeze on the expansion of your stomach in competition," he said. "I start my regime about two months before a big competition."
    Kobayashi got his start four years ago on the weekly prime-time "TV Champion" event. Later that year, he set the Japan record for eating Chinese dumplings by downing 400 in one hour on another show. He won his first hot dog eating contest -- setting the world record of 501/2 in 12 minutes -- four months later.

    I think we're in uncharted territory here. Pubmed has nothing on competitive eating -- a lot of eating research is directed towards understand obesity via impaired signaling of fullness, and Kobayashi's ignoring those signals. History's full of overeaters, though, and I recall Louis XIV had a stomach twice as large as his peers. He liked his large dinners, but died at a ripe old age regardless.

    Besides messing up his perception of satiety, I can guess Kobayashi is at increased risk of reflux, and maybe pyloric dysfunction (though this study on dogs shows no short term relationship between meal volume and gastric emptying). I can't guess what effect this periodic overeating is having on his bowels.

    He should probably check his cholesterol, too.

    I hope, when the Tsunami's old enough, he makes public the results of his screening colonoscopies (he'll have no trouble with the bowel prep). Maybe researchers can do endoscopy on him, as well.

    If he turns out healthy, he could publish a diet book, along the lines of "How to Eat 50 Hot Dogs in 12 Minutes and Stay Thin." I'm curious myself.

    Cross-posted to LingualNerve.com


    My football team is the best. And no, I'm not just talking about the New England Patriots, but my compatriots who are dancing in the streets of Sparta and Athens after the Greek victory in Euro 2004.

    I do wonder if all this celebration will take the urgency out of preparations for the Athens Olympics, just five weeks away. But the world can worry about stadiums and security ... later.

    The summer of Greek pride just got an early start.

    Gunpowder and sky

    Independence Day means different things to different people. As usual, I'll ignore geopolitical and economic considerations and indulge in more navel-gazing. Viewed thusly, July 4th has just two interpretations: that of Aimee Mann, or that of Galaxie 500 (later, Luna).

    Galaxie 500's "Fourth of July" casts a wistful, lazy look at midsummer and finds the potential for change, and reason for optimism. Mann's "Fourth of July" languishes in nostalgia, self-pity and regret:

    Today's the fourth of July
    another June has gone by
    and when they light up our town
    I just think what a waste of gunpowder and sky

    I'm certain I am alone
    In harboring thoughts of our home
    its one of my faults that I can't quell my past
    I ought to have gotten it gone

    Oh baby, I wonder if when you are older, someday
    you'll wake up and say "My God, I should have told her
    what will it take
    but now here I am and the world's gotten colder
    and she's got the river down which I sold her"

    So that's today's memory lane
    with all the pathos and pain
    another chapter in a book where the chapters are endless
    and they're always the same
    a verse and a verse, and refrain

    I think I need another burger.

    Merci Boca

    It's a weekend of barbecues and destiny. I just encountered a self-described Rastafarian, complete with dreadlocks, gray beard, and Bob Marley T-shirt. He was flipping veggie burgers at a local get-together.

    He greeted me warmly and seemed oddly familiar. "Have we met before?" I asked.

    "Yes, my friend, many times."

    I started, "Oh, I didn't recall --"

    "But this," he explained, "is our first physical meeting. We've met many times on the spiritual plane."


    He went on: "You study medicine, I know this. But medicine is not your true path."

    My eyes widened, and I quickly filled him in on all the career planning and decisions I made over the past week, the lingering doubts and seeming inevitablity of Emergency Medicine, the potential for research, and the launch of Lingual Nerve.

    "Ay, mon, so your choices are medicine, writing, or research?"

    Yes, I said, or hopefully some combination thereof, but striking that balance will be difficult.

    He paused for a moment, and looked over my shoulder, up at the sky. Then he looked at me and declared, "Your burger's ready, mon."

    And so it was.

    Progress notes

    Two perspectives on medical note-writing, from a newbie and an experienced hand.

    Memory Dump

    Via Metafilter, the BBC reports:

    Armed with just pen and paper as no computer was up to the job, for three months Lion Kimbro wrote down every thought that came into his head. It left little time for much else. Now, was that necessary?

    ...Why would anyone in their right mind want to do this? "Because of the incredibly clarity that comes with it," Lion says. "It may feel that for the first time in your life, you really have a clear idea of what kinds of thoughts are going through your head. I wanted to see if I could make myself smarter, by strategically placing notes to myself. Intelligence, as I define it, is getting the right information at the right time at the right place, towards whatever end you are going for."

    He's got instructions for how others can do the same -- download the guide.

    I agree that you can make yourself smarter with the right info at your fingertips -- it's why my white coat weighs about fifteen pounds. But I'm not sure mapping every single thought provides much insight. You've got to separate the wheat from the chaff. There's got to be a happy medium between ignoring your ideas and obsessing over every fleeting thought... I think blogs exist in that zone. And the hyperlinks are a nice bonus.

    A nice discussion is underway at Mefi, including a comment from an old apartment acquaintance.