Don't hate the payer

Graham Walker's been working hard on a flash animation promoting single-payer health insurance.

The animation is skillfully executed. With facts and examples geared toward the lay reader, Graham makes both reasonable and emotional appeals for the system. Funny ones, too. Plus, it's neat to hear another blogger's voice (I assume it's Graham).

I don't want to give too much away, because it's best to let these multimedia extravaganzas wash over you. All I'm going to say is: as a former DJ, I do not believe Prom Committees are benevolent entities. I mention this because feelings about Prom Committees may now dictate how the American health care debate unfolds. I would be reluctant, as a patient or doctor, to put my faith in equitable disbursements from the Prom Committee. They've been kind of petty and unreliable, in my experience.

But not all proms are the same.

Bruit humor

Knowing that Kevin, M.D. is not one to endorse just any website, I took his recommendation and visited

Carotids' layout and variety of posts make it a little hard to know what to expect behind each link, but the author usually choses stories and sites that are worth a look. I was entertained. And informed! Now I can say I've seen what a mad cow looks like (note: the cow is actually suffering from foot-and-mouth disease). And the author linked to this fascinating thread on pulseless hearts, which our neighborhood of the blogosphere completely missed.

Running Commentary

I was talking to my hot-shot high-powered Manhattan editor friend a few weeks back, when I remarked that I couldn't predict which of my posts would garner comments. She interpreted this to mean I should stick to writing, and leave the editorial decisions to people like her.

Well, I don't think even she could've predicted this. Mostly because she edits children's books, but still.

That thread has it all -- passionate positions, good arguments, hidden identities, and blockbuster revelations. Mix in some classic citations from the literature, and you've got a thread that will not be topped, unless my attending jumps into the fray. Or the ankle patient.

I don't think there's much more that needs to be remarked on, since Rose and Anonymous have explained their perspectives well, and came to some understanding. Input from Doc Shazam, Doc Lassiter, and JB was welcome as well.

If you're interested in the finer distinctions of evidence-based medicine, check out these posts from the early days of blogborygmi: Evidence for EBM, Circumstantial Evidence, and Handling the Truth. Kevin, M.D. has also posted on this subject, and wrote originally about the patient who demanded ovarian cancer testing.

Maybe EBM evokes such responses because it pits physicians' best ideals (trust, research to help patients) with their worst frustrations (costs, fears of reprisal). And this duel plays out every day, behind every patient encounter.

Chew on this

So it took eight years to go from point A to point B:

Worcester, 1996Kiel, 2004

But is this really progress? CNN is reporting today:

According to this week's issue of The Lancet medical journal, the German doctors used a mesh cage, a growth chemical and the patient's own bone marrow, containing stem cells, to create a new jaw bone that fit exactly into the gap left by the cancer surgery.

Tests have not been done yet to verify whether the bone was created by the blank-slate stem cells and it is too early to tell whether the jaw will function normally in the long term.

But the operation is the first published report of a whole bone being engineered and incubated inside a patient's body and transplanted.

I've made some small contributions to the study of cell attachment and mechanotransduction, with an eye toward enhancing applications like this. But having looked at Warnke's Lancet paper (subscription required), I'm a little disturbed. This research doesn't seem based on any hypothesis, practicality, or need.

As far as I can tell, the surgeons could've designed and built a well-fitting, complete titanium jaw and secured it with established, titanium osteosynthesis screws. This could've been done in one operation, with familiar and established risks.

Instead, here's what they did: they designed and built a titanium mesh, filled it with carrier bone mineral blocks, coated with a recombinant human bone growth factor embedded in cow collagen, squirted in some of the patient's bone marrow to theoretically supply stem cells for future bone growth, implanted it in his lat, waited 7 weeks, confirmed some bony synthesis with a radioactive scan, took it out, and put it in his face. They chose a course of at least three operations, involving cow parts, high doses of expensive growth factors, radiation, and unknown tissue products, with a plan to remove the original titanium scaffold in a year, and see if what's left can support force. The authors cite "ethical concerns" for not histologically sampling the tissue to see what, exactly, they're putting in the guy's mouth after weeks of incubation on his back. Is it bone? Is it mostly scar tissue? Is it osteosarcoma? Is the cow tissue causing inflammation? None of these questions were examined.

(There's some handwaving in the piece about how the patient could not have accepted an autologous graft, because his coumadin predisposes bleeding from potential donor sites. There's additional reports that the patient was miserable with his old, subtotal titantium implant, and CNN adds that total artificial implants risk infection. I don't see how the alternative -- titanium mesh, bovine collagen, and three or four times as many operations -- is any less risky.)

The commentary on the piece, by Stan Grothos, notes some of this:

The neccessity for large quantities of bone morphogenetic protein-7 (BMP-7) requires more critical assessment, especially in relation to the impurity of the cellular component used...

Warnke and colleagues’ procedure needs greater numbers of patients and a more rigorous scientific assessment of the nature of the implants over a longer time to improve efficacy. In particular, the analysis of the bony tissue in the implants provides no direct evidence that a normal mandibular structure had been formed or whether there has been successful long-term integration into the surrounding tissue. However, Warnke's primary goal was to produce an implant that approximated the dimensions of a normal mandible, to provide successful functional and aesthetic outcomes for their patient. Although an anatomically correct mandible might not be produced by the present method, a structure resembling a normal mandible needs further testing of the functional loading capacity of the bony substitute.

This is a roundabout way of saying that nothing has been accomplished, other than proof-of-concept. And, like the UMass mouse photo above shows, the concept was proven pretty well eight years ago. Actually, the original Vacanti paper is more innovative than this new work -- at least their initial scaffold was flimsy and biodegradable, and the subsequent engineered tissue was found to be histologically similar to elastic cartilage.

So, despite advances in stem cell differentiation and cell attachment research, tissue engineering continues to be a shotgun-driven field. But hey, whatever works -- the man is chewing his food again. One colleague remarked, "I'm not sure what's more disturbing -- the fact that they grew a jaw in his back, or the fact that his first choice for a meal was a bratwurst sandwich."

I'm willing to venture: the most disturbing thing about this is that it's wasteful, dangerous, doesn't tell us anything new, and probably wouldn't haven been approved in this country.

Worth pondering

I saw a patient today with a sore ankle, who'd been limping four four days since an inversion. I evaluated him, applied the trusty Ottawa Ankle Rules, and decided he didn't need an X-ray. Since his joint was stable, chances were very good all he needed was rest, ice, compression, and elevation.

When I told my attending, he smiled and reminded me that the Ottawa rules were about cost-containment in Canada -- "and in our country, I can't afford not to get an X-ray."

I thought about that exchange when I read Cut-to-Cure tonight:

An older physician brought this up the other day during a discussion about liability premiums and declining reimbursement. It is a good, simple expression about the frustration many physicians feel:

"Why am I worth so little when I do my job right, and worth so much when I make a mistake?"

Damn. Something tells me I'm going to miss these care-free, evidence-based med student days. Especially if I'm ever an attending who's worth a lot.

Bard-Parker, by the way, has listed Lingual Nerve under "Group Therapy" on his blogroll. It really works, on several levels.


I've been easily impressed by stupid Google Tricks, but the folks at MeFi have pointed out something far cooler: Google Hacks. From a Google engineer, the site is a collection of clever programs to exploit his company's vast search power.

To me, the most addictive app is Google Talk. You start by entering a few words (a common phrase, or a lyric) and google finds the next appropriate word, based on what's frequently found on the web. Then, the program drops the first word of your sequence, and searches again to tack on a new word at the end. The process repeats every few seconds.

It's good for surveying popular opinion (for instance, start with "George Bush is" and the program generates "the" ... and then ... "antichrist" ... before devolving into gibberish).

I've had more wholesome fun by typing song lyrics. I entered "everybody loves somebody" to get the next line of a Dean Martin tune (hey, I'm in a Rat Pack phase). Sure enough, Google Talk generated the appropriate next line, but in short order the lyrics morphed into a conglomeration of recent alt-rock hits, before settling into a loop of Pink's "just like a pill" (there seem to be sinkholes, or phrases that recursively clone themselves -- not unlike today's pop music!).

The term "blogborygmi" yielded "tracked: by the world news. And more"

GoogleTalk is like listening to the world free-associate.

So many other programs are also interesting. In Word Color you type in a term, and google sifts through the top image matches to find the most frequently-returned color. Not surprisingly, "sea" is blue, "money" is green, and "blood" is red. "Human," apparently, is brown, as is love and food. "Clear," if you were wondering, is kind of green.

When you're done playing, the site's author, Douwe Osinga, has an informed look at the the history (and future) of searching.

Match games

The Match, the process by which medical students are placed in hospital residencies, has been accused of anti-trust and artificially lowering doctors' salaries. Proponents argue that it's a simpler, fairer way to connect employees and employers based on mutual preference.

Maybe there's a common ground, according to Sara Robinson in today's New York Times:

Each residency program could offer up to three salary levels. Students would rank each level as if it were a separate program. Hospitals would include each student three times in their ranking lists, once at each level.

Dr. Bulow called Dr. Crawford's proposal "potentially a significant step forward" but said further study was needed to see how well it might work.

Mona Signer, director of the National Resident Matching Program, a private, nonprofit corporation that runs the match, said the board would look at the proposal.

I'm all for more choice, but this opens up some squirmy cans of worms. Instead of the approximately $40,000 salary (given an 80-hr workweek, about $10 / hr), maybe a place like MGH will offer residencies at 30k, 40k, and 50k. Will the salaries of house staff be published? Will people figure out which residents are making more than the others? How will that affect these stressed-out, competitive teams? I can imagine the chaos that will come when deciding on monthly schedules, call time, vacation days.

Also, money-matching would give state school grads, MD/PhDs, and younger single types another advantage at the prestigious hospitals (as if we needed it). Since these applicants would have fewer loans or financial / familial burdens, they'd be more likely to spring for lower salaries at better hospitals.

"The doctors have been wrestling with this; so have the lawyers and even the politicians," Mr. Marek said. "Perhaps the solution rests with the mathematicians."

Satisfaction with a mathematical solution is predicated on the notion that people think and act rationally. This may not be true, even for doctors.


I run into the cardiothoracic surgery fellow in the cafeteria line. We haven't worked together in nearly a year, but there's a bond among people who've shared call nights sucking pus from lungs.

We exchange pleasantries, and then he asks me where I'm rotating now.

Me: Emergency! (I always try to pronounce it with the enthusiasm of Kool & the Gang)
CT surgeon: Why are you doing that rotation now? This summer, you should be planning for your residency.
Me: Oh, you know, I actually want a residency in EM.
CT (shaking his head): But you were so good, man.

Pride and shame! A difficult pair of emotions to elicit simultaneously, yet he manages it. I want to tell him that Emergency has always been my favorite part of the hospital, that it's the best tailored fit to my skills, my personality, my needs. I want to quote Carter's speech to Anspaugh when he left the surgery residency on "ER" .

Instead, I ask him to just take care of the patients I send his way. We might yet share a few chest tubes together, but he'll be draining empyemas with someone else.

Lawyers, Time, and Money

There's a new development in Massachusetts: some private lawyers are being forced into public defense:

Judges in Hampden County have begun ordering private defense lawyers to represent indigent clients to ease a shortage of attorneys as a result of a fierce pay dispute...

In addition, William W. Teahan Jr., the chief administrative judge for the five district courts in the county, said in a letter to Bonavita that he will soon begin assigning lawyers to cases to ease the crisis.

"The attorneys' consent is not sought under present emergency circumstances," he wrote.

Citing the state Supreme Judicial Court's rules of professional conduct, Teahan said that lawyers must take appointments except for "good cause."

Exceptions include cases that would probably result in a violation of the law or court rules, that would pose an ''unreasonable financial burden" on the lawyer, or that would be repugnant to the lawyer...

...The reason lawyers have refused to take cases, he said, is because current pay rates have created a financial burden.

Wait! It gets juicier:

The private attorneys, known as "bar advocates," assist the state's public defender agency in representing poor defendants. But many have refused to take cases over the past few months because they say they can no longer afford to work at the the state's pay rate of $30 per hour.
The pay dispute has resulted in a shortage of bar advocates to represent poor defendants.

Ruling in two lawsuits filed over the lawyer shortage, the state's Supreme Judicial Court said last month that defendants cannot be held more than seven days without a lawyer and charges must be dropped against defendants who have not been represented by a lawyer for more than 45 days.

Earlier this week, a Superior Court judge in Hampden County freed three defendants facing drug charges on bail, resulting in an outcry from Gov. Mitt Romney, State Attorney General Thomas Reilly and local law enforcement officials.

So we're not even talking about pro bono work -- defendants have actually gone free because lawyers balked at $30 / hour. Now, they’re up in arms for being forced to provide this constitutional right.

There's some well-deserved schadenfreude amongst blogging doctors -- "at last, lawyers are forced to serve the indigent! Welcome to our world!" The next set of comments may also sound familiar: Will there be an exodus of lawyers from the county? Will the government step in and regulate how many billable hours can be claimed? Indeed, comparing the lot of primary care doctors and trial lawyers reveals many of similarities, and some key differences.

The roles of both physicians and attorneys are important enough to be mandated by law: As QDN states, medical providers must provide emergency assistance to anyone who requests it, regardless of their ability to pay. And the Miranda rights, a staple of the cop shows everywhere, famously states "If you cannot afford an attorney, one will be appointed for you."

But the similarities end there. Miranda assumes from the get-go that 1) legal representation is really important and 2) the more you can pay, the better your representation will be (why else would you pay for something that's offered free?)

Medicine resists the notion that one's finances lead to better care. Though progressives may assert that American healthcare is two-tiered, they'd be hard-pressed to admit inequality as codified in the medical culture compared to the legal world. In fact, all primary care doctors are providing the equivalent of public defense, every time they see a Medicare or Medicaid patient. For many, this is a huge fraction of their patient pool, and doesn’t even count the charity cases I’ve observed my preceptors take on.

The only primary care physicians that remotely resemble expensive trial lawyers are the practioners of nascent "Concierge Medicine" (also called retainer or boutique medicine). These doctors transition from a practice of 1000-2000 patients to just a few hundred. Their patients pay a straight-up annual fee, in the ballpark of thousands of dollars, and many continue pay for labs and meds, as well. For this, they get unlimited access to their doctors, 24 hours a day. Rich patients like the access, and doctors like the opportunity to spend more time with each patient. And, the money seems nice, too. But even concierge physicians promise that their patient are simply paying for access and face time, and (technically) not an increased level of medical care.

But such pay schemes, and the entire notion of doctors setting their own fees for service, is controversial. Last year, my school had a seminar on Concierge Medicine (also called retainer or "boutique" medicine), where a mostly one-sided panel of experts argued that more time with patients by itself is better care: more time for doctors to listen to symptoms, negotiate treatment plans, and educate patients should lead to better outcomes. It sounds reasonable, although unproven. The panel advocated working to make default primary care medicine so good that no patient would feel like visiting boutique doctors. Well, that's inspiring egalitarianism, but it doesn’t hold up to the marketplace demands of shorter visits, smaller reimbursements, and increasing insurance costs.

I wonder if the same thing happen at law school -- are the students encouraged to make public defending so effective, Johnny Cochrane can't compete? I doubt it, but maybe my law-school reader(s) can chime in.

For all the institutionalized altruism in medicine, for all the provisions for indigent care, few believe American health delivery is in good shape. Studies show that the average outpatient medical encounter is now just 6 minutes. It’s not going to get longer without a financial overhaul, and it can’t get much shorter without adverse health consequences.

On the other hand, there are more than enough lawyers to go around (with the aforementioned exception of Hampden County). While it’s a given that patients lack appropriate access to doctors, it’s front-page news when defendants lack access to attorneys. The public-defender situation in Massachusetts is a good opportunity to ask: should we smirk when trial lawyers are occasionally forced to work at government-set rates? Or should we wonder why primary care doctors have been doing so all along?

Typed and cross-posted at the Lingual Nerve


Emergency medicine keeps getting better and better. People warned me that, aside from the (relative) glamor of the traumas and rotor-wing aircraft, it was a lot of thankless drudgery and abuse. Not so! Or at least, I'm not at the point to consider it as such.

I'm sure I'll get around to posting about the lacerations, overdoses and other neat stuff I've been seeing. For now, though, blogborygmi fave Ingrid Jones has requested pictures from my recent helicopter trip. We were called by a smaller hospital to transpost a heart attack victim for cardiac catheterization. A routine flight for the crew, but I found it exhilarating. I apologize for the low-res cameraphone quality. And by the way, no one was harmed in the making of these pictures -- the patient did alright.

Above left: Dr. Tom's grin goes a long way in calming pre-flight jitters. The launch was the bumpiest part, and even that was fairly smooth. Right: I've been working and studying in these buildings for years, but can appreciate the new perspective. Can you see the construction crew on the building on the right? Of course not; too blurry. But our shadow is apparent, a few hundred feet below us.

Here are two shots of the narrow lake where I used to sail.

It turns out there's a delicate weight threshold for these trips. If it's too humid, or too cold, the helicopter blades can't provide lift for a student, patient, pilot, flight nurse, and flight physician, and their gear. The students are the first to get cut. In fact, we're told to bring a cell phone, or taxi fare, in case we find the patient is too heavy for both of us to make the return trip.

Mapquest says our trip, by car, would have been 22 miles and taken 33 minutes each way. I think we were in the air for just over ten minutes, round trip. A very memorable ten minutes.

Shrinking overhead

I'm going to miss those Google ads at the top of my site. Sure, they were ugly. And pretty much useless to readers. But they were earnestly trying to interpret my writing, and I can appreciate that (despite the occasionally strange results). Once, for instance, I wrote about putting in a nasogastric tube, and google plugged a bulemia treatment center.

Besides looking better, the new NavBar doesn't do a lot (but I don't think that blank space will go unfilled forever). Their search function already beats my Atomz bar on the right. And the "next blog" button is kind of like the portal in Being John Malkovich.

Give and Take

Rangel's blogging about Todd Krampitz, the 32 year old liver patient who bought billboards and a website ( to advertise his plight. Today, less than a week after his unprecedented blitz, he received a new liver from a cadaver.

Good news? Bad news? I think we can all agree that loved ones should be able to donate kidneys or liver tissue. We can also agree that selling organs is distasteful, at least to armchair philosophers and op-ed columnists.

Todd's case falls in between. Some family was moved by his situation and wanted to help (even though Todd's prognosis with the new liver is still poor). But other people (like Dr. Rangel) have no qualms writing this off as crass commercialism:

Todd Krampitz essentially bought his liver and screwed who knows which patient likely to be far sicker than Todd out of a chance for a cure of their liver disease and the addition of many years of life. Organ donations that specify the recipient are rare (only about 50 out of thousands of transplants each year) because cadaver organ donation is almost always an anonymous process. Unlike most transplant patients and their families, Todd Krampitz (who owns his own digital photography company) had enough money to pay thousands of dollars for billboard and other ads.

Because transplantable organs represent a very finite commodity, rationing is mandatory and the UNOS was supposed to impart as much fairness to the system as possible. Diagnosis, medical condition, and age are the criteria that are supposed to determine who gets to the head of a transplant list. Todd's media campaign for a new liver sets a very disturbing precedent. What happens if more and more patients begin their own ad campaigns? Will the organ go to that patient who spent the most and advertised the most? How will this be functionally and ethically different from allowing organs to go to the highest bidder?

I've sat in on these liver distribution meetings, and it's a grim calculus. Testimonials are read, psychological profiles and support structures are reviewed, and prognosis for the new liver is determined. If you give a liver to a former alcoholic, will he start drinking again? If you wait until the hepatitis patient is sicker, will he become too sick to survive the transplant?

These are tough questions. Rangel thinks the system, as it is, is fair:

According to Life Gift, in 2003 there were over 17,000 patients waiting for a liver transplant nation wide but only 2,771 transplants were done. The waiting list has dramatically increased from only 1,600 patients ten years ago and the average wait time to receive a liver is now almost 800 days! Without a transplant about 10% of those on waiting lists die each year (about 1,300 patients).

So yes, it's fair by the standard of ignoring human preferences. But hardly fair in the sense that hundreds die waiting. What I want to know is: did Todd find a liver from outside the existing donor pool? Did his advertising persuade someone to donate tissue, who otherwise would not have donated?

If that's the case, then good for him. Let others grouse about "dangerous precedents." Rangel worries that soon the airwaves will be crowded with appeals, and soon donors will only want to give to non-alcoholic cirrhosis patients, or only young people, or only specific ethnicities (or, if I may add, only people who 'compensate the donor for their troubles'). In my experience, donors tend to be more altruistic than that, but I'll concede it's a possibility.

So what? The current anonymous system is not getting the job done. People are dying, or waiting until they're so sick they don't do well with the new liver. I'll wager that private advertising and selective donations, while repugnant to some, will actually increase net donations.

And there is the small matter of it being the donor's tissue to begin with. If people want to donate it, or keep it, or drink it into oblivion, it's their choice.

UPDATE: The advertising did indeed bring in a new liver from someone outside the pool. The surgery happened on 8/12. Gruntdoc was all over this last week and has a comment which reads, in part:

A person in Oklahoma saw their story on CNN and decided to donate their son's organs to Todd. They had not previously thought about donating his organs so now many, many people were able to receive transplants last night due to their son.

Yet Dr. Pat Wood, the southeast regional director for Life Gift, calls this "a good day for the Krampitzes but a sad day for liver transplantation." I'm not so sure about that -- though it's certainly a sad day for regional transplant directors.

Made in Massachusetts

A four-part series begins today in the Boston Globe, detailing the relationship of two brothers, and their family, as they approach their weddings this summer. The younger brother, Brian Hyett, is my classmate. The older brother is gay. The piece is well-written, exceptionally candid, and almost painful to read at times. But it's a story worth sharing, and I'm looking forward to the next installment.

Wax ecstatic

I would never have predicted it, but my neuro rotation was the most draining since the surgery block. The reading was intense, we got slammed with consults, and the patients were heartbreaking. So there's a backlog -- I'm still catching up with some of the fascinating tidbits from Neuro, before I can start blogging about the nonstop conga party that is our Emergency Department.

Seizures come in many varieties, such as the "shaky" tonic / clonic kind, the blank stare of the absence seizure, or the vivid sensations in some complex partial seizures. Any of these can be terribly debilitating, but the meds to control them bring their own side effects. So it wasn't surprising when I read about noncompliance -- patients who refused the meds.

What did surprise me was that some patients liked their seizures.

One such series is described by Asheim and Brodtkorb in this article (emphases mine):

Reports focusing on auras of ecstasy or pleasure have been limited largely to single case descriptions. We examined 11 consecutive patients with such ictal symptoms. Eight had sensory hallucinations, four had erotic sensations, five described "a religious/spiritual experience," and several had symptoms that were felt to have no counterpart in human experience. Ictal EEG recordings were performed in four patients; two had seizure onset in the right temporal lobe and two in the left. In seven the onset could not be definitely localized. The diagnosis of epilepsy was often delayed. Eight patients wished to experience seizures; self-induction was possible in five and four showed treatment noncompliance. In patients with insufficient drug intake, in whom good compliance should be expected, it is relevant to consider seizures with pleasant symptomatology. According to the literature, experiential and ecstatic seizures seem to have had a substantial impact on our cultural and religious history.

They go on to elaborate in the paper (academic subscription required):

Although fear by far is the most common affective symptom [3 and 4], several patients experiencing varying degrees of pleasure during partial seizures have been described. Of 100 patients with emotional symptoms as part of a seizure, only 7 described pleasure [3]. However, in another series of 52 such patients as many as 12 reported pleasurable emotions [4].

The symptomatology of "ecstatic seizures" is defined as ictal sensations of intense pleasure, joy, and contentment [5]. Cognitive and spiritual experiences may occur as components [5 and 6]. Patients with these phenomena are rare and may remain undiagnosed for years [7 and 8]. There is little doubt that the Russian writer Fyodor Dostoevsky experienced emotions of ecstatic or pleasant quality during his epileptic seizures and "Dostoevsky epilepsy" is being used as a synonym to epilepsy with such seizures [3, 9 and 10].

What they're reporting isn't that common, but some of the patient's descriptions are worth a look:

Patient 1 -- The first seizure occurred during a concert when he was a teenager. He remembers perceiving short moments of an indefinable feeling. Such episodes recurred and a few months later evolved into a GTC. He characterizes these sensations as "a trance of pleasure." "It is like an emotional wave striking me again and again. I feel compelled to obey a sort of phenomenon. These sensations are outside the spectrum of what I ever have experienced outside a seizure." He also describes cold shivering, increased muscle tension, and a delicious taste, and he swallows repeatedly. He enjoys the sensations and is absorbed in them in a way that he can barely hear when spoken to. When in a particular, relaxed mood, he can sometimes induce seizures by "opening up mentally" and contracting muscles. He denies any religious aspects of the symptoms. "It’s the phenomenon, the feeling, the fit taking control." It lasts a few minutes and afterward he is tired with difficulties expressing himself for about 1 hour.

Patient 2 -- Seizure onset occurred at the age of 7. He felt a twitch in the right side of his face like a sort of a grin and "a profound relaxation, a plus in daily life." In the beginning, the attacks often occurred when passing a particular place on his way to school. He could trigger them by concentrating on recalling former fits. Later the seizures lost some of their pleasant character. At present, he feels that objects in focus move closer and become enlarged and that the surroundings feel strange and unfamiliar as if he is in another world. When undisturbed, he can still enjoy them. Sometimes a strong déjà vu sensation accompanied by nausea dominates, a sensation that usually heralds a GTC [general tonic-clonic].

While the concert-goer sounds like this guy I saw at Pink Floyd (Foxboro '94), he's got EEG findings to back him up.

And one wonders if we don't do something similar when we're sleep deprived. It's different, of course, from a real disease state, but in the same vein of what these patients describe (and it's well known that fatigue lowers the seizure threshold...)

There was one point during Neuro when I was more sleep-deprived than my usual. I pulled two back-to-back all-nighters (writing up the case report on this patient). During a MeFi study break, I discovered this cover Pulp's of Common People by William Shatner and Joe Jackson (with help from Ben Folds). I've been expecting great things from this album, and the song is better than I could have ever hoped. But it probably shouldn't have caused a quasi-religious experience at 4 AM. Right?

These little extraordinary moments are usually worth the sleepy haze of the next day. I've always viewed it, I guess, as the upside to the fear and loathing of procrastination. And if always getting a good night's sleep is going to take these moments away, well, call me noncompliant.

Cross-posted to

The Spin and Bounce of Sturm und Drang

As another close and personal presidential election nears, my favorite political blogger has got to be Mickey Kaus. He's reasonable, incredibly well-informed, and able to to discuss complex political strategy in a surprisingly entertaining way.

Reading Kaus is like watching a great game of chess. At high speed. With one person playing both sides of the board. Who explains the subtle cleverness of the moves in boldface! Or italics!

Read his August 10th post on the politics and tactics behind the leak of 'turned' Al Qaida operative, Muhammad Naeem Noor Khan. Or check out this July 5th post on how Kerry should manipulate his public election funds, pre- and post-convention.

It's dizzying analysis of each side's potential moves and countermoves, their possible motivations, and what they probably should have done instead. Imagine the best exchanges in the West Wing, except with real people maneuvering around real events.

No one's safe -- not the Bushies, their vitriolic enemies, or the hack press that clumsily pounces on both of them. Yet the posts are surprisingly upbeat and fun. [maybe it's because he's not beating you over the head with his ideology, instead letting the ideas do the dazzling -- ed.] Oh, right.

Spector in Sudan

I'm friends with a pediatrician involved with Medicins Sans Frontieres, Doctors without Borders. During his residency training he went to Venezuela and Southeast Asia, and before starting his practice he went to Angola. This summer he finds himself in the midst of the atrocities in the Sudan.

I've learned a lot about the situation there reading Ingrid Jones's blog, and that of her associate Jim Moore at Passion of the Present. Before he left, Moore and I (independently) approached my friend about blogging from the Sudan. We thought it would raise awareness and make for compelling reading, at a time when the media was not putting much effort into coverage.

He declined, citing security concerns and MSF's own publicity efforts.

Well, a few months have passed, and the press is starting to give the genocide crisis the attention it deserves. CNN has sent its chief international correspondent, Christiane Amanpour, into the Darfur war zone. I'm not surprised she found my telegenic friend:

Dr. Jonathan Spector is at war with malnutrition -- Darfur's biggest killer.

Spector is midway through a stint for the aid group Médecins Sans Frontières in Al-Geneina, the capital of western Darfur.

He is a long way from his pediatric practice back in Boston.

"In a developed country this child would be in intensive care, he would be on monitors, oxygen, a ventilator," Spector says as he examines an infant...

...In another tent, Spector relishes a success. "She's so much better, she looks marvelous," he says after examining a child.

But it's only a small success in a desperate bid to save about 2 million people in urgent need of food and medical aid.

Spector and MSF continue to inspire, and because of them, the word is getting out. Diplomats are doing there thing, but this week the Sudanese government has countered with accusations, lies, and propaganda. They don't want to stop, or negotiate.

I've heard so much about the benefits of a UN-led, multilateral approach to world crises -- let's hope it's not all talk.

UPDATE: A slightly longer transcript is available, by NewsCenter 5's Kelley Tuthill.

Huddled mass effect

The Altantic this month has some nice tidbits in their "Primary Sources" section.

First, Singh and Miller's reporton immigrants to America had some unexpected findings.

Whereas U.S.-born black men have a life expectancy of 64, their immigrant counterparts live to an average age of 73; and whereas U.S.-born Hispanic men live to 73, on average, their immigrant counterparts have a life expectancy of around 77. This gap—which prevails even though immigrants are poorer, less likely to have health insurance, and less likely to visit doctors than the general population—may reflect the tendency of immigrants to be among the healthier people in their country of origin; immigrants also have better dietary habits than the U.S. population as a whole, and they smoke and drink less.

These healthy habits -- and their effect on longevity -- erode with time. The exorbitant American lifestyle takes its toll (the "accumulation hypothesis"), but isn't it part of the reason immigrants chose to come here?

It's a trade-off, like any other choice. But I hope immigrants hold on to enough of their own culture to keep themselves healthy, and teach the natives a thing or two.

Sprawling waistlines

Remember all the fun we had talking about obesity in the last few months? We all know there's no substitute for exercise, and the essence of this truth is beautifully represented in the linear relationship between sprawl and weight:

The residents of the country's more sprawling counties tend to be heavier and have more weight-related chronic illnesses—particularly high blood pressure—than the residents of more densely populated counties....

...for every fifty-point increase in the degree of sprawl, the odds of a county resident's being obese rose by 10 percent. Cities encourage walking and physical fitness, the authors argue, whereas suburban homes are so far from friends, stores, and workplaces that even the most health-conscious residents are forced off the sidewalk and behind the wheel.

It's too bad they couldn't come up with a statistical slam dunk, like "each shopping plaza within 5 miles adds five pounds." And one wonders if the effects can't be explained by confounders like age or education (Manhattanites may be younger or more health-aware), but the authors insist they've accounted for that.

James Howard Kunstler, who has written eloquently about the effects of sprawl on our national psyche, should find this of interest. His first Eyesore of the Month was in Worcester, and other editions have targeted more... mobile eyesores.

Grand Rounds

As Galen has noted, I've been thinking about some kind of weekly rotating roundup of the general-interest posts in the medical blogs.

He's already got something along these lines, with the "blogosphere rounds." What I'm proposing was first suggested by Mike from Interested-Participant. We were discussing the impact of "Carnival of the Vanities", the weekly link-fest that attracts regular Instalanches and has generated many spinoffs. Could something like that generate new readers for the medical blogs?

And yes, traffic is what's driving this. Even the biggest medical blogs get only a few hundred hits a day, which is paltry compared to many politics, law, and economics blogs out there. I've been so impressed by some of the writing on medical blogs -- from Proximal Tubule, Intueri, Medpundit, Codeblog, and my colleagues at Lingual Nerve, among many others -- it's a shame more people aren't reading it.

Now, a certain fraction of medi-blog posts are too esoteric for the lay reader, but actually not that many. And that's part of the appeal: Each week authors would pick a post that general blog readers could understand and enjoy, and a rotating volunteer blogger would host the links. What gets linked would be at the host's discretion -- hopefully a nice mix of quality patient stories, science news, and policy points.

If we could guarantee some publicity from the heavy hitters, or even The Professor himself, plenty of new readers will visit the cited medical blogs. And they can always skim over the posts on spironolactone and CHF, if they're so inclined.

I'd like to get this going in September, when blogging's summer lull ends. The only real question in my mind is what to call it. Some early contenders:

  • Carnival of the Caregivers
  • Melee of the Medics
  • Party of the Providers
  • Hulabaloo of the Healers
    or simply... Grand Rounds?

  • Let me know what you think! I'd especially like to hear from those who write blogs, or read them, medical or otherwise. Pretty much everyone, in other words.

    Comfort Measures, Only

    Maria at has written an account of The Discussion. You know, the talk about limiting treatment.

    I would have to say the talk went well. You should read about it.

    Insert Joke Here

    You can understand how preoccupation with terror can cause the mind to wander, leading to simple mistakes. This Monday's news was stressful enough, but the front page made it a whole lot worse for some poor editor:

    The Worcester Telegram & Gazette, by the way, is a top 100 paper that I'm proud to have been published in... twice!

    ...Just not as proud as I was yesterday.

    Worcester T&G August 2, 2004 Posted by Hello