Completions and Connections

I'll always have a warm spot in my heart reserved for the Waitresses' Christmas Wrapping, the enduring tune that makes me smile every December (though it was inevitable that, this year, the Pogues' Fairytale of New York eclipsed Christmas Wrapping as my favorite holiday song.)

But I'm still impressed with what the Waitresses accomplished in their yuletide epic: they weave a complex tale of isolation and self-pity as a woman prepares her Christmas meal for one, interspersed with flashbacks to a yearlong, frustrated courtship. Yet the song is insanely upbeat, catchy, and singable -- remarkable qualities for any song, but more impressive when you consider it was one of the first mainstream proto-raps, written in 1981 (which makes the title a pun, always a plus in my book).

Christmas Wrapping also has the best sax part in any holiday song (except possibly Morphine's Sexy Christmas Baby Mine).

The finale involves a chance encounter that ties together multiple threads and leaves you optimistic for 1982 and beyond. The song takes on additional heft when you realize the singer, Patty Donahue, died of lung cancer just fifteen years later.

Perhaps because it's only played after Thanksgiving, the song never seems to get old. Or maybe it's beloved because it speaks to universal themes -- who among us hasn't endured a prolonged, punctuated courtship, only to have Christmas magic (or benevolent vacation scheduling) intervene?

Regardless, the lasting message of Christmas Wrapping is: this is no time to be alone. Here's hoping we can all be with friends and loved ones this season.

Escape from Manhattan

Last year I learned that, during the holidays, leaving New York's never easy. This year, it's downright difficult.

The significance of the strike was made clear to me today, while I, the intern, was griping about waiting in the cold for a hopsital shuttle that was running late.

A cardiology fellow was standing with me. He'd begun his commute well before me, and had budgeted the entire afternoon to get to the hospital.

"Why so much time? I think they'll understand if you're running late," I offered.

"If anyone has an ST-elevation MI tonight, and I'm not there..." His words trailed off.

We both stared down the avenue, searching for a sign of the approaching shuttle bus.


It looked like it was going to be a bad call on pediatrics. Signout was full of new, borderline admissions -- asthma exacerbations that were already improved, a rule-out sepsis or two with the mildest of fevers. Plus, we got word that two more RSV's were heading up to the floor.

On rounds we learned that the patients slated for discharge didn't want to leave -- or at least, the parents didn't want them to. I caught a mom feeding her (supposedly NPO) baby, then complain of his vomiting, five minutes later.

I was quickly becoming as cranky as some of the infants.

As the day wore on, though, the work got done. The new admissions were straightforward, the language barriers were easily surmounted. I still felt like a cog in a vast, inefficient machine, but at least we were moving forward.

When an opportunity for sleep presented itself in the evening, I took it. As I drifted off, I recalled an episode from morning conference, earlier in the week:

One of the residents has presented a potentially interesting case of progressive lower extremity weakness in a twelve year old girl -- the differential included Guillian-Barre syndrome and cord compression. Workup had been negative, and when it came time to do electromyography, the kid fought off the needles -- vigorously. She had been faking it, for days.

We then discussed conversion disorder vs. factitious disorder, a psychiatry consult was decided upon, and it was my turn to present a case. I had a two month old with cough that just wouldn't quit. At the top of my differential, I jokingly put "malingering." Everyone laughed, but I remembered thinking that such a remark a few wouldn't have occurred to me, a few months ago. Floor medicine was jading me, far more than any experiences in the emergency room.

Sleep that night was fair enough -- just one call to the floor (the NPO baby had somehow managed to spit up milk again). At around midnight, my resident woke me.

"A new admission?" I asked.

"Actually," she replied, "kind of the opposite." The pediatric emergency department was swamped, and the attending was requesting another set of hands. My resident, like any good resident, was protective of her call intern, but knew I was in EM and might agree to it.

"Sure," I said.

And so I went down to the peds ED, which was indeed busy. I only saw a few patients; just enough for the attending to get a handle on the situation. But in that short time, I got away from those perfunctory floor exams and took real histories, real physicals, and made real decisions on the info I'd collected. I reassured some nervous parents, made a few kids smile, and generally felt like I was making a difference.

It's been months since I've been assigned to the emergency department, and it will be months until I'm formally back. But this little midnight ED stint was more refreshing to me than any sleep -- making my last call for 2005 my best.

The Envelope, Please...

MedGadget has announced the 2005 Medical Weblog Awards, to considerable interest. There's even been some speculation as to how the awards ceremony will unfold.

Last year, I wondered if the show would run the show like other award telecasts:
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...

This year? We're in a position to make at least some of this happen. More details in the coming weeks...

"And the present is trivia, which I scribble down as notes."

There's a great scene in Memento where our afflicted protagonist, with only a short-term memory at his disposal, is trying to jot down a crucial clue revealed to him by the duplicitous Carrie-Anne Moss. He's looking around, frantically, for a pen and paper.

She knows his condition, walks out of the room and patiently waits. A few moments later, she abruptly returns to shatter his train of thought.

He forgets the important note and returns to baseline -- a mildly confused but otherwise blank slate.

I have moments like that, every night on call. Except, instead of Carrie-Anne Moss, the nemesis is a pager.

And instead of a single murder mystery clue, it's a half-dozen lab values or vital signs or abnormal physical exam findings.

And instead of just needing a pen and paper, it's also needing to find the right signout note, and a computer, and the getting the orders in, and the signout updated, before the pager goes off again.

But the frantic part? And the short-term memory? And the use of body parts? That's pretty much the same.

Grand Rounds: A New Partnership

This week's Grand Rounds is being hosted by Geena at Code Blog: Tales of a Nurse.

This week's collection of the best of the medical blogging is is notable for several reasons. Geena's now the first person to host three times, making her an odds-on favorite for the Five Timer's Club.

But, more importantly, this is the first edition of Grand Rounds to be promoted by Medscape.

That's right: the web's leading medical news corporation is getting involved with blogs, becoming the first major media site to sponsor a rotating carnival.

That they've chosen to do this speaks volumes of the high quality of writing on medical blogs, the efforts and creativity of each week's host, and the sophistication of our audience.

Medscape is performing a service to their readers, in linking to Grand Rounds each week. They're also doing a favor to the hosts of Grand Rounds, by sending them a new source of traffic: medical students, nurses, and doctors who are online, but haven't ventured into the world of blogs.

So, do Medscape a favor and check out their medicine resources, news alerts, and CME credit opportunities. It's a perfect match.

And, tune in next week when medical student Graham Walker hosts Grand Rounds, at his blog, Over My Med Body.

Sickness and Health

It was a Sunday morning shift, one of my first as an intern. I'd been out a little too late the night before, and hadn't had time to pick up coffee before the train to work. In other words, I was still a little bleary-eyed when I walked into the Emergency room.

And that's when I saw them.

Gracefully moving in long, flowing red satin gowns. They were ministering to the overflow patients lined up in the hallway. Beautiful women, four or five of them, with their hair done up and jewelry sparkling. The contrast between them and the bloodied, disheveled men in the stretchers could not be more striking.

One of the seniors noticed me, transfixed at the entrance.

I tried to address a question to him: "Did we hire... church volunteers... Sundays?"

"Nope," he replied. "Knife fight at a wedding last night. Those are the bridesmaids. The groom's in the trauma room -- hey, do you want to take a look at the best man's chin laceration?"

I considered the scene for another moment and said, "I do."

Genes for "Jeans for Genes"

I first learned about the Jeans-for-Genes charity when in London a few years ago. After the initial rush of long-supressed childhood taunts subsided, I thought it was a great idea. Now it's come stateside, in the form of a celebrity auction.

The idea is: celebrities sign a pair of jeans. You buy them. Proceeds go to the National Hemophilia Foundation -- "for all bleeding and clotting disorders."

I'm not sure if the celebrities have worn these jeans, or simply signed them. For that matter, I'm not sure how their wearing them would affect the jeans' value -- that's for the market to decide (my guess: used Tyra jeans would be worth more than, say, Jay Mohr's.) Bid on a pair and see for yourself.

I would stand in line for this

There is no doubt in my mind that the sharp siren sound the opens and loops through Moby's "Extreme Ways" is intended to evoke the charging and acceleration of an IRT train.

These trains have inspired other artists, in the past.

It's not a bad way to head off to work each morning.

A Tale of Two Calls

It was the best of calls, it was the worst of calls. It was a time of wisdom, it was a time of foolishness. It was a season of belief, it was a season of incredulity. It was the spring of hope, it was the winter of despair. We had straightforward admissions, we had lousy cross-coverage. In short, the resident slept soundly for six hours, the intern was busy with paperwork, hypotension, and desaturations all night.

When it was over, the next morning, the intern had prepped discharge paperwork for more than half of the admissions, with two more leaving against medical advice. The census would stay managable. And the cross-coverage patients had all survived.

They said of the intern, after the call that night, that it was the peacefullest man's face ever beheld there. Many added that he looked sublime and prophetic.

Some of the most remarkable sufferers of this same process have been allowed to write down the toughts that inspire them. If he had given any utterance to his thoughts that morning, they would have been these:

"It is a far, far better thing that I do, than I have ever done; it is a far, far better rest that I go to, than I have ever known."

-- Loosely adapted from Charles Dickens, A Tale of Two Cities.

Harmony in the ED

Look at the rightmost columnFrom the November 2005 issue of Annals of Emergency Medicine, by Goyal, Hollander and Gaieski at Penn:
"The Figure displays an underrecognized clinical phenomenon for which we are proposing the term 'synypnea.' Synypnea is seen across the country and is defined as when emergency department waiting room patients have the same respiratory rate. We think it is pathophysiologically linked to menstrual synchrony. There is little scientific exploration on this topic, however, which represents fertile grounds for original research."

This is too funny -- it exposes one of the more absurd aspects of a job full of unacknowledged absurdities.

Now, I'm too new at this to speak authoritatively on the historical perspective of respiratory vital sign reportage. My understanding is that, for decades, nurses would faithfully collect the blood pressure, heart rate, temperature, and would simply jot down "RR = 20" on patients that seemed to be breathing comfortably -- even though twenty inpsirations per minute qualifies as mild respiratory distress.

By the time I was a medical student on surgery, we was told to never present a patient "breathing comfortably at 20 respirations per minute" -- and that if we did, we'd be holding retraction for the rest of the month.

But since most patients had "20" listed on the vitals, and since actually collecting the vitals on our own was out of the question, the students had an internal debate: Normal was about 10-12. Some of the patients in pain were breathing at 16. What should we settle on?

It seems our compromise -- 14 respirations per minute -- has become the standard at teaching hospitals across the nation.

As for Hollander's interpretation of the phenomenon, I would drop the second "y", and call it synpnea (it's more true to the Greek roots). And I wonder if his linking this to menstrual synchrony was a subtle jibe at the nurses who collect the vitals?

Station to Station

It's November, and the interns are entrenched. The novelty of writing prescriptions and ordering tests has faded. It's dark when we go into the hospital, dark when we emerge.

And by now, interns have become fiercely loyal to our chosen specialties. Most of us have done a rotation or two in our fields, as well as a few off-service months. Hence, I'm hearing unsolicited comments like, "You're in emergency medicine? Here? That is so not for me. I can't understand how anyone could choose that."

I'm doing floor medicine this month, and while it's a tolerable experience, let me state for the record: It's not for me. The phone calls, the forms, the follow-up with consultants, the incessant paging... All for patients that I rarely even see. No thanks, I'll take my chaotic ED over that, any day of the week, two shifts on Sunday.

But I'm starting to understand how some people could enjoy floor medicine. I keep thinking back to a revealing experience during internship orientation, back in late June.

The hospital-wide orientation itself was a glimpse into the mind of Internal Medicine, since their residents dominate the incoming class. Granted, I wasn't expecting the bonding, team-building, and river-rafting experience of my medical school orientation, but I thought there would be an opportunity to make some friends and learn something useful.

And, sure enough, when I looked at the orientation schedule, I saw several fifteen-minute coffee breaks between lectures on "Filling out Death Certificates" and "How to Spot Suicidal Tendencies and Drug Abuse in Your Colleagues." (Oddly enough, I don't recall meeting anyone during those coffee breaks. I think we all stood quietly, by ourselves.)

At the end of orientation, there was the issue of certification. Hundreds of newly-minted doctors had to prove they were properly vaccinated, properly insured, properly credentialed, that they fit snugly into their white coats and N95 masks, and more. We had to observe up-close demonstrations of blood draws and line placement.

The process was set up in an alley off our hospital's vast lobby, in stations. After lectures got out, we'd visit each station, do whatever was required, and collect a sticker. When our sticker-sheet was complete, we could sign out and begin healing the sick.

Each station was a mob scene. No one's documentation was quite right, no one could understand how the butterfly needle retracted, and everyone could smell through the masks. Most stations were staffed by, shall we say, unsympathetic hospital administrators. At every juncture, there were barriers. The process seemed like it could stretch for hours.

Waiting in line at one station, I noticed a fellow intern's sticker sheet. She already had eight stickers, while I was still on number three or four. She would be done soon -- free to go home and unpack, or enjoy the city. I'd be cooped up in line on a sunny summer day for a good while longer.

We introduced ourselves. It turns out she was a Harvard grad, going into Internal Medicine. "How did you get all those stickers so fast?"

"I cut out of the last lecture early," she said. "Some of the stations were already set up."

"Oh, well," I remarked, "you missed an uplifting talk on persuading families to donate organs."

"That talk wasn't mandatory. This is."

And that orientation experience, to me, was appropriately representative of floor medicine: Obstacles everywhere. A long list of things to check off before you could go home. The patient, a distant abstraction.

I haven't seen that intern again, but I have no doubt that medicine is for her.

Post-call Postings

If I had the time or energy for another web-publishing venture, I think I'd organize a collection of all the post-call ramblings of interns and residents across the web.

I was talking about this recently with a prolific blogger. The moments after a call day represent a great opportunity for writing: the authors are either giddy or grouchy. They've spent the past 30-odd hours on the front lines of the human condition. Their judgement and motor coordination are equivalent to a BAC of 0.05.

It sounds like it'd be intriguing to read. But my own post-call rought drafts never seem as profound or emotionally charged, upon well-rested review. Maybe the readers would have to be post-call, as well.


I've got a pile of old unpublished posts in various stages, and just promised a regular reader I'd be finishing them up soon. Until then, here's Lileks, on his new book Mommy Knows Worst:
It’s a compendium of archaic child-rearing advice, going back to the 1920s, when parents were urged to give their kids sunburns and linseed enemas. It’s perhaps the only book I will ever write that devotes a substantial chapter to the greatest problem of the 1940s: CONSTIPATION. You have no idea how slow the bowels of American children moved in the forties. Dads will enjoy how stupid and useless they were made to look in the 50s; Moms will enjoy the detailed how-to-give-birth-at-home section from the WW1 era, and everyone will love the 1960s pamphlet on dealing with home stresses via industrial tranquilizers. It’s the usual retro-fest with many ads, laden with unfair commentary, and attractively priced; perfect for everyone who’s ever had a kid or a mother. I think that covers it all.

I think Lileks is downplaying the size of the constipation crisis among infants of the 40's, and even today. If there's one thing I remember from medical school pediatrics, it's that constipation causes a surprising number of hospital visits (a second fact springs to mind: parents aren't often satisfied with the diagnosis of constipation).

Now that I think about it, I should buy this book in preparation for my peds month in December. One or two of those chapters may come in handy on the floors.


She came in with their teenage son to see him. She was about forty-five or fifty, with makeup and earrings and a nice blouse. I didn't recognize her at first -- she wasn't what I expected.

When my patient told me his ex-wife would be coming to visit, I simply imagined someone like him. I tried to picture his home; the squalor and decay that I associated with a pathology like his.

I overheard her at the front desk, asking, "Why can't anyone tell me where he is?"

I looked up from my charting and saw her. "I'm sorry," I answered. "I'm taking care of him. I spoke with your son on the phone. We just moved him to isolation -- it's right this way."

I led them to him and opened the door. Her face contorted and her posture stiffened, then she went inside. Their son followed.

I stayed outside, by the desk, writing my chart. I had a lot of questions I wanted to ask her, about his medical history, his alcoholism -- but it could wait until they were outside again.

I didn't want to go back in there.

She emerged a few minutes later, and took a moment to adjust her outfit and take a few deep breaths. She briskly walked toward me.

"When is he going to surgery?" she asked.

"Hopefully within the hour."

She thought carefully for a moment about her next question, and asked slowly, "What is that godawful smell in there?"

In a moment, I tried to imagine their divorce, maybe a few years ago, as his drinking got worse. Was there an ultimatum? A custody battle? In the end, maybe she felt she there was nothing more she could do -- so she took their son, and hoped that somehow her husband would turn it around, by himself.

He didn't, and now it had come to this: asking the emergency department intern about the smell.

I pursed my lips and looked into her eyes. "It's the foot," I said. "His right foot is just dead tissue."

Celebrity Skin

It's October, 2005, and I'm continuing to coast on all the writing I did last year.

A few days ago, the Wall Street Journal mentioned blogborygmi in a piece on medical blogs (reprinted here). It looks like the reporter read though some of my archives, which is really nice. But she listed me as anonymous -- maybe because I requested that my hospital affiliation not be disclosed. Or maybe she thought "Dr. Genes" was a pseudonym (though the last time I was quoted in the WSJ, my name was the topic).

I also was interviewed by Dr. Kent Bottles of, as part of his series on medical bloggers. It's really a wonderful thing he's doing, recording the thoughts of early medblogging pioneers like MedPundit and Dr. Centor -- I'm really honored to be listed among them.

A few hours after doing the interview, I sauntered into work, my head still a little big from the attention. Internship can be a long slog, and sometimes it gives me a warm fuzzy to know this medical blogging scene is taking off, and I'm a part of it.

One of the seniors greeted me excitedly.
Resident: "Nick! You just missed all the cameras! The network was here. Our attending is going to be on that makeover show! They just swooped in and took her away."

Me: "Really? Dr. B? But she's so..."

Resident: "Pretty? Yeah, but she felt she had kind of lapsed a little bit since she started here. Anyway, they filmed in the ED, they got a shot of all of us, I'm going to be on national TV!"

Me, smiling to myself: "That's really... great..."

I guess, despite all the progress, medblogging still has a ways to go.

Diamond in the Roughage

I often wondered which medical blogger would first make it onto's "Blogs of Note" first... would it be the news and views from mighty Medpundit? The rich examining-room tales of Dr. Charles? The heartbreak and introspection from The Cheerful Oncologist (you know, before he moved off blogspot).

As far as I can tell, none of these fine, erudite blogs have been featured. But this one is: Ah Yes, Medical School. Ah yes, they've chosen to spotlight the bawdy writing from a still-adolescent twentysomething male, preoccupied with breasts, poop jokes, and whining about work.

It's really funny.

It looks like he's labored without much recognition for years, before finally getting some attention this month. I wonder how many others are out there like him. Maybe now with google's blog search, it'll be possible to find more of these hidden sites.

Year Two is underway

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

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

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

The City That Never Sleeps

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

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

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

Jane, who was sitting at the computer, called up the report. "Yep, it's in here:"
"Portable chest X-ray, good inspiratory effort, the lungs are unremarkable with no infiltrates, effusion, or evidence of pneumothorax. The heart is within normal limits. New York is prominent and calcified."

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

"New York is prominent and calcified."

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

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

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

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

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

Snelgrove, Apres Mort

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

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

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

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

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

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

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

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

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

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

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

But the way Snelgrove died will undoubtedly come up in the Snelgrove's lawsuit against the makers of the FN-303 pepperball gun:
The letter sent to Falk by the Snelgroves' attorney, Patrick T. Jones, disputes that contention, saying that in its marketing material, FN Herstal suggested that the projectiles would break apart when they hit someone, which Jones argued led Boston police to believe the "projectiles are safe and contributed to an attitude by the shooters . . . that they could not cause any serious injury."

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

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

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

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

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

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

Grand Rounds #52

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

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

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

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

More to come...

Dispatches from New Orleans #1

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

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

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

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

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

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

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

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

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

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

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

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

I do need to tell you some of the stories.

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

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

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

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

And one more:

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

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

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

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

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

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

Dispatches from New Orleans #2

This letter is making the rounds on EM residency lists:
let me start by saying that i am safe and after a very rough first week
am now better rested and fed

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

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

the numbers are absolutely staggering

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

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

we did not practice medicine

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

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

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

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

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

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

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

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

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

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


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

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

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


Several supporters of Grand Rounds have contacted me about the Carnival study from Free Money Finance -- are there conclusions here that can help expose the writers and hosts of Grand Rounds to a larger audience?

In short, I don't think it has much bearing on our practice. Former GR hosts on the discussion board can learn why; I'm not interested in airing this publicly. In the meantime, I look forward to watching Carnival of the Colonoscopists and every other niche group try to manipulate Instapundit into greater traffic -- if that's not a zero-sum game, it's asymptotically approaching it.

But have no doubt: the writing in Grand Rounds is worthy of a wide audience. Go check out the latest edition, now up at

Next week's host is Healthy Concerns. It's worth noting that both these blogs feature a lot of advertising, and are, in fact, part of corporate ventures. I've been a part of another such enterprise for several months now.

Has sponsorship compromised these blogs, these writers? Is advertising something you're sad to see? Mull it over, because the path to boosting Grand Rounds traffic may lie in this direction.

Time and Place

I've been reading and writing about global positioning technology for a few years now, and still to partake in the occasional geocache hunt from time to time. But Wade Rousch has written something pretty insightful and novel on the subject:
Indeed, GPS is transforming geography in much the same way that mechanical clocks and watches regularized our once fluid experience of time. As soon as there were simple ways to measure time, we could organize our actions around specific moments; every school bell and factory whistle in the nation could sound at 8:30 A.M. The concept of synchrony set the stage for the 19th-century revolutions in industry and transportation.

Similarly, now that we can easily measure latitude and longitude, we can organize our actions around specific locations. Adventurers can navigate to the same remote spot at different times, as in geocaching; businesses, artists, or historians can share online information about any physical thing using its GPS-supplied coordinates rather than a Web-type Uniform Resource Locator (URL). Call it "synlocality."

The author thinks it's inevitable that cell phone companies turn on the GPS devices they've included in their phones. I think there will be some tentative steps in that direction, but there's potential for a huge backlash against location-tracking.

Maybe it's like broswer cookies: if the benefits outweigh the potential loss of privacy, and if people can opt-out if they want, then the technology will be adopted.


Circadiana is hosting the 47th Grand Rounds. Check out the latest from the medical blogosphere, and be sure to peruse this interesting sleep research blog.

Maybe somewhere in Bora's archives is the answer to why I'm awake right now.

Next week's host is Kevin Pho, M.D., coming to you straight from the doc. Email me if you're interested in hosting future editions of Grand Rounds.

Buried Treasures

Lileks was in rare form with today's Bleat -- disclosing the secret Amazon customer service number (800-201-7575), wandering around renovated malls, and musing about Shakespeare's role in Psalm 46:
Count 46 words from the start, and you get "Shake." Then count 46 words from the end. You get "Spear." The KJV was published in 1611; Shakespeare turned 46 in 1610.

Like that man a hundred years ago, who discovered the (potential) Easter egg in the King James Bible, the question is not so much "who put it there?" but -- "how was it ever discovered?" Then again, if you look at a typical science grad student's day, it's spent poring over data, looking for trends in excel spreadsheets.

I guess the difference now is we generate our own data, rather than analyzing and re-analyzing the masters.

I think about this sometimes when I'm quickly scanning through slices of a head CT, looking for gross blood. How many megabytes am I skimming through? How many head CTs will I order tonight? How many will be done in this ED, in this city, just tonight?

These are images of the seat of consciousness, and I spend about twenty seconds scanning for particular patches. When I don't see them, I close the window and move on. After the radiologist confirms, that data is consigned to the dustbin, maybe never to be viewed again.

I'm confident we (almost never) miss anything that could affect the patient's short-term health. But maybe we're missing something else.

Against the Tide

I remember riding the subway on Friday evening, heading to the first of three night shifts in the emergency department. I had slept poorly during the day, and didn't know what to expect from these first weekend overnights. Traumas? Procedures? Would I be able to handle the pressure?

I surveyed my fellow passengers. The subway seemed bouyant, full of laughter and the relief of people leaving the work week behind. I felt a pang knowing that, whatever happened these next few nights, I'd be missing the party.

But I was wrong -- the party, as it turned out, came to me.

Riding back on this morning, with my post-shift giddiness, I scanned the solemn Monday morning faces. Are they concerned about the same things I was? Could they possibly enjoy their jobs as much as I do mine?

A More Significant Diversion

My phone received a text message last night, from a friend who knew me back when:
"Olivier Dubois is the new Nick Genes!"
I didn't know what this cryptic phrase meant, until I picked up the Metro this morning and saw Dubois all over the front page, relating details from his airline adventure.

And as my texting friend noticed, there are some parallels in Dubois' account of a normal descent, no cautionary word from the cockpit, etc., and my tale from a few months back.

Except, you know, his plane crashed and caught fire, and he could have easily been killed, while my flight was just diverted for a few hours. Details.

Of all the passenger interviews, Dubois gives the best summary of what happened on Air France 358, and what it felt like, and wisely leaves the editorializing to passengers like Gwen Dunlop. So, kudos to him for keeping cool and remembering details after an unbelievably distressing experience.

But it remains to be seen, of course, where Dubois goes from here. A blog? Memoirs? Movie of the Week? Because his ceiling is sky-high, let me tell you.

Pitching Relief

Two articles caught my eye recently, dealing with Red SOx pitcers and the physicians and psychologists keeping them on the field.

In today's Boston Globe, there's a discussion with noted sports psychologist Harvey Dorfman, on why he thinks Matt Clement will successfully return to the mound after being beaned in the head by a line drive:
"A lot of it has to do with where you've been hit, believe it or not," said Dorfman, who has worked with the Athletics and Marlins and is now on the staff of sports agent Scott Boras.

"I was watching on TV when Matt was hit and the first thing I said to myself was, 'I think he'll be all right, it was on the side of the head.'

"Look, you can't predict the future. How people respond is up to them individually. But what I mean when I say it was better that he was hit on the side of the head is that it allows a guy the idea that essentially, he got out off the way. Of course, that's almost absurd in a sense, but he was turning out of the way of the ball. When you're hit flush in the face, that's a different story."

Interesting, that a split-second response, barely effective, might save him from debilitating fear down the road. I would have thought the severity of the injury (in this case, luckily, minor) would play a larger role.

Also, from a few weeks ago, the LA Times had good report of Dr. Bill Morgan's dismissal from the Red Sox last fall (if you can stomach some of the sportswriter's overwrought style). The best part of the piece was the physician's perspective in watching Game 6:
While others were writing off the season, however, Morgan was having a brainstorm. Instead of fixing Schilling's ankle, he wondered, what if it were somehow possible to temporarily freeze its malfunction? What if the dislocated tendon could be held fast to the bone, just to keep the thing from flicking back and forth?

An intriguing idea. Just one small problem. It had never been done before. In the annals of medicine, in the annals of ankles, the procedure Morgan proposed was unprecedented, the surgical equivalent of coming back from 0-3. "I've never thought of doing it myself, nor have I ever read of someone else doing it," says Dr. Robert Leach, professor of orthopedics at Boston University Medical School and former team doctor for the Boston Celtics.

Morgan ran his idea by Schilling and found the pitcher willing. Nervous but willing. "I walked in the training room," Schilling recalls, "and Doc looked at me and said, 'Let me throw this at you.' It was a last gasp. We'd exhausted all our options. It was either this or I didn't pitch. I'd resigned myself to the fact that I was done."

Once Schilling—and Sox officials—agreed to the procedure, Morgan decided he'd better practice first. He needed to make sure the procedure was even feasible, that the tissue around a human ankle bone was soft enough to be penetrated by sutures. With time running out on the season, Morgan performed a dry run on a dead body.

The practice surgery worked. Sort of. There was no way to really test it because there was no way to send the dead guy out to face the Yankees. Then, turning from corpse to ace, in a remote training room far below Fenway Park, Morgan knitted Schilling's ankle with five or six deep O-shaped stitches.

Schilling's teammates, meanwhile, partly inspired by the specter of their comrade laid out on a makeshift operating table, managed two wins against the Yankees, staying alive until Schilling could take the ball again.

October 19, 2004. Game 6. Cameras zoomed in on Schilling's ankle and millions of Americans saw the sock slowly turn red, as Schilling's face turned white. "I was scared to death," Schilling says. Tentatively, perilously, he stood propped on his Morgan-repaired joint, peering at New York's batters over the webbing of his glove.

Fans everywhere held their breath. Morgan, watching on a TV in the clubhouse, held his breath, too. Some bleeding was normal, he knew, but what he looked for, what he dreaded, was blood on the sock that appeared "frank," or dark red, which would mean the sutures had torn.

Everyone in the Sox organization had a lot at stake that night, but Morgan and Schilling were risking the most. They both knew that if Schilling's tendon ruptured, if infection set in, if any number of things went wrong, Schilling could fall to the ground like a man shot with a deer rifle. More, he might never heal properly. He might date the end of his brilliant career from that night, that game, that unprecedented procedure.

A great look behind the events of that week. But some details are missing from the larger picture: though he touched upon Morgan's drinking, the the writer should have informed readers about Morgan's driving record. More importantly, the reporter neglected to mention the Red Sox management's principle of non-sentimentality. Hell, they traded the high-energy Cabrera and even Dave Roberts, who stole second base and began the greatest turnaround in sports history. Both these guys became fast fan favorites, performed above and beyond expectations, and certainly didn't cost much.

Breaking News

I like to browse the headlines on ScienceDaily, looking for stuff to read or blog about. I don't know if it's my mood or a particularly obvious set of headlines, but this Friday's edition gave my inner snark some material to work with:

Do Free Drug Samples Influence Residents' Prescribing Decisions?
I think it depends on how fastidiously the residents take the drugs.

Nuclear Weapons Continue to Pose a Serious Health Risk to Europe
I actually thought this was lazy headline-writing -- that it was really an article about storage leaks or background radiation. But no, the report is about nuclear weapon detonation being a health risk. Because, you know, they're weapons.

Delirium Associated with Premature Death
But what a way to go!

Knee Pain Often Linked To Pain Elsewhere In The Body
This was particularly true of patients who had been run over, or had fallen from great heights.

Top Ten Reasons Blogborygmi's Been Quiet

10. This new city I'm living in has more things to do
9. Furniture shopping can expand to fill all my free time if I let it
8. I've been writing on Medgadget (and using the royal "we" has left me without a sense of identity)
7. I have two posts about moving, two on orientation, and one post about my first shift that still need some polishing
6. Making new friends, keeping the old
5. The PGY-2's are 'teaching' me poker
4. It's really humid
3. I find myself reading more medical journals, instead of surfing medlogs
2. Interns don't seem to talk a lot

And the number one reason I haven't posted here in a while:

1. The networks stopped calling me, what's the point anymore?

Inside the Beltway

Last year I blogged about Nathan's Hot Dog eating contest. This year, I gave some thought to attending this spectacle of competitive eating (these plans were laid to rest the night before, when I enganged in the spectacle of competitive drinking).

Anyway, it doesn't look like I missed too much. The same guy, Takeru Kobayashi, won again (though last year, he was frequently called by his nickname, "the Tsunami." Not so much, this year).

Also unchanged: the dearth of scientific inquiry into this ... sport. I mean, it's been over twenty years since competitive race-walking was examined in detail -- is that any more of a sport than competitive eating? Which activity is of more relevance to the obese American taxpayer?

All I can really find on the matter is this press release from the International Federation of Competitive Eating:

The November 2003 Popular Science addresses the tendency for thinner, in-shape gurgitators to beat heavier eaters in competition. Many intuitively believe that a larger individual has more room to hold food, but this is not the case. The magazine states that the size of the stomach at rest is inconsequential and that the ability for the stomach to expand is all that matters.

This is the conclusion reached by former world champion hot dog eater Edward Krachie in his 1998 scholarly journal article, "CAN ABDOMINAL FAT ACT AS A RESTRICTIVE AGENT ON STOMACH EXPANSION? An Exploration of the Impact of Adipose Tissue on Competitive Eating." In his article, Krachie goes a step further and proves that the stomach of a heavier eater is prevented from expanding by a "belt of fat."

The IFOCE and Edward Krachie submitted his piece to numerous academic journals including the New England Journal of Medicine. Sadly, all journals rejected his piece.

Sadly, Popular Science doesn't really conclude the 'belt of fat' theory is correct. The reporter just asserts it, and goes on to talk about satiety signaling. The entire piece is not much longer than the IFOCE press release.

I think there's plenty of room for more ... data. Granted, I have an appetite for this stuff, but I think it's worthy of extra helping from the scientific community. Because the few morsels of information we have now are hard to digest (as are these puns. I'm sorry.)

Krachie and company are arguing, essentially, that a belly of fat is more compressive than skin and muscle are distensible. I'm not convinced. I wouldn't be surprised if the thin eating champs were born with weak pyloric sphincters, or exhibit higher capacity for smooth muscle relaxation. But until we start doing some barium swallows and endoscopies on these people, we're just guessing.

Sooner or later, the reward money for these contests will prompt some competitors to fund their own clandestine research. And it would be a shame if these athletes were smeared with allegations of shady practices. Let's keep the research open and freely available -- let science have a seat at the table.

Escaped from the Madhouse

A conversation fragment from the incoming resident orientation (I used proper names in reality):

Me: "So, you did your medical internship at Hospital X? Maybe you know Madhouse Madman?"
2nd-Year Resident: "Oh, yeah. He's great. Actually, he told me to look out for you, that you'd be here. He said you two met online."
Me: "Uh, well, I wouldn't put it that way, really. I mean, I heard of him through his website..."
PGY-2: "You've never met him in person?"
Me: "No. I don't even know what he looks like. But I've seen pictures of his new daughter, though. And he just got back from this trip to Israel, it sounded nice."

PGY-2 pauses to wonder how I know these disparate pieces about a man I've never seen.

Me: "He leads a very public ... private life."


Tim Gee of Medical Connectivity is hosting Grand Rounds this week:
Grand Rounds always impresses me with the diversity, richness and good writing that comes from folks in the many areas in health care, and today is no different.

Well said. As a medical connectologist, Gee is an interesting and underreported player in the health care industry. Stop by his site, learn about what he does, and check out the latest from the medical blogosphere.

Next week's host is Shrinkette.

Lordy, Lordy: Grand Rounds 40

David Williams' Health Business Blog is hosting Grand Rounds XL (though it looks the appropriate size). Go check out the latest and greatest from medical bloggers around the world, and get your submissions to Medical Connectivity for next week.


Today, Lileks compares antique stores to funeral parlors -- the sadness that surrounds forgotten treasures of our past, abandoned when we go off to school. Coincidentally, I was just musing to a friend about my old Snoopy pencil-case today, which always signified the end of summer and start of another year of elementary school.

It's taken twenty-five years, but I'm not a student anymore. Tomorrow is my first day of work.

I wish I had more to say, more I could articulate about this transition. I'm going to try to heed Doc Shazam's advice, and record my early impressions of doctoring and internship. But for these past few weeks, it seems I've lost my voice. Blogging, for me at least, requires some modicum of stability, and these heady times have been anything but stable.

But I've found a new home, and a busy schedule is about to be thrust upon me. Order will reassert itself soon enough. And as Ben Folds reminds us on his new album, it's not wise to get nostalgic about the last ten years, before the last ten years have passed.

I think I get what he means. But of course, it's his song about airlines and new beginnings that really speaks to me:
If you wrote me off, I'd understand it
'Cause I've been on, some other planet
So come pick me up... I've landed.

The entry below is actually something I wrote a few weeks ago, around graduation, but couldn't quite bring myself to post. Now seems like a good time to clear out the drafts -- a new wave of experiences begins in a few hours.


Graduation week alone should be more than enough to consume me, with its good-byes, fond remembrances, and the commencement of a grand and challenging career.

But add to the mix the ups and downs of apartment hunting, furniture shopping, trying to find a home for my cat and my car, a bachelor party in Cancun, and making sure I'm sufficiently overexposed, in print and on TV. I've got a full plate.

It's been over three months since I've seen a patient, and I'm missing it. This weekend our class heard some speeches about the privilege and noble duty of medicine, of treating the sick. Among the things that have stayed with me is a talk honoring a faculty member who passed recently. The speaker said:

"She was so enthusiastic about connecting with patients, really, deeply connecting. She sometimes called those encounters 'Level 5 Interactions' -- I have no idea what that means but it sounded really intense."

I think I know what she was talking about (and it's not hospital billing codes).

I think I need those kinds of encounters to stay grounded. I sometimes worry if that's pathological, but frankly, there's more pathology in the extremely fun but ultimately superficial interactions that have preoccupied me since I got back from Greece.

Our graduating seniors take the Oath of Maimonides, and the excerpt below seems particularly relevant:

The eternal providence has appointed me to watch over the life and health of Thy creatures. May the love for my art actuate me at all time; may neither avarice nor miserliness, nor thirst for glory or for a great reputation engage my mind; for the enemies of truth and philanthropy could easily decieve me and make me forgetful of my lofty aim of doing good to Thy children.

I'm very, very lucky to be in medicine, and to have such family and friends.


The phenomenon that is medical blogging receives coverage in today's LA Times. The reporter, Marianne Szegedy-Maszak, chose to focus on physician blogs, but that's ok, what with me now being a physician and all. My Medgadget colleagues, Dr. O and Dr. Bradley, are also featured.

And I like how she introduces the topic:

The family pictures on the desk. The diplomas on the wall. A few magazine subscriptions, perhaps, or some sailing, tennis or golf memorabilia scattered around the office. In the past, a curious patient could only turn to these bits of evidence to try to know more about the individual behind the medical degrees, the white coat and the carefully scripted bedside manner.

The temptation is understandable. After all, when someone holds your life in his or her hands, it would be nice to know a bit more about what makes them tick. But today, anyone with an Internet connection can have access to the fevered, funny, angry and very human thoughts of these men and women who help us navigate the perilous shoals between illness and health. The vehicle? The doctor's blog. A blog is the name used to describe a weblog, the constantly updated platform for the idiosyncratic and highly personal musings (or rantings) of anyone who wants to set one up in cyberspace.

"It's a direct line to see what doctors think that you won't pick up in the office or from television shows," says Michael Ostrovsky, a cardiac anesthesiologist in Daly City, Calif...

I'm consistently surprised about what makes it into the final version of a story. For instance, the reporter and I were discussing how bloggers discover each other, how we cross-reference posts. Sure, there's, and now Grand Rounds (which she graciously acknowledged). I also mentioned one post which really seemed to put me on the map last year -- "Hard to Swallow", a pun-laden critique of a Austrian nose-picking advocate.

Well, very little of the conversation about blog cross-linking and meme propagation made it into print. But, naturally, my views on nose-picking are prominently excerpted in the sidebar (in stark contrast to the really insightful quotes from Dr. Charles, the Cheerful Oncologist, and others -- I suppose it's appropriate that the print debut of "Dr. Nicholas Genes" is a little... juvenile).

At any rate, the article provides a good survey of doctor blogging, and the various motivations behind it. And the reporter leaves her readers (and interviewees) with some good questions: will blogging improve the doctor-patient relationship? Will it help disseminate medical data amongst peers? Will it "spawn the next Oliver Sacks?"

I've tried to be cognizant of the risks in believing our hype, of overestimating the potential of medical blogs. So it's exciting to hear an outside reporter asking these questions. And I look forward to learning the answers, in the coming years.

Lacrimation Day

I was standing in the buffet line of one of the many graduation fetes this weekend, next to a dear physician on my school's faculty. But she was suffering:

Distinguished faculty: My eyes are watering, my nose is running, I feel awful.
Me: Allergies?
Distinguished faculty (chuckling): Yeah, how could you tell?

I smiled back and said, for the first time, "Well... I am a doctor."

Not surprisingly, at the ceremony today, quite a few of us graduates, faculty, and family members got a little misty-eyed. Must be the pollen.


Michael Chaplin is hosting this week's Grand Rounds, the best posts of the medical blogosphere. It's chock full of quotes, and a discerning description of yours truly. Go check it out! He's got doctoring in his blood (or at least, that's my translation of Iatremia.)

Next week's host is Dr. Sanity!

Our Place in the Sun

I took my med school's course on nutrition back in the 90's, when Vitamin E was all the rage. If I recall those heady days, the only question about E was whether we should slather it on our skin, eat it, or freebase it.

Times change. Now, E is out and D is in, in a big way. You may know that Vitamin D is the vitamin we make, by sitting in the sun's UV rays (technically, since we produce it, can't be a vitamin, but I digress).

Some oncologists and dermatologists currently believe D is so important in fighting cancer, it's actually worth running the risks associated with increased sun exposure (namely, cancer. And wrinkles. But mostly cancer). Needless to say, this is controversial:

...Dr. Edward Giovannucci, a Harvard University professor of medicine and nutrition ... laid out his case in a keynote lecture at a recent American Association for Cancer Research meeting in Anaheim, Calif.

His research suggests that vitamin D might help prevent 30 deaths for each one caused by skin cancer.

“I would challenge anyone to find an area or nutrient or any factor that has such consistent anti-cancer benefits as vitamin D,” Giovannucci told the cancer scientists. “The data are really quite remarkable.”

It gets juicier:
“I am advocating common sense,” not prolonged sunbathing or tanning salons, Holick said.

Skin cancer is rarely fatal, he notes. The most deadly form, melanoma, accounts for only 7,770 of the 570,280 cancer deaths expected to occur in the United States this year.

More than 1 million milder forms of skin cancer will occur, and these are the ones tied to chronic or prolonged suntanning.

Repeated sunburns — especially in childhood and among redheads and very fair-skinned people — have been linked to melanoma, but there is no credible scientific evidence that moderate sun exposure causes it, Holick contends.

“The problem has been that the American Academy of Dermatology has been unchallenged for 20 years,” he says. “They have brainwashed the public at every level.”

This guy, Dr. Michael Holick, helped discover how Vitamin D works. But when he published his book about the benefits of UV and the dermatology brainwashing, he was stripped of his professorship (which no doubt led to more ... exposure)

Via metafilter, who reminds us that Baz Luhrman's advice about sunscreen, and life, is suddenly suspect.

Red Scare

Here's some provocative, if underpowered, research findings (via the guy at Scared Monkeys, whose name is actually... Red):

"Across a range of sports, we find that wearing red is consistently associated with a higher probability of winning," report Russell A. Hill and Robert A. Barton of the University of Durham in England. Their findings are in Thursday's issue of the journal Nature.

Red coloration is associated with aggression in many animals. Often it is sexually selected so that scarlet markings signal male dominance.

Just think of the red stripes on the scowling face of the male Mandrill, Africa's largest monkey species. But red is not exclusively a male trait. It's the female black widow spider that is venomous and displays a menacing red dot on her abdomen.

Similarly, the color's effect also may subconsciously intimidate opponents in athletic contests, especially when the athletes are equal in skill and strength, the researchers suggest.

One's thoughts immediately turn to the Red Sox, who didn't wear much red until the past few years. In their previous world series appearances, they've lost to teams like the 1949 Cardinals and... 1975 Reds... But you can't overlook the fact that the most dominant team last century wore blue pinstripes. Also, in NFL football, the dynasties of the Patriots, Cowboys, Steelers, Packers, Bears... not a red shirt or helmet in the bunch (The Patriots in particular have done much better since moving away from red).

There ought to be a more innovative way to study this, a la Steven Leavitt's Freakonomics, where looked at the statistics behind Sumo matches and found it's likely some important status-determining matches are thrown. The current red study just doesn't seem to have a lot of data behind it, especially the team sport analysis. I'm not sure how they can do better, though, short of having the same teams play each other dozens of times, switching uniforms halfway through.

Besides, even if there is a visceral reaction to the color red, it's hard to say whether it would always be negative. If red arouses the fight-or-flight response, it seems just as likely that opponents would fight harder, rather than be intimidated. I think bulls would agree with me.

And if this turns out to be true, it may go a ways toward explaining the "Red Shirt phenomenon" of classic Star Trek, in which hostile aliens would always spare Kirk, Spock, and McCoy but kill the random crewman with the red shirt.

AMA, Premium

While I was away, my colleagues at went beyond our usual pithy medical device commentary and actually took on the AMA:
We have reported earlier about the proliferation of free, open-source, online medical journals. When it comes to the spread of information, the American Medical Association (AMA), however, is moving in the opposite direction.

It has come to our attention that the AMA, has quietly announced that it will make the contents of its AMNews online edition (website) available for AMA members only. Bylined as the "The Newspaper for America's Physicians", the AMNews was the last AMA publication with current content available online for free (for your information, JAMA, which publishes research that is mostly funded by the U.S. taxpayer, has never been available to the general public.)

It reminds me of the this year's Homestar Runner April Fool's Day subscription plan, called Pay Plus!, which was pitched as "Same content! New annual fees! Just Pennies per Pixel!"

The Medgadget call to action got the attention of the AMNews editor, who responded by saying, essentially, that membership has its privileges. However, as GruntDoc suggests, it's actions like this that guarantee AMA membership will become more irrelevant as time goes on.

In case you're worried, Blogborygmi will continue to remain free, as the administration costs are almost entirely supported by revenue from Storeborygmi, the online shopping experience.


After two weeks of seeing extended family in Greece, I was returning home in a mood to start writing again. I had some layover time in the Milan airport before the second leg of my trip, and had prepped a few posts. But nothing was quite as blogworthy as what happened on the flight home.

Even so, the first seven hours of yesterday's Alitalia flight 618 were uneventful. I was too sleepy to appreciate the movie, too hungry to mind the airline food, and not pleased with the International Herald-Tribune crossword. I settled into a light sleep about halfway through, with occasional wakeups for snacks and drinks.

I woke up with a start, for instance, when the captain announced we’d begun our descent into Boston. He said the weather was partly cloudy. The elderly Greek woman seated next to me noted the temperature – 12 C – would be a big change from what we’d enjoyed in Athens.

As we past through the cloud layer, I peered through my window seat to look for landmarks. I didn’t see any, but was pleased that things looked I lot greener than when I left in April. We got closer to the ground and I fretted that I couldn’t spot the Boston skyline –- or even the ocean. What approach was this? As we touched down, the passengers applauded, but I was growing alarmed: this didn't look like Logan. I saw a fleet of gray military cargo planes outside a hangar. There were no passenger planes from my view, just wet tarmac and an overcast sky. Where were we?

The Greek lady remarked she’d made this flight twenty times, and had never seen this part of Logan. The woman behind me suggested, “It might be that new runway they’re talking about.” The cockpit told us nothing. Some passengers had unfastened their belts and began to retrieve carry-on bags. I thought about turning on my GPS receiver. The Greek lady checked her watch and announced that, wherever we were, we landed a half-hour early.

After about a minute of growing unease, the captain announced (in Italian first, then English) that we were in Bangor, Maine, and under what he termed “police control.” As I was translating this to the Greek woman next to me, the plane was boarded. Four men in black uniforms, along with a plainclothed man with a large ID badge, walked past us to an aisle seat about eight rows behind me. They surrounded a man who calmly stood up, and then they all quietly walked out. The whole thing took less than a minute. I got a good look at the deposed passenger (but was afraid to reach for my camera): he was tall, maybe 6’, with light brown skin, a curly beard, no mustache, and short black hair.

The captain told us we were still under police control, and the passenger who was removed was wanted by US authorities. We would stay in Bangor until they identified and removed the man's luggage, a process they estimated would take 30-45 minutes.

We were allowed to circulate during the luggage search, so I got up and interviewed the man nearest to the deposed passenger (note: I am not a journalist). Here's how the interview transpired:

Me: Hey, wow, was he, like, sitting right there?
Nearby passenger: Yeah! They just came right in and took him! They didn’t even ask his name.
Me: Is that his jacket?
Him: He just got up and left. Didn’t take any carry-on with him, either.
Me: Was he doing anything weird during the flight?
Him: No, nothing I could see.
Me: Um... So, what did you think of the movie?

Another passenger remarked, “He didn’t seem surprised at all. It’s like he knew they’d be coming for him.” I wouldn’t ascribe so much to that brief encounter, but then again, we didn’t have a lot to work with.

That’s when Mom called. She and Dad were supposed to pick me up at Logan. She was really worried about how the Arrivals board switched from “On Time” to “Delayed” so late in the flight. The group of reporters massing at Logan alarmed her, too, until Channel 5’s Kelly Tuthill explained to her that we had a suspected terrorist aboard, and had landed safely in Maine.

“How did all these reporters know so fast?” Mom wondered. Tuthill revealed: The network told them.

When I explained that the luggage search, refueling, and flying home would take at least another hour, Mom asked what we were still doing on this plane. It’s a good question: if this man is wanted by the US, and dangerous enough to prompt a landing at the first available international airport on US soil, why not evacuate the plane during the luggage search? Wasn’t it possible we were sitting on a ticking bomb?

As if on cue, the cockpit requested we take our seats but keep our belts unfastened (“the better to evacuate us,” I suspected.) Flight attendants positioned themselves by the exits, and for the first time since we were boarded, I got nervous. But soon after, the luggage was found and we were told we’d be underway again soon.

As we maneuvered onto the runway, I saw some TV trucks and photographers gathered by a fence, to film us. Of course, by now, our cameras were snapping away at them (a fellow passenger joked, “Reporters observed strange flashes of light from within the cabin...”).

Back in the air, I publicly speculated Alitalia had spare snacks on hand, for just such an occasion. But if they do, we didn't see them -- we were served only water. I took the opportunity to ask our flight attendant when they learned of the diversion. “Was it just a ruse when the cockpit said we were descending into Boston?”

“No,” he replied. We learned we were landing in Bangor right after that announcement.”

When we finally landed at Logan, I worried that we’d be subject to lengthy inspections or questioning at customs. At this point I really just wanted to go home. Other passengers were trying to catch connections. But the lines moved pretty quickly, and the only questions I was asked came from the Boston news stations.

The reporters were angling for the frustration angle – why not check the passenger lists before the flight leaves? While that sounds well and good (though is apparently technically difficult) I’m more confused about other aspects of the way this emergency was handled: The location to which we were diverted, and the apparent lack of concern after the suspect was removed.

The no-fly list is reserved for those with known or suspected links to terrorism, or other “threats to aviation.” This man was considered enough of a risk to scramble escort jets from Canada and the US, and enough of a risk to divert us to the nearest US airport available to a 767. On other occasions, however, the US has refused international planes carrying no-flyers, forcing diversions to Canada. And we were over Canada for a good long while.

I’ll try to guess what Homeland Security was thinking: since Flight 618 had made it across the Atlantic without incident, the risk of the suspect trying something between Canada and Bangor was apparently not worth bringing the plane that early, and maybe the US wanted custody of the suspect. But the risk of him flying into Boston was too great. OK, I can buy that. So the plane was diverted to Bangor, and the suspect removed. But, his carry-on and jacket are left behind for at least fifteen minutes (I didn’t see if when or if they were taken off the plane). The luggage compartment was checked for over thirty minutes to find and remove his items, while 200 or so passengers are kept on board.

Why is this man considered such a risk to Boston, but his suitcases and personal items are considered no risk to the passengers?

I don’t know. Maybe the authorities have their secret reasons, but I’m not so sure. This is the second such diversion in a week, and there’s been no announcement about improving the existing system, despite complaints from a Massachusetts congressman and hundreds of inconvenienced passengers.

What I did learn from this experience:
  • Window seats aren’t just for fun anymore, they're educational.
  • Mom is more media-savvy than I give her credit for.
  • If the in-flight movie is dull, maybe something else will enliven the trip.
  • The Smooth Retsina

    Posting will be light the next few weeks. I'm, well, globe-trotting again.

    Second Helping

    I set up a draft of this post a week ago, it's probably a little outdated by now. But I thought this news about how the CDC changed its calculation for obesity's lethality was still worth mentioning:
    According to the new calculation, obesity ranks No. 7 instead of No. 2 among the nation's leading preventable causes of death.

    The new analysis found that obesity - being extremely overweight - is indisputably lethal. But like several recent smaller studies, it found that people who are modestly overweight have a lower risk of death than those of normal weight.

    Biostatistician Mary Grace Kovar, a consultant for the University of Chicago's National Opinion Research Center in Washington, said "normal" may be set too low for today's population. Also, Americans classified as overweight are eating better, exercising more and managing their blood pressure better than they used to, she said.

    We blogged a lot about this inflated figure, last year. Whatever the statistics say, I'm traveling a country now where the figures are not so inflated, and the difference is noticable.

    And I'm particularly surprised by the data on protective effects of mild obesity. I really ought to look at the JAMA article and figure out how they're calculating this. Are they just weighing the recently deceased? Because a lot of time, you know, people lose some weight in the months before they die. Or, they take on a lot of water weight, possibly moving them into morbidly-obese classification.

    In any case, obesity is still epidemic in the US, and I think the public knows it's not healthy. It's not helpful when the CDC manufactures hysteria to try to further educate people. Because then, we risk these consequences:
    LOS ANGELES (Reuters) - A group backed by the U.S. food and restaurant industries on Monday launched an advertising campaign aimed at dismissing as hype concerns about the large number of obese Americans.

    The full-page ads in major U.S. newspapers were inspired by new government data questioning government assertions that obesity causes nearly as many deaths as smoking, according to the Center for Consumer Freedom, which paid for the ads.

    The group, based in Washington, does not disclose names of its donors, though spokesman Mike Burita said casual dining restaurant chains "are predominant sources of funding for us."

    A spokesman for Darden Restaurants Inc., the nation's largest casual dining company and owner of the Red Lobster and Olive Garden chains, could not say whether Darden was among contributors to the group.

    At the Olive Garden, they treat you like family. But, then again, so does La Casa Nostra.