Grand Rounds 3.14

Welcome to Grand Rounds, the collection of the best posts in medical blogging!

Grand Rounds has come a long way since the last time it was hosted here. By my count, eighty-nine unique bloggers have hosted 118 editions. This includes doctors, nurses, students, patients, administrators, analysts, entrepreneurs... with the occasional doula or transplant coordinator or epidemiologist thrown in, for good measure.

Many bloggers have changed over this period – I've lost track of all the births and graduations, but can't forget some of the trials and disasters some fellow bloggers have endured. Others slowly changed focus of their writing – from medicine to political commentary, or from work musings to home life. Some have merely changed their web address (eleven, by my count, with the lion's share jumping to SEED's scienceblogs family).

Twenty-nine bloggers have hosted Grand Rounds more than once, including ten of the first twelve hosts. But, in this time of year-end reflection, I'm thinking about the nine bloggers that seem to have stopped writing online altogether –- Galen, Shrinkette, Code Blue Blog, 'Doctor' from Chronicles of a Medical Madhouse, Mudfud, Iatremia, Red State Moron, Dr. Andy, and Geeknurse. Some have archives available for your perusal and fond recollection. Some, sadly, are gone. A few appear to be overwritten (does typepad recycle?).

Hopefully, our missing colleagues all doing ok. Bloggers talk to each other enough, reading and commenting on posts so frequently, that when one of them disappears, it feels like we're losing a friend.

But, with internet anonymity being what it is, it's conceivable these writers have surfaced on other sites, and we just don't know it. Or, they're just waiting for a time where their schedule permits more public reflection.

It's like they say: Great blogs don't die, they just... go on hiatus, and re-emerge with newfound resolve and a burst of creativity. This year, we witnessed the comebacks of Medpundit, The Blog That Ate Manhattan, Dr. Dork, Doc Around The Clock, and Intueri. They had their reasons for taking a break, but we're delighted to have them back -- even as the medical blogging world continues to grow...

This week, the final edition of 2006, I asked bloggers to submit their best work of the year. Some have undoubtedly been improving their writing week by week, so their best post is simply their latest. Others looked to posts that were the most fun to write, or generated the most comments. Some bloggers let me decide! Now, it's your turn -- see what you think. I've loosely organized the posts into the following categories:

Medical News and Commentary
Bloggers are renowned for their abilities to comment on the news (often, in pajamas) but on a few memorable occasions, bloggers can report news, too. Such is the case with Dr. Steven Palter of Doc in the Machine, who announced his award-winning endometrial diagnosis technology on his blog. It's part of a series Dr. Palter has written, on the radical transformation of surgery.

Mighty GruntDoc, probably the most consistent contributor to Grand Rounds and current favorite to reach Four-Time Host status first, submits this analysis of a case where law and medicine collided in the ED.

The blogger On The Wards digs deeper into an intriguing new finding on obesity -- are certain bacteria responsible for making you fat?

A new blogger on the scene, Sandy Szwarc, whose blog Junk Food Science argues from the perpective of enjoying food and accepting body shapes, pokes holes in recent reporting on the obesity epidemic.

It's getting cold outside -- and outdoor enthusiasts are paying the price. Healthline writer Dr. P.S. Auerbach provides a timely primer on hypothermia.

What if our insurance companies could provide us with "Nutrition Facts"-style info on basic surgeries and diseases? Henry Stern of InsureBlog interviewed the Chief Innovation Officer at Blue Cross Minenesota, to learn about this new initiative in health care transparency.

Reflections on the Job
Frustrated in dealing with the radiology department? The Not Dead Dinosaur coins the term Rad Rage after weeks of trying to get an x-ray properly interpreted.

Old-school blogger Dr. Anjali Taneja of To The Teeth wrote me a nice note, promoting the work of her colleague Andru Ziwasimon, who asks a simple question: Why do we cut the cord immediately after birth?

Faithful GR contributor (and two-time 2006 host) Kim, from Emergiblog, recalls giving a needy patient shelter from the storm.

Dr. G.C. George, of Odysseys of George, once wrote that being included in a recent Grand Rounds made his day. That's high praise, because shortly afterward he described this day, which captures the sheer joy this surgeon feels at work.

Speaking of a surgeon on a strange trip, Dr. Jon-Mikel Inarritu-Castro of Unbounded Medicine wrote about his most memorable patient this year: The guy who woke up with an arm... somewhere else.

Integrating what we learn in the classroom to what we see with patients is one of the trickiest parts of medicine. Dr. Signout notes that it's even trickier when the patients aren't in the hospital, but rather, encountered along the side of the road.

Geena from CodeBlog, who provided us with a memorable singalong before getting distracted this year, relates the tale of a patient with a rapidly expanding bust size.

A young resident physician, Dr. Couz, ponders a taboo subject, and precisely why patients and physicians choose to ignore it in their encounters.

Who doesn't love a year-end Top Ten list? At one point, I was thinking about compiling a few such lists here, like Dr. Charles once did... But Yan Minis has submitted such an audacious Top Ten, it may put to rest all future medical lists: The Top Ten Health Practitioners of All Time.

Medical Student Jeffrey Leow over in Melbourne writes about a role model that he hopes will influence his future practice of medicine.

The Other Side
One of the best parts of Grand Rounds, I think, is hearing the patient perspective (in fact, before my time, hospital Grand Rounds used to actually involve patients.) In that spirit, the award-winning blogger at DiabetesMine opened up the floodgates with her post, the Diabetic Partner Follies, which has "become host to hundreds of responses and astonishing emotional catharsis."

What if your medication changed size, shape and color, but everyone pretended it was the same? Rachel of Tales of My Thirties writes on one of the few times generic switches are risky with her thyroid pill switch.

Ever think about what it's like to wear a Holter monitor? Find out, when Dr. Dork becomes a patient (but remains, thankfully, a lovable dork).

Just in time for the New Year (okay, a week early) -- one of the contributors to Chronic Babe shares some tips on finding the right doctor for your individual needs.

When life gave her lemons, she wrote Lemonade Life. Allison Blass shares her frustrations on being a role model and poster child for diabetes, all while struggling with its physical demands.

A pastoral care volunteer writing at Barefoot in the Snow warns that doctors need more counseling than they're getting. She should know -- she stirringly describes of what it's like to be the frightened patient.

Urostream's blogging urologist, KeaGirl, sends in a fascinating post about the Jehovah's Witness dilemma before elective surgery -- it gets more enlightening in the comment section, when a Jehovah's Witness writes to clarify the specifics of their beliefs.

The Persistence of Memory
Most bloggers are writing from a safe distance from the Iraq warzone. But as the psychiatrist Maria from vividly demonstrates, the front lines are everywhere when soldiers come home.

Rita, the credentialer of the medical blogosphere, shared the value of compassion in her interactions with PTSD patients. Writing at MSSP Nexus, she learned Sometimes people act irrationally for very rational reasons.

At a funeral, a parent asks Neonatal Doc about advances in NICU care. It's a conversation prompted by an unforgettable loss.

Poet's Corner
Susan Palwick is a poet and novelist writing at Rickety Contrivances of Doing Good. She's started a series of poems based on her work as a volunteer chaplain in an emergency department. (check the sidebar for more).

A beloved blogger from down under offers a harrowing depiction of psychotic depression.

Maybe it's the season, but two blogging surgeons known for their cutting remarks and dour temperment submitted some funny stories this week:

Sidney Schwab was called into the OR for a obese patient in a curious predicament...

... and Aggravated DocSurg, waxing nostalgic, tries to explain that chemotherapy is a lot like a TV show or method of mass transit.

A senior cardiologist and colleague of Dr. Wes reflects on end-of-life issues. It actually makes a lot of sense.

Dr. Anonymous is upset about me being named Time magazine's Person of the Year (and here I was, thinking you were the choice). He proposes something else -- something that can be part of us, and yet, is distinctly not us...

Well, this was a busy week... but it's been a thrill hosting again, and reconnecting with this far-flung community for the end of the year. If you have any memories of these bloggers or others I may have missed, please share them in the comments!

Next week, Musings of a Distractible Mind will ring in the first Grand Rounds of 2007!

Grand Rounds Comes to Blogborygmi 12/26/06

Hey, everyone -- I'll be hosting Grand Rounds next week!

Some of you are probably asking, "Why?" Or more pointedly, "Are you still blogging?"

Yeah, I've got some explaining to do: I wanted to give my editors at Medscape a break -- Christine Weibe and Susan Yox have brought coherence to my disjointed interviewing style, every week for the last thirteen months, without reprieve. Their ideas and enthusiasm have helped Grand Rounds in innumerable ways -- and they deserve recognition and relaxation.

Plus, I've gathered data from several years, several sites, and it's pretty clear that fewer people read medical blogs around the holidays.

So, no Pre-Rounds spotlight next week -- no eager new blogger or grizzled, esteemed vet to take the center stage. It just wouldn't be fair.

And yet, canceling Grand Rounds seems unnecessarily drastic -- especially at the end of the year, a time for reflection and "best-of" lists. Plus, it would totally ruin the numbering scheme.

So I'll host! Yay. Send me an email -- with the url and description -- of your best posts of the year to nick /at/ . Submissions are due Christmas morning (Eastern Daylight Time).

I'm also looking for links, posts or remembrances from blogs and bloggers that 'retired' in 2006.



It's some combination of sound and sensation. It starts in the middle of the workday, and lurks in the back of my mind as I make my way through the ED. My pace isn't quite the same; my balance is ever-so-slightly off.

The unsettling feeling gains traction on the commute home -- spilling into conscious thought the moment I walk through the door, into the quiet, familiar apartment.

Yes, there is definitely something stuck to the bottom of my shoe.

Before I even look, I'm performing damage assessment: how bad can it be? I've only taken a few steps in my kitchen...

Fear and loathing give way to surprise and recognition -- I've never expected to find something pleasant under my shoe, but today I saw a sticky pad from an EKG lead, nestled near the heel of sole.

I pulled it off and speculated on when we first came together. Was it at the bedside of the bradycardic woman? Maybe during the central line? The lead pad reminded me of some interesting patients, some memorable rhythms.

I threw it out. And then I washed my hands.

Selection Bias

The bulletin boards of every major hospital I've worked in are bombarded by signs of variable quality, soliciting research subjects or volunteers. Passers-by are asked to call a phone number if they fit within a certain demographic, take a certain drug, or engage in a certain behavior.

Where I went to medical school, the research solicitations were amateurish and fun. For whatever reason, investigators at that hospital were performing a lot of research with alcohol (on, with, and for)... Signs were frequently up, in bright neon colors, asking for young men and women to drink alcohol and give blood (for an immunoassay), drink alcohol and enter a driving simulator, drink alcohol and take a quiz. I have many fond memories of being paid to drink -- doing my part for science.

Now, I notice in some hospitals where I work, the ads are a little more slickly produced, but the 'image' conveyed to me is not exactly upbeat. Investigators are looking for patients with refractory depression, or active genital herpes, or WTC responders with respiratory problems.

When I see that many of the contact-stubs have been torn off of these solicitations, it prompts a different reaction than when the "drinking quiz" was recruiting.

Of course, I'm glad research on these diseases is being conducted. It gives hope, for both the volunteers and all patients.

Maybe the ED is warping my perspective on illness. Since I don't spend much time in clinics anymore, it's hard to remember what patients look like when they're not having an acute infection, or flareup of some chronic condition.

When all the tabs are ripped off the posters, it hits home that there are sick people everywhere, making their way, just walking around me in the lobby, by the bulletin boards.

And that's when I really wish for another alcohol study...

Champagne for Saline

Via Grahamazon (and yes, it makes me nostalgic when I start a post like that) comes this rich tale of a doctor who subbed saline for spinal fluid:
A former emergency room doctor fired for sending saline rather than spinal fluid to a laboratory was reprimanded for that incident Tuesday by the Maine Board of Licensure in Medicine.

Dr. Cesar O. Garcia, who had lived in Hampden while working at MaineGeneral Medical Center in Waterville and Augusta, was fired by the hospital in July 2004, shortly after the mistake was discovered.

I'm intrigued by this story -- because I think this subterfuge has crossed every ED doc's mind at some point. When you're confronted with tapping a morbidly obese patient, with poor landmarks and a low threshold for pain, for instance -- or an insanely busy shift where a patients' "worst headache ever" got better with one tylenol...

Fortunately, no harm was done to the patient. But really, I don't understand how this doc thought he could get away with this, to begin with. Sure, sending saline could reassure the patient that there's no excess of blood cells in the CSF, no bacteria... but can anyone get around ordering glucose and protein, things that saline might lack? Wouldn't the chloride level be off?

Answers To...

Names that patients, nurses, colleagues and superiors have used to get my attention in recent days:

  • Doctor
  • Doc
  • Doc-torrr (en espanol)
  • Doctor Nick
  • Doctor Genes
  • Doctor Gens
  • Doctor Gee-nes (hard g, one syllable or two)
  • Doctor G
  • Genes
  • Jean
  • Nick
  • Nicky
  • Nick-o
  • Papi

    And maybe a few others I'm forgetting now. Now that I think about it, that last one seems to work the best.
  • Time Out of Mind

    The last couple of months have featured some difficult work scheduling, bookended by some ambitious travel plans. Occasionally, usually on a bus or train or plane, I would jot down what I figured was a blogworthy observation or two. Many of these made little sense upon review, but I've transcribed a few disjointed thoughts below for your perusal.

  • Cabin pressurization is seemingly balanced by passenger decompression. This was made clear to me upon boarding a recent flight to Europe -- after an endless ED shift, frantic packing, and stressful journey to the gate. I settled into my seat and fussed with my carry-on as the pilot began to speak to the crew, in his crisp, proud, and utterly unintelligible German:
    "Begrüßen Sie an Bord, ist dieses Füllermaterial, weil es dieser Verfasser könnte verstehen was ich sagte, und zweifellos nahm nicht Anmerkungen unmöglich ist. Mindestens, nicht bis später. Der Film auf dieser Reise ist ... Akeelah..."

    Wait, what was that last thing he said?
    "...And the Bee."

    Of course. I had a chuckle at this, and a few of my fellow passengers were amused, as well. There would be more hurdles to cross after landing, but for now we could relax a little.

  • People who have been fated to sit next to me in recent weeks include: a former navy pilot-turned-Hitachi VP; a dancer; a preternaturally aged schoolteacher who coldly graded essays with a red, red pen; and the obese, hairy, loudmouth lawyer who turned out to be a pro wrestler, on the side (he played the heel, naturally).

    My decidedly undemocratic survey of our conversations suggests the vast majority of travelers are leading rich lives. And we did't even fly first class.

  • I'm editing a pre-rounds in transit, and marveling at just how much some people care about their blogs. They speak of addictions, of loving maintenance. Meanwhile, I contemplate my bimonthly posting regimen, and cast a wary eye at blogborygmi's ghost-town blogroll -- a tumbleweed-strewn replica of the medblogosphere circa fall '04.

    I do love blogborygmi, of course, but in the same way I'm fond of that old buddy from school, who taught me how to approach girls. He was really valuable to me at one time, helped me out a lot, but circumstances intervened and new we're just not so close. Every now and then I think of him, and give him a call, but if we stay on the phone too long it just reminds me of all the new priorities and obligations that occupy my time.

  • No matter where you go these days, you may encounter someone asking for money for martial arts lessons, because ninjas killed his father. Either there's an underreported patricidal ninja epidemic, or the nation's panhandlers are cribbing Overheard in New York.

  • Forgive me, seasoned poker players, but isn't emergency medicine a little bit like no-limit hold 'em? The way doctors and patients size each other up, try to read each others' hands. Even so, most hands are straightforward -- you know how it'll unfold from the flop. Other times, you have to wait for labs to come back, there are raises and calls. But no matter how benign the situation might start out, you never really know which patient is going to take you "all in."

  • On my flight to the ACEP conference in New Orleans: I counted six residents and five attendings -- and that was just from the few programs in the city I'm familiar with. Should a passenger experience a medical emergency en route, he or she could do worse than to pick a flight packed with emergency physicians.

  • Transitioning from a high-acuity shift in a New York City ED to a tourist in New Orleans -- in the space of twelve hours -- is pretty much the most profound change of pace I've experienced. I recall being miffed that the folks on escalators in New Orleans don't spontaneously organize into standing and walking lanes, like they do in New York. But I knew I was having trouble adjusting to the laid-back lifestyle when I consumed a po' boy in less time than it took to make it.

  • Many friends asked me for some reportage on how New Orleans has changed. Well, before this week, my last trip there was for the millennium (coincidentally, my fellow resident and current hotel roommate was also present for that party). On the shuttle ride from the airport into the city, I kept pointing to caved-in roofs, derelict poles and transmission lines, and asking if it was unrepaired storm damage. "No," a local would correct me, with a sigh. "That building was like that, before..."

    The best recent commentary I've read on the city actually comes from today's Grand Rounds host, Dr. Michael Hebert, who writes:
    And finally, from Douglas McCollam of Slate, we have this: "It's fair to ask why, in a city where vast swaths remain uninhabitable, all this money is being spent to fix a stadium. You won't hear that question in New Orleans . . . If they can fix the Dome up after all it endured, then perhaps other things can be fixed as well. Perhaps, after all, the city need not die."

    This angst is real, the conflict between tragedy and frivolity. New Orleanians feel it too, just as they felt it before as they celebrated the first Mardi Gras after Katrina. But in this town, tragedy and frivolity have always walked hand in hand. Name another city where cemeteries are promoted as a major tourist attraction. Where its most famous holiday (Mardi Gras), a celebration devoted to excess and debauchery, is counter-levered against the most solemn religious period on the calendar, Lent, and on purpose. In New Orleans, the jazz funeral starts with a dirge and ends with a riotous party at the gravesite. We don’t sweat it here. Maybe because we ignore tragedy. Or maybe because we are so used to it that we understand that if you don’t dance at somebody’s grave there is nowhere to dance at all.

    A town where tragedy and frivolity walk hand in hand... No wonder so many emergency medicine conferences are scheduled here -- it's a natural fit for our practice environment.

    And, speaking of dancing at the gravesite, I've got a parade to get to...
  • Kicking Down the Cobblestones

    In a city of fast walkers, I take some pride in being among the fastest. But lately, thanks to an adjustment in my train-hopping commute, I've come across some speedwalking that's startling to behold.

    If you get on a Brooklyn-bound 6 train, about 2/3 of the way back, and get off at 59th street, you're let off onto a broad, dimly-lit platform that extends about a hundred feet. At the edge, there's a short staircase descending to the ancient N, R, and W trains.

    Every weekday morning, between 6:30 and around 9, you'll see the 6 train's doors open, and dozens of snappily-dressed, well-coiffed men and women emerge. The smart ones will just break into a sprint, right there. The majority will speedwalk with a vigor and determination bordering on maniacal. A few pitiable souls will leisurely stroll out the train doors, only to be brutally elbowed aside by those determined not to miss the next ride to midtown.

    The thundering of the speedwalkers' footfalls could easily be mistaken for the rumble of another train. The few children that witness this procession invariably begin to cry. I, too, was horrified and awestruck when I first took this route. But so often in this ambitious town, the transformation from surprised bystander to competitive participant is brief.

    Interference pattern

    I remember working in a lab during the summer of 1999, the summer between first and second year of med school. I was building a cDNA library and would occasionally have to show up in the middle of the night to check my colonies or adjust the broth.

    Every time I went in, no matter how late, the lights were always on in the adjacent lab. The Mello Lab. The techs were always there, 'round the clock.

    "What are those techs working on, over there?" I'd ask my labmates, at a more reasonable hour.

    "RNA-i," they'd reply.

    When the concept of RNAi was first explained to me, I remember feeling impressed and vaguely irritated. I had taken many bio courses in college (Mello's college, no less) and again in med school, and had learned nothing of this powerful, simple mechanism cells had developed for silencing specific genes.

    I had already spent several years working on viral transduction, and had become jaded to the whole field of gene therapy, for research and for treatment.

    RNAi sounded too good to be true. And the fact that it was discovered and fleshed out just fifty feet away from my humble cDNA library lent an air of unreality to the enterprise.

    But Mello and his techs knew they were onto something, and they had the fortitude to see it through. Now the college textbooks have been rewritten, and Craig Mello has won the Nobel Prize for Medicine.

    Let the Sun Shine In

    Movies I have thoroughly enjoyed, featuring the word "Sunshine" in the title, in descending order:

    1. Eternal Sunshine of the Spotless Mind
    2. Little Miss Sunshine
    3. Sunshine State

    This is New York

    I'd long ago concluded, mistakenly, that the emotional power of 9/11 lay in its capacity to make people relive the awful fear, confusion and loss in the days following the destruction.

    At least, that's what had affected me most, in reading about the World Trade Center, or talking with responders. But five years out, the real impact and pain may not come from looking back, but in looking at us now. That was the resounding message of this week's New Yorker (the cover recounts Phillipe Petit's famous tightrope act between the towers -- now, he's literally walking on thin air) .

    Roger Angell, who usually writes about baseball and boat trips, absolutely floored me with this brief piece, the end of which is excerpted below:
    Those of us in our eighties or late seventies can still remember when this was called a young country (it was said all the time in school) and, if we lived in New York, retain the vision of earlier iconic towers—the Empire State, the Chanin Building, the George Washington Bridge—going up, week by week, to prove the point. The Depression and Pearl Harbor and Guadalcanal and Dachau and Hiroshima aged and toughened us, to be sure, but perhaps not as much as the History Channel would have it. In the early sixties — in our forties, that is — we suddenly cheered up when some historian noticed that the late, Massachusetts-born, white-mustachioed Supreme Court Justice Oliver Wendell Holmes, Jr., who had served on the bench into the nineteen-thirties, had in his long lifetime shaken hands with John Quincy Adams and also our new incumbent, John F. Kennedy. How young we were, after all!

    None of us, no one in the world, holds such a notion today.
    Our United States feels as old as Tyre. Also anxious and bloodied; also short of sleep. What’s a shock, as this special September comes along, is that 9/11 is only five years back. Boys and girls born that spring and summer are entering kindergarten this year, and before they leave elementary school will have learned and tucked away the date in about the same place as Antietam and the typewriter and the Great Plague—that is, if they’re paying any attention at all. We worry about them, as elders do, but what we know about them that they don’t is that they are the older generation. Even while this ancient, inescapable irony dawns, we think back more often to a deceased parent or to a friend gone too early, to a favorite teacher or poet or departed doubles partner—anyone who died before September 11th—and wish ourselves that free again, and that young.

    The New Yorker's architecture critic, Paul Goldberger, nails home the point with a little less poetry:
    Amid all the squabbles and revisions, it’s unsurprising that so many people who once cared passionately about Ground Zero have simply lost track of the developments there and have stopped caring. This summer, the success of the first movies about 9/11, and acclaim for a clutch of important novels dealing with the subject, showed that the public is still hungry to make sense of the tragedy and what it means for America. But they are no longer looking to architects, contractors, and developers for answers. By the end of the day on September 11, 2001, it was clear that the terrorists’ act had enormous symbolic power in the eyes of the world, and, in the months that followed, a consensus arose that whatever happened at Ground Zero should make a powerful symbolic statement of our own—of the values that America, and New York, stand for. Five years after the terrorist attacks, the saddest thing about all the many absurdities surrounding the rebuilding—the personal wrangles and group rivalries that have obscured any sense of commonality, the pious statements masking an utter lack of conviction, the maxed-out budgets and cut corners — is that they may say a lot more about us than we’d like to think.

    Indeed, browsing through the criticism and disappointment over the Freedom Tower, from the architects, students and fanboys over at Wired New York, has been instructive. The appeal of the original World Trade Center was not simply its boxy bulk, but the fact that this mass was duplicated. It commanded attention, even as you searched for an facet to focus on. The new 1WTC shirks that, instead seeming to superimpose the twins into one slightly taller but thinner building.

    But today, the designs for World Trade Center Towers 2, 3, and 4 were unveiled. We already knew the site would feature the western hemisphere's tallest building -- now it looks like the site will have two additional towers to rival the height of the Empire State Building, and another tower as tall as the Citicorp. There are no twins, but rather, a very well-nourished set of siblings.

    It's dizzying to think what downtown will look like in a few years, with four neighboring skyscrapers under construction. Comparing the scene to images from the twin towers' rise, it should be enough, I think, to make anyone feel young again.

    Can You Hear Me Now?

    I used to wonder why Gizmodo et al are always taking jabs at Verizon. To me, they've always been friendly, with good plans and coverage. Sure, Verizon disables some cool features thge manufacturers put on their phones, but that just makes hacking them more rewarding, right?

    Then I got a text message from the company, noting that I hadn't visited my "Pix Place" (online repository of my camera phone pictures) in 150 days, and if I didn't log in within 30 days, all my pictures (approximately fifteen, in total) would be deleted.

    Cheerful, huh? Because these blurry photos must be taking up about 200 kb on Verizon's servers, and clearly, a competitive company in a cutthroat industry can't afford to give out free memory...

    Then, when checking my voicemail a few days later, I heard a disturbing new automated message. Instead of informing me I had my regular three saved messages, I learned I had "three saved messages, whose retention time is about to expire."

    A confession: I saved some messages for a long time. One, for instance, dates back to when the Sox beat the Yankees in the 2004 ALCS, and a friend called me up and made some kind of drunken hooting noise that I thought was worthy of repeated listens. Every 21 days, Verizon would play the message to me and ask if I wanted to delete it, and I'd always smile and press no.

    Well, I guess they'd had enough, or maybe Verizon is run by a Steinbrenner acolyte, because in a few days those treasured messages were erased.

    I think someone at the Onion is also frustrated with this company:

    Verizon Introduces New Charge-You-At-Whim Plan
    August 21, 2006 | Issue 42•34

    NEW YORK—Verizon Communications, Inc. announced a new service package for its wireless and residential customers that would charge them widely varying, but always high, fees every month depending how the communications giant feels at the time. "Our Charge-At-Whim packages offer the same mediocre quality and insufferable level of customer service you’ve come to expect," a Verizon spokesman said Tuesday. "But it adds an unjustified, arbitrary and, if you’ll allow us to boast, frankly unjustifiable method of determining just how much you’ll pay for them." Packages start at "oh, $69.99 a month, let’s say?" and went into effect about three or four months ago.

    Feels about right.

    Lost my Driving Wheel

    I just concluded the best, hardest month of my residency thus far.

    I've taken call many, many times before this, but never with the same potential for frenzied activity, 27 hours straight (24, for my readers on the Bell Commission). After the first few calls for the medicine ICU, I grew efficient enough to get in an hour or two of sleep. But, unlike floor medicine, where the overnight intern is awoken a dozen times for generally trivial concerns, all my pages in the ICU were genuine problems.

    I performed more emergent intubations, more lines, more spinal taps, and about a thousandfold more ABG's than in any single rotation before this. Running a code no longer paralyzes me with fear. Most incredibly, from my perspective, was that I was making so many of these critical decisions.

    Because of the crazed sleep schedule, in which I'd be unconscious for about 15 of my 21 free hours post-call, life outside the hospital became filled with malaise and dysphoria. My apartment has never been messier. So many obligations got punted to September -- relationships, phone calls, emails, workouts, blogging.

    Nothing was getting done -- nothing was worth doing. I didn't get out much, and when I did, things seemed unbearably slow or purposeless. I never felt really alive until I was on call again. Isn't that a lark? Maybe I was so conscious of my agency because most of the people around me were heavily sedated.

    I did call my parents a lot, often to thank them for happy childhood memories that would surface at odd times. This was likely prompted by the wrenching conversations I would have with families about their sick loved ones. Until now, too often, talking with families in the ED was been a chance to gather history and transcribe medication lists, or explain why someone is going to be admitted / discharged (when all the family wants is for them to be discharged / admitted). But this month had more than its share of conveying painful news, of asking families to make difficult decisions.

    It's remarkable, how thoroughly and abruptly lives can be disrupted, how strong people are forced to be, at their most vulnerable.

    I can see clearly now

    If you want to simulate the development of visual cognition in newborns, take a course in ultrasonography. I remember when I was a med student, and a resident showed me my first blurry, shaky FAST images (focused assessment of sonography for trauma).

    Resident: See that? That's Morrison's pouch, showing no free fluid between the kidney and liver.

    Me: I think that's just static, and you're playing a trick on me. Can we adjust the image?

    Resident: No, actually, see, this echogenic area is the renal pelvis...

    Me: Really, just stop, you're not fooling anyone.

    A few years later, and here I am, identifying venous thrombi and peri-pancreatic stranding, the common bile duct and the superior mesenteric artery. It's unbelievable what you can see in that static-y window. I especially like how, the better I get with ultrasound, the more it seems to help (compare that with sub-subspecialties like toxicology, where the effort of accumulating greater expertise finds diminishing returns for patient aid...)

    Other observations:

    In my surveys, whenever I apply the ultrasound probe over the male bladder, the men always crack a smile and ask me if they're pregnant. It never gets old. (The women, they don't ask out loud).

    There is a striking correlation with EM ultrasound expertise and a past life as a disc jockey. In fact, it turns out I used to listen to one of my U/S mentors, on the radio. Different frequencies now, but same catchy appeal.

    The Secret of Acronyms

    I've received some great feedback from my post the other day, on acronyms in medical research.

    I soured on the whole field of "research on research" when I learned articles like Stanbrook's weren't just bar-room talk that led to an afternoon browsing pubmed, but rather, institutionalized bodies of research with conferences, grants, endowed chairs, etc.

    Don't get me wrong, I love cocktail-party research like this (where would Blogborygmi be, without it?) Papers like Stanbrook's make us think, and keep us mindful of influences. Even if that's all it can accomplish, well, it's something.

    But look at some of the output of one of the ART in Medicine authors, Dr. Donald A. Redelmeier. Over the years, he's produced such gems as "Oscar winners live longer than other actors" and "Why cars in the other lane really do go faster."

    If you're going to get funding for producing a series of provocative but disconnected pop-science pieces, that are fun to talk about but hard to act on, you ought to eliminate the middle man and work directly for NPR.

    But I don't mean to single out Dr. Redelmeier, who in addition to his occasional cocktail diversions, has a distinguished career as an investigator. In fact, he was one of the authors on an influential CHAMPS study (not the same Avonex / MS study a commenter mentioned, but hey, even six-letter acronyms need to be reused).

    Is Redelmeier cynically manipulating doctors with his catchy titles? Or is he just one of those "exemplary investigators" who "generate both clever acronyms and important research" ? I'm inclined to say the latter, but I wish he had fully disclosed his ties to the acronym industry. Maybe he missed those talks on conflict-of-interest at the last conference.

    Operation SMARM

    It's always nice when a topic can be both funny and worthy of serious thought. Such is the case with the use of acronyms in medical research.

    Inspired by an exhaustive list of medical trial acronyms, last year I wrote wrote a post that still makes me smile (the part where my mind's eye conjures Batman at a medical conference). Here's an excerpt:
    It's comforting to see our best minds are studying LIFE and LIMB, MIRACLE and MIRAGE. The aforementioned CALM is balanced with EXCITE. You can also learn the difference between SYMPHONY and OPERA. As for more conventional names: ADAM, DAVID, MONICA, RUTH, and SONIA are all ALIVE, with VIGOR and GUSTO.

    There are too many more to mention, though I was a little dismayed to find the really memorable ones were often sponsored by pharm companies. Though they're catchy, I have no idea if the studies are well-conducted, or tell us anything important. For this reason, I'd like to organize a study examining whether clinical trials with fancy acronyms have higher impact than serious studies denoted by plain collections of letters. We'll call it ABSURD -- Acronym Behavior overShadowing Useful Results and Data.

    Well, last week, the NEJM (um, the New England Journal of Medicine) published such research -- Acronym-named Randomized Trials in Medicine - The ART in Medicine Study (I like my proposed title better). An excerpt is reprinted below:

    As compared with studies without acronym names, acronym-named studies had higher Jadad methodologic quality scores, enrolled five times as many patients, had follow-up periods half as long, but were not more likely to report positive results. Acronym-named studies were four times as likely to be funded by the pharmaceutical industry and eight times as likely to be authored by an industry employee.

    Acronym-named randomized trials were cited at twice the rate of trials that were not named with acronyms (13.8 vs. 5.7 citations per year)...

    Although other explanations are possible (for example, exemplary investigators may generate both clever acronyms and important research), these results support the hypothesis that naming randomized trials with an acronym may enhance the citation rate. ...

    Enhanced attention to and recall of studies through the use of acronyms may facilitate the appropriate translation of research findings into clinical practice. If acronyms exert influence independently of normative markers of clinical credibility, however, such influence is not rational scientifically, even if it is understandable psychologically. Consequently, this subtle linguistic tool could undermine evidence-based practice. The observed close association between acronym use and sponsorship by the pharmaceutical industry amplifies this concern.

    Stanbrook et al deserve credit for sifting through the literature, quantifying 173 studies and drawing some important conclusions about article quality and citation rate.

    But these authors's work is part of a burgeoning field of research ON research, a meta-analysis, if you will, on how science is conducted and disseminated. There are now whole conferences studying peer review, bias, and the impact of "impact factor" (Stanbrook originally presented this research at one such event).

    Thus, we can expect more research into this topic. Is it easier to apply an acronym scoring system like APACHE, or an eponymous one, like Ranson's criteria? Do patients fare better when they're told they suffer from POEMS, or the Crow-Fukase syndrome of polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes?

    I wish to contribute to such research, but right now all I can offer is another title: the Study of Medical Acronyms in Reinforcing Memory. It may be unfairly catchy, but I think its very acknowledges something overlooked: the attractiveness of meta-research may well be disproportionately higher than its actual usefulness. There are more important to study, debate, and get sanctimonious about.

    "Everybody falls, the first time"

    It's the intern's first day. We're walking down the hallway from the ED, so I can show him the lounge.

    "Are you ready? You know, the computer system here is pretty complex," I said.

    "Yeah, they gave a lecture on it, but it was pretty confusing," he replied

    "The system can do absolutely everything -- charting, orders, prescriptions, admissions, discharges... but's got so many features, it takes a while to master. At first you'll be like Neo looking confused at the green streaming letters in the Matrix, but eventually you'll transcend it.. and just start moving faster than you thought possible."

    "But wait," the intern interjected. "Didn't Neo have to die before he could do all that?"

    I stopped walking, turned, and faced my young charge. "We all had to... It's very painful."

    We continued walking down the hallway, in silence.

    An Inappropriate Truth

    This month's Annals of Emergency Medicine has a series of articles on ED usage, plus an editorial entitled, "Frequent ED Visitors: The End of Inappropriateness." Given the tenor of posts from seasoned ED bloggers, I expected this editorial would be about denial-of-care protocols, full of anecdotes about abusive patient freeloaders.

    But in fact, this editorial is based on evidence. The one anecdote included is a doozy, about a father who took his infant to the ED, got a diagnosis of OM, but his insurance denied payment due to the "inappropriateness" of the visit. The father, of course, was the board-certified EM physician who wrote the editorial.

    He goes on to delineate the separate but related complaints of overcrowding, frequent flyers, and inappropriate ED use, which he defines as follows:

    Generally defined as an ED visit by someone with a nonurgent or less-urgent condition treated more efficiently and cheaply in an office or clinic setting. In its more malignant form, inappropriate ED use has been characterized as visits by people of lower socioeconomic status who are "gaming" the system by claiming benefits and services to which they are not entitled...

    ...In this issue of Annals, 2 articles provide compelling evidence that the "inappropriate" ED visit is nothing of the kind.

    Dr. Bernstein concludes his piece:

    The notion of the "inappropriate" ED user is largely apocryphal. Fuda and Immekus and Hunt et al convincingly demonstrate that frequent ED users are sicker, with considerable mental illness and substance use, than infrequent or nonusers. Frequent ED users come to the hospital because they need care. Infrequent users may avoid the ED with expanded access to primary care, but this is not at all clear. Constructive policy change will not result from a blame-the-victim analysis.

    Perhaps a wiser health policy goal would be to focus on the delivery of high-quality, convenient, accessible care to all patients in all clinical settings, ambulatory, emergency, and inpatient. Intensive case management of frequent ED users and expanded off-hours access to facilities delivering primary care, especially mental health and substance use treatment, may decrease the frequency of ED recidivism, but additional work is needed to test the efficacy of these interventions. In health care's current political climate, which emphasizes cost containment and personal responsibility, it is difficult to see this happening. But for now, let us put to rest future conversations about "inappropriate" ED use.

    Sadly, I don't think Dr. Bernstein's recommendations will be heeded in ED conference rooms and EM blogs. I, too, have been guilty of letting the stress get to me, generalizing from one encounter to an entire waiting room. But I've also made a conscious effort to adopt well-conducted new research into my practice, and these findings should be no different.

    Resident Alien

    I've given two talks this year: one in November and one just a few weeks ago. Both were "Joint Conferences" with mixed audiences.

    In November, as I reviewed the PowerPoint slides before I presented, I remember going back to the title slide, and removing the references to my doctorates. In their place, after my name, I entered "PGY-1" -- thinking that maybe the attendings and residents of other department would go easier on the intern.

    When I was preparing my talk two weeks ago, hiding behind the "PGY-1" label seemed a little absurd. I didn't think I needed to, anymore, and besides -- my internship's days were numbered. What was the difference between the me of mid-June and the me of July 1st, anyway?

    But tomorrow, I think I'll miss that shield of internship. Though the increase in responsibility for EM residents is not as dramatic as in, say, internal medicine, more is nontheless expected of us: To take the sickest patients. Manage our section of the ED. Nail the tricky procedures on the first try -- hell, not just do them but teach along the way.

    I recently led a simulation in which I made some mistakes -- I failed to give antibiotics to the sim-patient as soon as I could have; I let him go to the CT scanner with unstable vitals. Afterwards, a resident told me not to beat myself up about the case too much -- "after all, you're still an intern."

    Not anymore.

    Post-Exposure Pronouncements

    Rabies is no laughing matter, but I did chuckle a bit upon reading today's NYC DOH alert. The email subject was:

    Rabid Kitten Confirmed on Staten Island

    We've come a long way from ominous headlines like "Anthrax in New York" -- unless, of course, that kitten's got some nasty, big pointy teeth...

    Goals and Objectives

    I'm working on a project for my residency's journal club -- a website to archive the papers we discuss, along with our analyses (if you're wondering about the format -- it's a blog! Just call me Johnny One-Note).

    But the project's got me thinking about my approach to scientific literature, and just how much has changed since my research days. I've already quoted that axiom -- "The role of the physician is to express confidence. The job of the scientist is to express doubt."

    That quote just deals with the way information is presented and projected, however. I'm now experiencing a fundamentally different mindset when first evaluating the literature -- I'm now asking myself, "will this change my practice?" from the outset, and organizing my assessment of the paper around that question.

    It occurs to me that many of my peers have already been doing this, but I recall a time when I was more interested in novel methodology, or surprising conclusions, whether or not it was immediately relevant to urban academic emergency medicine.

    Researchers, I think, squirrel away such data for future reference -- you never know when it might prove useful, in explaining a quirky lab result, or building a case for your next grant. Physicians, on the other hand, tend to discard a lot clinical information that they come across -- as though we can't afford to expend mindshare on articles that aren't going to influence decision-making.

    The trio of fun articles I covered a few weeks ago on GruntDoc's site has already been boiled down to one high-yield question I can ask drunk college-aged patients (in case you're wondering, my request for handheld lasers in the ED is not expected to go through).

    It's too bad -- because reading about a clever experiment, or unexpected finding, can be a true delight. This kind of thoughtful reflection and recollection defines what a scholar is, to me. I hope I can retain some of that, and enjoy the intellect and creativity that goes into many underappreciated manuscripts.


    Last week I saw yellow tape go up along my street. Cops were shouting at passersby to turn around. Anyone who emerged from their apartments was asked to go back inside or make their way, escorted, to Third avenue. Without the constant sounds of traffic, things became eerily quiet.

    I sought refuge in the cleaners next door; the unflappable woman who works there was ironing behind the counter. "Bomb threat," she told me, offhandedly.

    She was right -- I later learned a man had left a suitcase in a trashcan on my corner. It said "A BOMB" in big, taped-on letters. The NYPD closed four blocks within 30 minutes. When they determined the package was no threat, they quickly carted the suitcase away and reopened the streets. Within a few minutes, everything was back to normal. The story didn't even made the evening news, or the paper.

    * * *

    This morning, I saw yellow tape going up, along my street. A man was setting up red cones along the open parking spaces. Two towtrucks were busily hauling cars away.

    "Excuse me," I said, to the man with the yellow tape. "Why are all these cars being towed?"

    "Filming a movie."

    Oh, yes, we've been here before (though this is shooting literally outside my front door.) I got some details on the movie -- called "The Brave One", starring Jodie Foster... There was one more thing I wanted to know:

    "Why move all the cars? What's happening in the scene?"

    "A traffic jam."

    I love this town.

    On a related note: Grand Rounds is up, with a movie theme.

    Update: The Reeler's got the lowdown on this morning's towing, and some investigative reporting on how much NYPD is paying to accomodate the filmmakers and inconvenience the car-owners of my fair street.

    Agent Provocateur

    On the topic of my dear old buddy, who visited this weekend for an MSF meeting, and, as is his habit, made some mischief and provocative conversation with everyone he encountered:
    GF: So, your friend, he's, uh, really something.
    Me: Of course, he's a member of Doctors Without Borders... but it's also true he's a doctor without boundaries.

    I miss him already.

    Fat Arguments on Thin Ice

    Via Kevin, MD comes news of MedGenMed's latest video (registration required), featuring Dr. Michael Dansinger, excerpted below:
    Is that white-coat feeling a little tight? Many physicians are overweight or obese for the same reasons our patients are.[1] Many of us do not eat right and get enough exercise.[2] We work long hours, making it seemingly impossible to squeeze regular exercise into our busy daily routines. We eat on the run and unhealthy food (often served in our own hospitals) is commonplace.

    Physicians rally against obesity, and yet, we are not doing all we can. Sadly, those of us who fail to embrace lifestyle recommendations in our personal and professional lives promote a public perception that lifestyle change is ineffective or unrealistic.[3] Despite dramatically increasing obesity rates, we have failed to improve our dismal obesity counseling rates.[4] The physicians who fail to recognize and treat obesity are often the ones who personally fail to heed lifestyle recommendations,[5] and these doctors may sometimes lose credibility with their own patients.[6]

    I know we can do much better. First, we must recognize that the human body needs at least an hour of exercise daily for optimum health, and every able-bodied physician should strive to achieve this...

    Sigh. Does anyone keep track of all these mandates, to sleep more, eat better, exercise an hour a day, build strong, healthy relationships, etc? Because it adds up to about a 33-hour day, by my calculations.

    Go look at the comments to my earlier post -- the physicians who wanted me studying on a Saturday night in residency, rather than having a beer with my new colleagues. Maybe they would allow me an hour a day to exercise -- not for my health, of course, but so I can better counsel my obese patients. I'm guess I'm fortunate we live in an era where I can listen to lectures on my music player at the gym (and, by the way, I drink lite beer when circumstances warrant).

    Anyway, back to the video -- I'm not impressed with Dansinger's citations. #5, for instance, seems to imply that doctors with obesity issues are less likely to bring those same issues up with patients. Well, it's based on a mailed survey to 355 pediatricians (!) in North Carolina. If I were a fat pediatrician, I might be a little reluctant to counsel a fat child, myself, because, you know, little kids can't abstract like adults can. But then again, maybe Dr. Dansinger was hoping his viewers couldn't abstract, either.

    The important study that Dansinger cites, #6 -- the lynchpin to his whole argument -- is this small survey study from three years ago. Patients from five (5) doctors in Georgia were surveyed about their counseling and recommendations. Two were obese. The patients from the two obese physicians had less confidence in their recommendations about illness and health advice. Fine. What's interesting, and invalidates Dansinger's whole argument, is that there was NO significant difference in patient's confidence on their obese doctor's weight and fitness advice.

    Kevin MD's commenters said it best:
    I would rather have an overweight Dr. try to educate me about obesity, than some litle skinny guy who never had to watch anything he has eaten in his life.

    ...Well, who can better explain obesity than one who is suffering?

    I don't know many obese physicians, but all of them are working on losing weight. Accusing these struggling doctors of somehow hurting their patients, by citing some ridiculously underpowered and inappropriate studies, is completely unwarranted.

    I think Medscape treated this complex issue with more sophistication when they ran my Pre-Rounds interview with Fat Doctor. Yeah, it's anecdotal evidence, but it's honest in a way that Dr. Dansinger's video is not.

    Hematogenous Spread

    It's been quiet here recently, but that's not to say I haven't been writing.

    Aside from the usual medical device love-fest over at, I've been guest-blogging this week over at GruntDoc, which has been fun -- it's a pretty interesting audience, a different group from the fans of Medgadget and Blogborygmi.

    I also wrote an article for AAEM's Common Sense (pdf), about how students interested in emergency medicine should arrange their fourth-year curriculum.

    There's always Pre-Rounds, with now thirty columns profiling your favorite medical bloggers.

    And there are some projects in the works, exciting projects involving over-eating and over-exposure...

    CME Credit

    It was a warm weekend evening, and the new interns were completing some of their first shifts in the ED. We were drained, but exhilarated, and a little punchy. One of the senior residents was sitting in the corner of the lounge, by himself. He was reading our textbook -- Tintinalli -- and by the looks of it, he'd made it to page 1675 or so.

    One of the interns approached him. "Hey, buddy, we're got the rest of the weekend off. We're thinking about going out for some drinks tonight -- you want to come?"

    The senior waved him off, "No, I've got a lot of reading."

    Undeterred, my fellow intern pushed, "Come on, what for? You have boards coming up or something?"

    The senior looked up from the book, and said something I'll never forget: "I'm reading to become a better doctor."

    I don't remember what we ended up doing that night, but whatever it was, the senior's comment had lowered our enthusiasm for it by more than a few notches. In those heady days after graduation last year, nothing else would make the point so succinctly to this newly-minted intern: We were done with medical school, but we weren't done being students.

    "I'm not the man they think I am at home"

    So, I went out this morning at the crack of dawn for my brioche and coffee, and I saw a rocket ship on the curb, by the trash.

    The model looked like it was out of 1950's sci-fi features: a silver metal cylinder with riveted wings, and a thick antenna nose. It was about a foot and a half long, angled upward on a metal pedestal with a thick base. There was a loose electric cord dangling from the base; it was not immediately apparent what electricity would do for the model.

    I stood for a moment on the sidewalk, flummoxed over the model (remember, I still hadn't had my coffee). The rocket, almost certainly, would not fit in with my apartment decor. But dammit, it was practically on my doorstep, and I was curious about the plug.

    I resolved to get my breakfast, then pick up the rocket on the way back. Just to try it out, of course -- and if it didn't work, or didn't fit, it'd go back to the sidewalk.

    When I returned, ten minutes later, the rocket was gone.

    It was not yet 5 AM. Once again, I have underestimated the depth and breadth of geekdom in this town.


    Speaking of which, I shouldn't have made that mistake, so soon after the Fifth Avenue Apple Store opening. I went, mostly because there was a rumor on teh internet about a big-name concert outside the cube. That, and I thought I might finagle a free T-shirt during the opening and giveaway, Friday at 6 PM.

    After all, it had been raining that afternoon, and who really goes to these things, anyway?

    It turns out, a lot of people go to these things. This, for instance, is the blog of a guy who travels the world, going to Apple stores. The line wrapped around the GM building, from Fifth to Madison and back. There was no concert, no Steve Jobs speech, but a mob scene nonetheless.

    I quickly gave up on the free-T-shirt idea, or even getting into the store. Instead, I wandered around the cube. I found a nice roped-off spot near the northern fountain, where spectators were speculating on the identities of the honchos moving in and out of the store's entrance.

    After a few minutes, one of the young, all-black clad Apple employees walked over to our area. He asked, politely, "Are you ready to come in?"

    It turns out he wasn't talking to me, but rather to Elizabeth Berkley, who had appeared right behind me. Maybe she was in town for this. Or maybe everyone's a geek, now.

    My patient, the car

    I misinterpreted the title of a Polite Dissent post -- Doctor or Auto Mechanic? -- which immediately conjured a version of this classic game in my mind.

    And since, well, some doctors are called "auto mechanics of the body," I started making a list of tools and terms that sound like they could go in either profession -- medicine or car repair.

    So far my list includes the peak flow meter, front fascia, nebulizer, curing lamp, 4x4, clean-catch, head gasket, pacer leads, valve grinder, hepatic duct, surgi-lube, colposcope, universal joint, and of course, a Hemi.

    I'm sure there are many more such terms, especially within the realms of orthopedics and ... emissions.

    Familiar Quotations

    Here's something I realized recently: a good fraction of the books I've read over the past year -- maybe half -- have been with written by people I know. Or at least, in some cases, by authors with whom I've corresponded.

    Yes, it's partly because of the rise of independent publishing, and partly because I've been hanging around academics for more than a decade. And certainly, this wouldn't be the case if I read more of the classics, or bestsellers. But knowing these authors is a nice trend, seems likely to continue, and lends itself well to sparkling dinner conversation.

    I must keep in mind Uglow's assertion -- that a group with the right mix of insularity and homogeneity can produce great things. Alas, Uglow (and Gladwell) are two authors I haven't met.

    Cause for Alarm

    For as long as I can remember, I've been reading reports in the lay press (and, in recent years, medical journals) about the growing problem of antibiotic resistance. I recall the faint, faraway dread these articles inspired, about a future when even community-acquired staph infections will be methicillin-resistant, when mighty vancomycin and linezolid will be rendered useless.

    I get the same feeling, now, with my wakeup alarms. Long ago, I gave up on my weak bedside clock radio. But twice this past month, I slept through the moderately-loud cell phone alarm, and even the powerful digital egg-timer. Double coverage, failed!

    The egg-timer's use was once restricted to critical situations -- like interviews and presentations -- but gradually became overused during intern year. Now, resistance has developed.

    Fortunately, in both cases of alarm resistance, lateness was avoided -- through frantic, accelerated morning routines and a bit of freak subway luck. Next time I may not fare so well. New, out-of-the-box approaches may be required to confront this problem.

    I could also try sleeping regular hours... but that's too unsettling to contemplate, for now.

    Post-Call Stress Syndrome

    My medical school prepared me very well for my floor medicine months, in terms of how to function as an intern, what to know as a physician, and even how to relate to patients and families.

    What I haven't been taught, nor have I seen mentioned anywhere, is how to manage the curious camraderie-withdrawal that occurs among colleagues, after a call month ends. The scenario, spelled out:

    You've just spent pretty much every day of the month with a resident, maybe a co-intern and student as well -- and every third or fourth night you'd serve together in an exhilarating, giddy, sleepless haze of admissions and cross-coverage. You share a lot of laughs, maybe shed some tears, learn a lot, and certainly freak out about the workload on a frequent basis. Then, the month ends and you may never see your teammates again -- certainly, never in the same context.

    So, what to do? Get together for drinks, a few weeks later? That doesn't seem right -- you spent all your time together wishing you were with family and friends, and even if your new schedule permits it, revisiting your old medicine colleague seems like a step in the wrong direction.

    Instead, there's the occasional email, and a wave and a smile across a crowded amphitheater. If you pass each other in the hall, you reminisce briefly about that nurse who waited until 5 AM to page you about a diet order, or the frequent-flier DKA patient who said, "Doc, I think I've got The Diabetus again."

    And you move on to the next month, the next team, the next set of memories.

    Happiness Writes White

    The bird on the fire escape has been with me for over a week. She's chosen some of my scraggly philodendron vines as the basis of her nest, and is guarding her eggs (the second egg appeared on Orthodox Easter Sunday).

    Sometimes I give her some privacy by lowering the blinds -- I suppose my proximity to her nest gives could give her some anxiety (she's three feet away as I write this). But I like to think she's getting used to me, and my offerings of Wheat Thins.

    On both Monday and Tuesday afternoons this week, around 5:30 or so, I was present to observe a similarly-marked brown bird land on the fire escape. They both gazed warily at me for a few moments -- then the nesting bird promptly stood up and took flight. Here to stay as the replacement, the new bird hopped into position over the eggs, in the nest. I can't really tell which bird is the father, or even if such gender roles apply to birds in Manhattan, but I very much enjoy this family growing outside my window...

    The routine of floor medicine continues, with its steady supply of triumph and tragedy, teaching and tedium. It's springtime for the interns, who have more or less gotten the hang of it, and made peace with their roles and abilities. In a few hours I'll go to work, then from the hospital I'm off to my best friend's wedding. I'll be back at the hospital in time for call on Sunday, to return to this roost Monday morning and file a column.

    These are that days, and the stage in life, that my friend and I have wondered about for about fifteen years. We couldn't have predicted all the specifics; no one could have. But this work, this place, these people in my life -- it's everything I had hoped.

    In Voro, Veritas

    This month's Atlantic has the best writing I've seen on competitive eating (and naturally, that includes my musings on the topic). In the past I've called for scientific investigation into this subject, but in the meantime I'll settle for amazing anecdotes and in-depth reporting:
    Brian "Yellowcake" Subich, a top-twenty eater, tells a story about a baked-bean contest from the summer of 2004. The field included Sonya, Subich, and Cookie Jarvis. After just two and a half minutes, George Shea announced that Sonya was almost done with her 8.4 pounds of beans. "I said, 'You have to be freaking kidding me,'" Subich told me. "What does she do? Pour ’em down her shirt? Put 'em into a plastic bag?" At Shea’s announcement, Jarvis lifted his head, glanced at Sonya, registered what Subich calls "the most crestfallen look you could ever imagine," and vomited beans through his nostrils.

    Sonya was forcing a realignment in American eating. When asked for the secret to her success, she would just wink and describe her love for her adoptive country, as if that explained everything.

    "In America," she told me, "if you have desire you can do anything. Is big. Big." She holds her hands out wide. "Big country!"

    Sonya Thomas is known as the Black Widow. She's not the only personality on the eating circuit, though. Besides Kobayashi and her, the organizer of the major competitions, George Shea, also seems like a character for the ages. He narrates the events like some kind of postmodern auctioneer. The effect inspired the Atlantic's writer, Jason Fagone, to some lofty prose:
    Shea’s eating contests are poetic in their blatancy, their brazen mixture of every American trait that seems to terrify the rest of the planet: our hunger for natural resources that may melt the ice caps and flood Europe, our hunger for cheap thrills that turns Muslim swing voters into car bombers. If anti-American zealots anywhere in the world wanted to perform a minstrel show of our culture, this is what they’d come up with. Competitive eating is a symbolic hair ball coughed up by the American id. It is meaningful like a tumor is meaningful. It seems to have a purpose, a message, and its message is this: Look upon our gurgitators, ye Mighty, and despair. Behold these new super-gluttons, these ambassadors of the American appetite, these Horsemen of the Esophagus.

    ...Here on the gluttony circuit, atop the same cultural terrain that made me feel, in my bitterest moments, ashamed to be an American, the eaters were planting their dearest desires—for fair and honest competition, for a pat on the back, for a chance to get noticed, to prove themselves, to make their kids and spouses proud.

    Some statistics, for future reference to just how disgusting the sport is (going back to the original meaning of disgusting):
    The key benchmark of greatness in competitive eating, akin to rolling a 300 game in bowling or scoring under par in golf, is to eat twenty Nathan’s hot dogs in twelve minutes. This is called "doing the deuce." By the time an eater has done the deuce, he or she has consumed 4.4 pounds of solid food and a few pounds of water, has taken in 6,180 calories, 403 grams of fat, and almost 14 grams of sodium, and is ready to lie down someplace air-conditioned, close to a toilet.

    More analysis from elsewhere on the web:
    It is possible to train ahead of time for an eating contest, although the IFOCE does not recommend it. Competitors can train their brains to ignore the "full" feeling (actually the stomach muscles relaxing as they stretch) by repeatedly filling the stomach with large meals or through water training. Water training requires drinking an entire gallon of water in 30 seconds. The water stretches out the stomach. Supposedly, this makes it easier to down food in huge quantities. Neither of these activities is healthy. The water exercise can be very dangerous, resulting in perforations of the stomach lining and water intoxication, which is potentially fatal...

    When small eaters like Thomas and Kobayashi first arrived, some eaters developed the theory that fat actually hinders competitive eating. The idea was that a lot of fat around the mid-section made it too difficult for the stomach to expand. This theory was originally proposed by eater Ed Krachie. His paper on the subject, "Can Abdominal Fat Act as a Restrictive Agent on Stomach Expansion? An Exploration of the Impact of Adipose Tissue on Competitive Eating," was rejected by numerous scholarly journals, including the New England Journal of Medicine. However, a 2003 Popular Science article supports the theory: "The size of the stomach at rest is inconsequential. All that matters is the stomach's ability to expand, to adapt itself to the amount of food being shoved down the esophagus. A skinny man's stomach has little fat to push against it and fight the food for space" [ref]. Some eaters believe that a muscular abdomen hinders stomach expansion as well, although Kobayashi's muscular body would seem to contradict this theory.

    I've never bought that explanation; I think instead they've got some kind of smooth muscle constriction defect or loose pyloric sphincter. But the closest thing I can find to a scholarly approach to competitive eating is this master's thesis -- sadly, it's for a degree in fine arts -- the document is a story.

    One last admission

    There's so many things to do overnight on medicine call. I've got to see the new admissions, write up the H+P's, order labs and tomorrow's procedures, handle dozens of cross-coverage checks and answer random calls from the floors.

    So, when it's all over and I come home, the list-making tends to continue. Today was no different -- I sat at my computer by the window, overlooking the glorious spring day unfolding just beyond my fire escape, and began composing the list of post-nap tasks and activities.

    Some movement caught the corner of my eye. There, on the fire escape, a bird had nestled in amongst the tangled philodendron vines. She adjusted her position, I guess, to better assess the threat.

    We stared at each other a few moments. Most birds don't linger on my fire escape for too long, but she seemed pretty invested in the place. Was she sick? Injured? Or just resting?

    "I've had that plant for a while, do you like it?" I asked. She winked at me.

    "OK. Maybe you had a rough night, too. Tell you what: If you're still here when I wake up, we'll call a consult and consider some imaging. OK?"

    She consented, and I had a new item for the top of my list.

    The Status of Bloggers

    Envision Solutions, a marketing firm, has put together a 110-page guide to healthcare blogging. It's available for $36.95, but will become more expensive after May 30th (which is curious, because it ought to be obsolete right around then). Amy from DiabetesMine alerted me to the publication, and from the table of contents, I can see they've excerpted her. It seems like "Healthcare Provider Blogs" got about 6 pages... which is nice.

    Hopefully they mentioned medical student Graham Walker -- but if not, he may get some consolation from the fact he appears in the new graduate rankings issue of US News and World Report, in their article on academic blogging/

    Daniel Drezner is also interviewed:

    Those already working in academe may also find themselves in hot water. Political science Prof. Daniel Drezner, for one, believes that his own well-known blog,, may have played a role in his being denied tenure at the University of Chicago last year; he now cautions graduate students and untenured peers to think carefully before creating web diaries themselves. The ivory tower's old guard, he argues, is likely to overestimate the amount of time it takes to maintain a blog and also fail to acknowledge any potential intellectual value, among other downsides. "One of the problems with blogging is that it provides an alternative route through which academics can attain status, outside the more proper, traditional, peer-reviewed path," adds Drezner, who'll move to a tenured post at the Fletcher School of Law and Diplomacy at Tufts University this summer. "As a result, there's always going to be hostility toward people who manage to do that, in the same way there is toward those who write only popular books."

    Of course, the peer-review that leads to general popularity in the acamdemic blogosphere is at least comparable to what goes on in a manuscript review. Drezner otherwise hits the nail on the head.

    Another way of putting it: Atul Gawande has about 25 citations in pubmed, many of these are articles in JAMA and the NEJM -- but very little of it is actual new research. Mostly it's his interviews, summaries and opinions (we're not even counting his New Yorker pieces). His stuff is extremely well written and enlightening, but I've noted before there's some resentment towards his position and frequent pontifications. I wonder: will he be penalized compared to an age-matched peer with 25 publications, when it comes to tenure review?

    Similarly, I'd be curious to see how Graham and others handle questions about blogging during residency interviews (the new season is just six months away). My freelance writing and blogging didn't come up much on the interview trail, but when it did (and since) the reactions have been fortunately positive. So far.

    ED Visits from Homeless Alcoholics, Revisited

    This month's Annals of Emergency Medicine has a report from the Serial Inebriate Program in San Diego (it sounds like a dispatch from Spring Break, but in fact is an attempt to stop the revolving-door of drunks in the ER).

    I blogged about Malcolm Gladwell's coverage of programs like this, just recently. To borrow from his latest column, he provided "story" reasoning, whereas this Annals article provides a "technical account" explanation.

    The long and short of it, from the intro and discussion:
    California law also provides judges the option of offering such individuals an opportunity to complete an alcoholism treatment program in lieu of custody. Before the implementation of Serial Inebriate Program, local treatment programs were unwilling to accept these clients because of their recidivist behavior, and jails rarely housed them longer than 72 hours. In 1999, the San Diego Police Department recruited a treatment provider to collaborate in the development of a novel pilot program tailored to this population. The San Diego Police Department also secured the support of the city attorney to develop new booking and sentencing procedures. Importantly, the public defender lent its critical support to program development after concluding clients would be afforded valuable new support and care. Volunteers of America staff were asked to define the criteria that should constitute a "chronic inebriate" (and therefore Serial Inebriate Program client), and the superior court endorsed a trial program...

    ...This study documents the extraordinary consumption of EMS, ED, and inpatient resources by one city’s population of homeless chronic alcoholics. Assuming an average observation period of 4.5 hours (Dunford, unpublished data) these patients consumed nearly 15,000 hours of ED staff time at 2 of San Diego’s major regional hospitals, which equates to a 34% chance that a Serial Inebriate Program client was occupying an ED bed at one of these facilities at any moment during the 4-year study. These data provide evidence that a relatively small number of individuals can have a large impact on a community’s safety net.

    This study also demonstrates that a community-supported alcohol treatment strategy that incorporates legal consequence can reduce the consumption of emergency health care resources. There was a 50% decline in the use of ED, inpatient, and EMS resources for the 156 individuals who accepted a 6-month outpatient treatment program in lieu of custody. Conversely, there was no change in resource consumption by the 112 individuals who elected not to enter treatment. The Serial Inebriate Program’s success derived primarily from its impact on the most recidivist individuals. Those accepting treatment were typically older men who had been transported by EMS and treated in ED twice as often as nonacceptors.

    Many more nuggets in the article, with citations to many more articles on homelessness and ED frequent fliers (yet another medicine / airline analogy). And, of course, profound limitations that leave many questions of costs and long-term effectiveness unanswered (EM research, sigh).

    Moreover, San Diego's program is not as revolutionary as Nevada's or Denver's, in that it relies on courts and legal threats more than largesse and social work. The authors expressed surprise that they were able to persuade even 156 of San Diego's chronic alcoholics to sign onto 6 months of treatment (even with the threat of jail) -- Gladwell reported no problems recruiting recidivists in his article.

    Either way, it seems that programs like San Diego's or Nevada's are going to prove their worth. The most hardcore chronic inebriates are just too expensive to be treated and streeted every few days; special programs to handle them are bound to be cost-effective.

    Revisiting Traumatic Choices

    The New Yorker has an article by Dr. Jerome Groopman on allowing families to view resuscitations. It's not offered online, though some of it is excerpted in the press release:
    Groopman notes that while laypeople are now routinely involved in decisions at the National Institutes of Health and on hospital review boards, "family presence in emergency rooms, which is part of this larger trend, remains controversial. Not only does it represent an incursion by the public into medicine’s inner sanctum; more than any other recent development, it reveals the extent to which the power to decide how medicine is practiced is no longer an exclusive prerogative of doctors."

    Reverend Hank Post, a former chaplain at Foote Hospital, in Jackson, Michigan, tells Groopman that he regarded his effort to open the hospital emergency room to families as a campaign for "human rights." Beginning in 1982, he encouraged doctors to allow him to stand with family members at the patient’s bedside during resuscitation attempts, and Foote became one of the first American hospitals to approve the practice. "It moved grieving along," Post says. "The families saw quickly how hopeless things were, and, by being present, the family can own part of what went on." Patricia Howard, an emergency-room nurse from Kentucky, persuaded the Emergency Nurses Association to formally endorse "family presence."

    "We’ve always taken excellent clinical care, but not always excellent psychosocial care," Howard says. Groopman writes, "Like many proponents of family presence, she argues that today Americans are better prepared for the gore of resuscitations than they were ten years ago, because they’ve seen realistic imitations of such procedures on television." But those dramas, such as "ER" and "Rescue 911," Groopman reports, have highly idealized the success of resuscitations, with large majorities of patients returning to their normal lives. In reality, Groopman explains, "just fifteen per cent, at most, are successful." And, he adds, "patients who survive resuscitations often have brain damage or debilitating neurological conditions."

    One group whose members have actively opposed family presence is the American Association for the Surgery of Trauma. In a 1999 study co-authored by R. Stephen Smith, a trauma surgeon in Wichita, the A.A.S.T. compared the demanding tasks involved in resuscitation to those in an airline cockpit. Groopman explains: "Like pilots, they wrote, emergency-room teams must assimilate large quantities of data in a short time and make quick decisions; potential distractions, such as the presence of a family member, could jeopardize the success of a resuscitation." Groopman writes, "Smith believes that hospitals should retain the right to invite a patient’s relative into the E.R. on a case-by-case basis. At the same time, he said, laypeople need to realize that they may not understand much of what they see there." Smith says, "It’s like me taking a tour of a nuclear power plant." Groopman concludes, "Keeping families out of the emergency room, however, ultimately may be impossible." "We are entering an era of openness in every field," Alasdair Conn, the chief of emergency services at Massachusetts General Hospital, says. "You want to know whether your stockbroker is a good broker. You want to get a second opinion on a legal decision. It’s happening in medicine, too. In many medical situations, there is no one right way to do things. There is this questioning, a search for alternative answers.... If my daughter or my wife or any of my relatives were in pain and in the emergency department, I would want to be there with them."

    Groopman writes that trauma surgeons generally view families as a hindrance during resuscitation, echoing Bard-Parker's observations from his conference. It's interesting that one trauma surgeon, R. Stephen Smith, invokes the pilot analogy -- a favorite ploy of NHS Blog Doctor. I can just imagine it: "Ladies and gentleman, we're experiencing some turbulence. Who wants to cram into the cockpit and watch us navigate?"

    But of course it's not the same (and in fact, passengers used to be able to listen to the "cockpit channel" with their headphones -- airlines are bucking the trend of openness that's permeating medicine and business).

    When Cut-to-Cure and I blogged about letting families watch resuscitations two years ago, I wondered about the literature. Groopman's got the answer -- mostly just one oft-cited English study, involving 25 relatives of patients undergoing resuscation attempts. That's it! But surveys of the eight relatives who saw a loved one die, none said the experience was traumatic and all reported they were pleased with their decision to observe.

    Groopman also talks a little about the history of emergency medicine, citing a new book by University Michigan EM attending Brian Zink. It's going on the wish list, along with the hope that my family is spared from viewing any resuscitation attempts, any time soon.

    Grand Rounds, brought to you by GlaxoSmithKline

    OK everyone, I've been kind of quiet regarding the recent controversies on hosting issues. Partly it was because of a punishing intern schedule, partly because the hosts are doing a great job sorting this out themselves -- but mostly because of a big deal I had in the works.

    Over the past few weeks I've been negotiating with a team at GlaxoSmithKline. They want to "get into this blog business," and we're looking for ways expand the readership of mdical blogs. I saw an opportunity.

    Since its inception, Grand Rounds, the weekly compendium of the best in medical blogging, has exemplified two principles: 1) there's no better way to learn about healthcare than from those in the field and 2) self-promotion is a powerful motivator.

    Glaxo recognizes this, and they want to capitalize. It's the high quality of written submissions, the creative hosting efforts, and brazen opportunism that have make Grand Rounds great -- and led us to this unique new collaboration.

    So, starting this week, the GlaxoSmithKline homepage will run a link to Grand Rounds every Tuesday morning! Also, Glaxo drug reps will start handing out cards with the URL of the Grand Rounds archive to doctors and students they identify as "computer-oriented" or "loners."

    Now, in return for this torrent of traffic, Glaxo has asked for something in return. They would like each host to run a link to and, as appropriate, to individual product sites. The hosts can choose to whether to place this link in the body of the Grand Rounds post, or high up in their blog's sidebar. Hosts can also choose the color of the text.

    This ties in closely with something else: Glaxo will be encouraging more "theme" editions. Now, some of the best Grand Rounds have featured themes. These new themes will revolve around some of the drugs Glaxo makes.

    For instance, the upcoming April Fourth edition will be hosted by a urologist, and so will naturally feature submissions on erectile dysfunction. Specifically, posts about Levitra will be prominently displayed up at the top of Grand Rounds.

    While I suspect this may ruffle some feathers, I want to stress that bloggers can write whatever they want about Levitra -- Grand Rounds is still very much an open forum (though representatives from Glaxo have asked to evaluate each submission before its inclusion in Grand Rounds; the hosts will comply). If you're worried about participating in some kind of viral marketing campaign, remember: Glaxo makes antivirals.

    The biggest upside of this new partnership and Glaxo's "theme" editions: if enough bloggers link to these Grand Rounds posts on Levitra, google searches for Levitra will start to point to the hosts page! That's a bonanza of hits, people, and it could finally give medical blogging the mainstream audience we deserve.

    So, as I see it:

  • Advantages: Huge exposure, more popular theme issues, relevant posts grouped together

  • Drawbacks: None that I can think of.

  • So, that's it. The Medscape Pre-Rounds series will continue, but will obviously change its focus -- instead of featuring the upcoming hosts of Grand Rounds, more of an emphasis will be placed on GlaxoSmithKline products and achievements. Bloggers, start thinking about Paxil, because the host for 4/11 is Anxiety, Addiction and Depression Treatments. And readers, prepare to be dazzled!