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, www.danieldrezner.com, 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 GSK.com 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!