All Saints' Day

The Dean's Letter goes out to residency programs tomorrow, November 1st. Our applications are complete at that time, and there's nothing left to do but sit and wait for more interview offers.

The Dean's letter, also called the Medical Student Performance Evaluation, is an overview of all our clerkship grades and evals. Most of the comments doctors and residents gave us in the past year find their way into this document. At our school, students are given a chance to correct grammatical mistakes and errors. It's a good thing, too -- I spotted one evaluator's comment that read:

Clearly, Nick was one of the students this past year.

I really hope an adjective was missing.

But in talking with my peers, many who are usually well-balanced and easy-going, we have discussions that George Orwell and Garrison Keillor could both enjoy. It's because we've become adept at reading between the lines of evaluations.

"Outstanding" is the best adjective to describe your candidacy for residency. It's nice to have it mentioned as often as possible, in fact: next to your people skills, your initiative, your knowledge base. "Excellent", by contrast, is really a let-down. It's the second-best adjective. Only in medical school can someone dread being called "excellent," but it happens. And don't get me started on "Very Strong" or "Very Good". That's damning by faint praise, as far as I'm concerned.

Maybe it's different at other schools, but I thought this was the code all program directors used. Actually, it's discouraging to think some of my graders might employ real English, and some are using eval-speak.

Fall classic

I slept for a long time last night, catching up on a deficit spent on the ALCS, the World Series, Halloween parties, and pediatrics call. This morning, I experienced the pleasant gift of an unearned extra hour.

I wrote about Daylight Saving in the spring. But it's a topic whose time has come again.

Bask

There's so much love in New England right now. Last night, for instance, I saw strangers share many a weepy embrace. Families strolled the eclipse-lit streets at midnight. I myself high-fived over two hundred people.

We took pictures with the man wearing a functional replica of the Fenway scoreboard. We cheered the cops and taxi drivers as they slowly rode by. There was even a guy handing out Baby Ruth candy bars in Central Square. It was perfect: don't just beat the curse -- eat it.

Yes, there's a spirit of magnanimity in the air, a generousity that comes naturally from a land that has produced this year's NFL and MLB champions.

With this in mind, here's a big thank you to my readers. October will break blogborygmi traffic records, which is kind of unexpected because 1) I think I'm posting less and 2) the Grand Rounds instalanche was back in September. But this has been a month of pleasant surprises...

Also, I have to thank the commenters, who have made so many posts more interesting and enjoyable by sharing their thoughts.

The mark of courage

Did I mention how great my readers are? Erin writes:

I'm desperately seeking a photo of the FrankenSchilling
sutures, due to a bargain I made with god/satan/whoever
regarding the World Series.

I can't find a picture anywhere, but I'm wondering
if any of you, with your expertise, could hazard a
guess as to what that must have looked like?
Vertical or horizontal? Above or below the ankle
bone? I promised the ghost of Babe Ruth that if
the Sox won this series, I'd tattoo those sutures
to my ankle.

First, take the time to get this right. Everyone will be talking about this magical month for the rest of their lives, but you'll have something to point to. Make sure it's accurate. Ask a surgeon blogger, or someone who's named his blog after a stitching technique. Or, hey, try asking Curt Schilling himself -- he posts to Sons of Sam Horn...

Failing that, at least print out a picture of a dislocated peroneal tendon and show it to your artist.

But from what I've gathered (and from Noah's input) I think you'll have four stitches total. They'll be in pairs over the outside knob of the right ankle (lateral malleolus). On each side of the forward-displaced tendon, two stiches, running lengthwise and parallel to the tendon, made a new groove for it to slide in.

I also heard Schilling had four sutures in Game 6 of the Yankees series, but Dr. Bill Morgan and company used only three in Game 2 of the World Series.

Good luck!

Calling a Code

Geena's the first nurse to host Grand Rounds, over at CodeBlog.* Go check out the latest and greatest in the medical blogosphere.

*(Not to be confused with CodeBlueBlog, cited below.)

A tale of two mobs

Bravo to CodeBlueBlog for asking a question that's somehow slipped everyone's mind:

How, exactly, did Victoria Snelgrove die?

This 21-year old fan took to the streets with thousands of others after the Red Sox beat the Yankees in Game 7 early Thursday morning. The police were called in, armed with new weapons purchased (but not used) for crowd control at the Democratic National Convention. Some poorly trained officers sprayed pepper-bullets into the mob. Snelgrove was struck in the eye and died hours later.

CodeBlueBlog is right to criticize the media's coverage of this sad event. At this point, no one in the press actually digging up facts anymore. The ratio of commentary to real news is so out of whack, you have to wade through hundreds of "me too" articles on Google News just to find out the smallest wrinkle in the story. The press has become just as unruly and misguided as the drunken revelers they're criticizing. The key questions -- mechanism of death, coroner's report, past medical history -- are not even being asked, as far as I can tell.

So, props to Code Blue for raising these questions. He performed an armchair literature survey of similar accidents -- above and beyond anything unearthed in the mainstream media. His findings? Among the hundreds of cases of paintball-to-eyeball injuries recorded, none resulted in death. Something's fishy here, and the truth may illuminate some of the polarized policy discussion now underway (Bostonians are being asked to either reinstate Prohibition or submit to the stormtroopers).

It's interesting though, that CodeBlue thinks the media's rush to commentary has led to an anti-police bias. I think the Boston press has been unconscionably pro-police, at a time when even the cops are admitting a major error. Either way, this debate needs more data, and journalists are failing us.

It's a sad coincidence that Snelgrove herself was a journalism student. I like to think she still has a story to tell -- if only her peers were asking the right questions.

Editorial

Malcolm Gladwell writes with an outsider's clarity and wit, which has served him well in such books as the Tipping Point, an excellent and readable introduction to phenomena in sociology and marketing. Hell, he can even make ketchup compelling.

But he's now tackling drug prices, and while he makes some excellent points, I wonder if his final conclusion isn't off the mark.

It is accurate to say only that the United States has a different pricing system from that of other countries. Americans pay more for drugs when they first come out and less as the drugs get older, while the rest of the world pays less in the beginning and more later. Whose pricing system is cheaper? It depends...

In fact, drug expenditures are rising rapidly in the United States not so much because we’re being charged more for prescription drugs but because more people are taking more medications in more expensive combinations. It’s not price that matters; it’s volume.

So true, and not emphasized enough. But then Gladwell focuses on a significant problem in prescription drugs: new meds with side-benefits that aren't cost effective or particularly efficacious. An example he gives is pravachol (one of many "me too" cholesterol-lowering drugs), which was shown to lower strokes in a small, select population but actually raises stroke incidence in a bigger, more vulnerable population.

He doesn't squarely blame the drug companies for advertizing these benefits, and he doesn't exclusively blame doctors for overlooking the caveats buried in the scientific literature. Instead, he implicates a new target: medical journal editors, for not doing their jobs and properly highlighting the advantages and drawbacks to new drugs. This criticism is all the more damning, since a powerful former editor, Marcia Angell of the NEJM, has just written a book about Big Pharm's duplicity (and, um, dropped the ball on pravachol).

I've edited some manuscripts myself (for publications with substantially smaller impact than the New England Journal of Medicine), but can still vouch for its difficulty. Clarifying the results and conclusions of some scientist-authors can be like herding cats. And even after I've done a spiffy job, I still can't be sure which section of the paper, which figure or conclusion, will be seized upon by other authors. Some data that I considered superfluous might be the puzzle piece that allows another lab to move forward.

I don't think it's different for clinical publications on drug efficacy. I'd bet that, no matter what results an author uncovers, and no matter how skillfully these results are arranged and highlighted by an editor, drug company marketers will still find material to work with. They'll always be able to find obscure, questionable benefits to justify new drug prescriptions over less-profitable generics. These results will make their way into Big Pharma handouts and presentations, where they'll be repeated ad naseum for years. They've got more money, and they've got more interest. The editors can't compete.

Via Medrants.

Social services

Kevin highlights a BMJ article about a male nursing home resident with a pressing need:

It seemed that Mr Cooper had persistently been asking female members of staff to have sex with him. The problems seemed to have begun when Mr Cooper's regular visits from an elderly female friend had ceased.

Although rather deaf and undoubtedly frail Mr Cooper did not have significant cognitive impairment. He volunteered that his visitor had been providing him with paid sexual services, and that since this was no longer possible he wanted to hire another prostitute. He said his deafness and poor vision had now made it difficult for him to do this for himself, and he had consequently sought help from the staff. He had been firmly refused. I gathered that after a stalemate of many months he could think of nothing to do other than proposition the staff.

As usual, Europeans have a very sophisticated approach to these matters. I recall a story earlier this year in which an unemployed German man asked his government to finance his sexual activities, since his wife was couldn't return to his country.

This case also reminds me of the uproar when health plans started covering Viagra but continued to exclude birth control pills. Why is restoring intercourse considered a medical necessity, but preventing its consequences is considered a lifestyle choice?

I never had a good answer, until I read of the havoc caused by this libidinous nursing home patient:

His situation deteriorated. An extra male staff member was hired, devoted solely to following him around all day to prevent him from making improper suggestions. Both the staff member and Mr Cooper found this constant observation trying.

Later, staff at the residential home obtained the telephone numbers of prostitutes, and one agreed to meet Mr Cooper at a neutral venue. The staff were still divided, although the man who had followed Mr Cooper's every tottering step for many weeks was reported to be relieved.

Read the whole thing.

Uncharted territory

So, um, the Sox beat the Yankees.

Here's a simple guide to peroneal tendon dislocations, like the kind that used to bother Sox ace Curt Schilling. Judging by his bloody red socks, and this Bill Morgan transcript, it seems the tendon was anchored out of its anatomical location, to a site anterior to the lateral malleolus:

JD: “I’m still not sure I understand how you create a wall, what did you attach the sutures to? Skin to skin and that created what, a barrier? Is that the deal?”

Dr.M: “Well the tendon is out of position and out in front of the bone and the problem is that it would slip back again to where it was supposed to be and then slip out again. And it was really just to create a barrier between the skin and the underlying tissue which is called facia so that there wasn’t let’s say a tunnel subcutaneously underneath the skin, it just kind of anchored the skin through the underlying tissue so it would stick the tendon where it was supposed… where it was, so it couldn’t sublux at all."

JD: “If I understand you correctly, you sewed this in a position with the tendon not where it eventually will be when it’s repaired, it’s out of position for the entire game last night?”

Dr.M: “Just for last night. Those sutures are out now.”

GC: “And you assure us he’ll be ready for the World Series correct? You’ll do this again and have him ready for the World Series…”

I think they should change the Red Sox logo to reflect this groundbreaking procedure. Can we get a photoshop on this?

And I expect anatomical gift programs in the Boston area will experience a boom when fans learn how cadavers were used to guide the Sox to victory:

Epstein spoke of how [Sox doctor Bill] Morgan practiced the procedure on cadavers (a common exercise for orthopedists) before using it on Schilling. After applying the anesthetic Marcaine to the area, Morgan sewed in three stitches directly through the skin and attached them to both ligament and deep connective tissue located next to the ankle bone itself. Schilling was satisfied that the procedure had worked during a light throwing session before Monday's Game 5. On Tuesday night, he was proven right.

They'll try it again before Game 2, apparently.

Stitched together

I'm going to continue these late-night ramblings because, as has been the case all week, the Red Sox Are Facing Elimination and in 24 hours I might be too depressed to share.

Bill Simmons, the Boston Sports Guy, pulls off the difficult job of relating the Fenway experience to both die-hard fans and perplexed outsiders:

For two straight days, I watched my beloved Red Sox stave off elimination against the Yanks, needing 26 innings over 27 hours to stay alive for Game 6 in New York. These weren't just baseball games. They were life experiences. They broke you down in sections. They made you question God, the meaning of life, whether sports should possibly mean this much. On Sunday night, I stewed in my seat vowing never to raise my kids as Sox fans. On Monday night, I skipped out of Fenway wondering if any other team could possibly mean this much to a group of people.

...Game 4 ended a little after 1:30 a.m. Fifteen hours later, I was sitting in my same seats in section 116 with my father, glancing around and wondering if we ever actually left. Apparently we did. There was only one major difference between the two nights: in Game 4, the fans were waiting for the Yankees to win the game. In Game 5, the fans were waiting for the Red Sox to come through. Now everyone in New England is pinning their hopes to the greatest comeback in baseball history. It happens that fast.

Emphases mine. Some of the best writing on the Red Sox is coming up at Surviving Grady. Start at the bottom and work your way up from the despair of the early Yankees drubbings, to the whiff of respectability when we won one, to the glimmer of hope Tuesday morning. Now? Chest-thumping and a dare to dream. On the ankle-sutured heroics of Curt Shilling, Red says:

The absolute fantastic-ness of this event is impossible to overstate. Two days ago, he was a gimp. A horrific footnote [pardon the pun] to the 2004 season. A million dollar horse that went tits-up when we needed him most.

But then the balls took over. And he was literally a one-legged guy at an ass-kicking contest. And his cleat did find ample ass to strike. And he turned in a one-run-over-seven-innings performance with blood soaking through his socks and sweat coating his back.

It was simply the gutsiest thing MLB has witnessed all year.

On the flipside, we had A-Rod resorting to schoolboy tactics, blatantly knocking the ball from Arroyo's glove on a close play at first, then whining incessantly when he was called out for it.

Maybe God's finally paying attention. Maybe he sees what's up.

Yeah, a little boisterous, but everyone who's up and blogging about this right now is drunk on something. Read the comments to those posts, as well, because the fans are writing poetry.

Penetrating Trauma

I'm writing this Red Sox story now, because I can't predict my emotional state this time tomorrow. After the Sox momentum these past few days, the tale feels distant, and receding, but I suspect it can never be too far from our thoughts...

Last year, during Game 7 of the epic 2003 American League Championship Series matchup between the Yankees and Red Sox, I was on call. Admitting patients. To the Surgery team. Every day was a long slog but call days especially so; this one was bearable only though occasional dispatches from the nurse's lounge: "Sox up 5-2!" "Pedro's looking strong!"

By the eighth inning, I was on the floor, admitting a middle-aged guy with alcoholic pancreatitis. Volume depletion is a big problem with pancreatitis -- we needed to know how much urine this guy was making. Precision required a foley catheter.

I tried to inform the patient of this as he looked over my shoulder, at his wall-mounted TV. He was watching our tired ace, Pedro Martinez, give up one hit after another.

Me: "So, uh, you're going to need a foley."
Patient: "Why is he still in the game? He's done!"
Me: "A tube will go through your penis."
Patient: "Whatever. Take Pedro out of the game!"

I slowly set up my foley kit (in retrospect, this was probably my second or third career catheterization). I glanced over my shoulder a few times, seeing Pedro give up a run and manager Grady Little come out to the mound.

Me: "Looks like Pedro's out."
Patient: "No! They're leaving him in!"

Pedro then gave up a ground rule double to Hideki Matsui -- there were two on with one out in the eighth. The score was 5-3, Red Sox. Jorge Posada came up to bat. I tuned everything out as I inserted the foley.

As the tube went in, I glanced up at the patient's face and saw an expression of abject horror and revolting pain. I will never forget that look, and I never want to see it again. I assumed at this point I had just obliterated the man's prostate.

Me: "What is it?! What is it?!"
Patient: "Posada doubled! The game's tied."

I looked up at the TV and saw the real damage. Pedro was pulled after that -- two hitters too late. The Yankees went on to win the game and move on to the World Series. The Red Sox manager was fired shortly thereafter.

The 2004 season brought a new set of memories and frustrations to the Sox/Yankees rivalry, but never doubt that the sting from that Game 7 lingers in the hearts of New Englanders. All I have to do is remember that face, and a pain far worse than any foley.

Reinforcements

The best and brightest in research, engineering, and medicine have been working nonstop to solve one of the most pressing problems facing the nation.

Of course, I speak of Red Sox Nation, and the problem of stabilizing Curt Shilling's right achilles tendon.

Reebok has built a custom high-top cleat to do the job. I expect to hear much more on this miracle of science soon, now that Game 6 has gone from "extremely hypothetical" to "Tuesday". For now, this story from the Globe will do:

The suspense surrounding Curt Schilling's possible return to the mound in the American League Championship Series intensified yesterday as the Red Sox indicated Schilling has found the footwear that would enable him to pitch if his injured right ankle permits it.

Manager Terry Francona said Schilling was experiencing normal soreness in his ankle the day after he tested a customized high-top cleat in his first bullpen session since his injury-shortened start in Game 1. The only problem was the shoe, built by Reebok, was too small and hurt Schilling's toes. He received a new pair of cleats yesterday.

"I think he's real comfortable with that high-top as long as he gets the right size," Francona said, indicating Schilling could pitch without an additional brace. "That was Plan A going out to the bullpen, and I think it worked pretty successfully."

The only remaining question was whether the footwear and a dose of the anesthetic Marcaine would permit Schilling to pitch effectively with a dislocated peroneal tendon. The tendon, whose protective sheath ruptured Sept. 26, runs around the back of his ankle.

"I think he kind of feels like we do, that the door isn't closed," Francona said. "Until it does [close], you keep the hope and faith, and try to work hard and do what you're supposed to do. We'll kind of see how it goes."

That attitude is slowly bringing us back from the brink, one game at a time. On a more personal note, residency matching has taken on an added dimension...

Vaccine fever

The flu vaccine shortage of 2004 has indirectly caused its first death:

LAFAYETTE, Calif. (AP) -- A 79-year-old woman who stood in line more than five hours for a flu shot collapsed and died after striking her head.

Marie Franklin and her husband, Robert, had been standing with hundreds of other seniors outside a Safeway supermarket on Wednesday when she became pale and weak. She collapsed as she walked toward shade.

Franklin, an award-winning local artist, died from those injuries Thursday. The Contra Costa County coroner's office ruled the death an accident.

"We see it as a fluke accident and choose not to blame anyone," said the Franklins' daughter, Ginni Poulos of Portland, Ore., who flew to her parents' home in the San Francisco Bay area city of Orinda. "We do think it could have been better organized. People wouldn't have had to wait so long if they had more workers or created a better system."

The daughter is exhibiting a fair and expansive attitude in a difficult time.

I wonder if the next victims' families will be so reasonable. Remember, you can't spell "fluke accident" without some of the letters in "flu vaccine shortage" (and when you have vulnerable patients waiting in lines overnights in October, you're bound to have more morbidity).

Why are patients being forced into this bizarre distribution system, anyway? If you're healthy enough to camp in line outside all night, you should be rewarded with concert tickets, not potentially lifesaving meds. At our pediatrics clinic, docs are making sure the infants with a history of lung disease get the influenza vaccine -- the most vulnerable, first. We're not having the kids arm-wrestle each other for it. So why are the elderly subjected to endurance tests?

Skin deep

Symtym's back with a spiffy new look. The custom skinning was implemented by Moxie. And that logo! A neat use of the icons behind medicine and law.

Anyway, he's got the goods on the VeriChip, the implantable RFID developed by Applied Digital Solutions and recently approved by the FDA. A transmissable past medical history would make my job in the emergency department a lot quicker... but maybe at a price (and I don't mean granulation tissue).

Spheres of influence

Galen's got some commentary on my post about influence and bias in journalism and medicine. And although he graciously identifies his political bent, he stays mum on his stance re: NoFreeLunch.

But hey, I'm staying quiet, too. I've got interviews coming up, and don't want to stake any positions more inflammatory than "the media could do a better job". (If a residency director ever quotes blogborygmi back to me in an interview, I will either rank that program #1 or claim someone has chosen my name as a pseudonym).

Anyway, I came across two interesting quotes about bias in journalism, and the state of the media:

"I think what happened to the media is ambition and stardom have overwhelmed purpose. People always talk about how there's a liberal bias and a conservative bias. But the main bias of the news is personal ambition, because a lot of choices are made based on not burning this source or not causing a conflict in an area that is your ladder upward.... the media is utilized purely as a strategy by people in power."

"Former CBS News-man Bernard Goldberg has written a best- selling book called Bias, in which he maintains that the real problem with the media is not a bias based on liberal vs. conservative or Republican vs. Democrat. It is a bias based on the sameness of worldview caused by social, intellectual, educational and professional inbreeding. These are folks who travel in the same circles, go to the same parties, talk to the same people, compare their ideas to people with the same ideas, and develop a standard view on issues that makes any deviation from them seem somehow marginal, or even weird."

The first quote is by Jon Stewart, host of the Daily Show, as told to Rolling Stone (sadly, the excerpt is only in the print version). The second quote comes from Pat Sajak.

In this era of celebrity journalists and fake news, we're lucky to have some entertainers with the insight and courage to call journalists to task.

Can I bring this back to medicine? Lemme try: Is there a medical equivalent to what Jon Stewart and Pat Sajak have done? Not unless the cast of ER starts giving interviews about the selfishness of doctors.

I don't think that's happened. The task of reigning in drug marketing's influence on doctors has been taken up by... doctors. And it's something to be proud of.

Update: Jon Stewart just went grapeshit on Crossfire today. Via metafilter. Some of the CNN transcript:

STEWART: What you do is not honest. What you do is partisan hackery. And I will tell you why I know it.
CARLSON: You had John Kerry on your show and you sniff his throne and you're accusing us of partisan hackery?
STEWART: Absolutely.
CARLSON: You've got to be kidding me. He comes on and you...
STEWART: You're on *CNN*. The show that leads into mine is puppets making crank phone calls. What is wrong with you?

and later:

STEWART: [after the presidential debates] you go to spin alley, the place called spin alley. Now, don't you think that, for people watching at home, that's kind of a drag, that you're literally walking to a place called deception lane? ...
BEGALA: ... They actually believe what they're saying. They want to persuade you. That's what they're trying to do by spinning. But I don't doubt for a minute these people who work for President Bush, who I disagree with on everything, they believe that stuff, Jon. This is not a lie or a deception at all. They believe in him, just like I believe in my guy.
STEWART: I think they believe President Bush would do a better job. And I believe the Kerry guys believe President Kerry would do a better job. But what I believe is, they're not making honest arguments. So what they're doing is, in their mind, the ends justify the means...
CARLSON: I do think you're more fun on your show. Just my opinion.
STEWART: You know what's interesting, though? You're as big a dick on your show as you are on any show.

And one point Stewart asks them to stop, stop, stop broadcasting, because they're hurting America. It's really something. The clip is available at Media Matters.

Differentiation

Over at Kill As Few Patients as Possible, Dr. Bradley and I have been going back and forth about embryonic stem cells, the public's perception of the issue, and how much Kerry should be castigated for a misstatement in the second debate.

I think we're coming to an agreement on the following:

1. Kerry's position is contorted
2. The media could do a better job
3. We're going to stay away from the 'is it murder' question

But you know, when I put it like that, it's sounds bland. Getting there is where the interest lies -- so go check it out.

Reflux

Back in July I asked, "Where are the Med Students?" -- specifically, why are there so few medical student bloggers compared to law students?

One quote I used came from Mary, a law student who brought up this subject in March.

Now the topic is revived again, thanks to some deep digging from Izzy. Check out his perspective on the question, and some of the comments it generated (including a fun cameo by the aforementioned Mary).

I do look forward to the time when people stop asking, "where are the med student bloggers?" -- because soon I hope they'll be ubiquitous. Until then, consider visiting some of the student sites collected on my sidebar.