Now That's a Medical Miracle

I am referring to having just spent two weeks in the same house as my in-laws and NOT having sent someone to the hospital in need of "trauma-surgery" STAT!

Speaking of trauma surgery (now that's a nice transition), this weeks Grand Rounds are at Cut-to-Cure, a blog who's author is a real live trauma surgeon. I didn't manage to submit, or write anything, this week. That was due to the ninety degree weather I was experiencing. Amazing how it inhibits creativity and idol time in front of a computer screen INDOORS.

While I get this thing up and running again, I demand you go and have a read.

And I wanted to thank everyone for the input on the previous post. I will try to take some of your advice and incorporated it. I am back home, grateful to the airline industry for managing to keep me out of any burning infernos.

Friday Intern Topic of the Day VI: How Can We Make This Blog Better

So I would like a little constructive criticism of how I can make this thing a little more interesting.

anyone...anyone?

What?

Saturday was my day off. I decided to spend part of it catching up with my brother who recently ventured off on his own and began a startup internet price engine. We spoke about the business and the general state of the market.

During the two hour conversation he told me about how "spiders” were “continually crawling his site” and “indexing pages” into the search. How he had to track “IP address” and other “browsers” to determine charges that would be incurred. This incomprehensible soup was spewing out of him like honey. Had I the guts to explain I understood but a simple portion of our initial conversation and nothing else (Specifically, when we exchanged goodbyes) I would have endured an hour long lecture. But the experience truly shocked me, the exploration of my internet age ignorance that is.

When did it get to this? We speak English mostly everywhere but even our English is divided into Spanglish, Slang and Rap. Then there's Ebonics and Spanish and in certain areas you can't get along if you don't speak the local vernacular.

I am so glad that as a part of the medical community we are not privy to these types of miscommunications, everything is plain and simple. Our vocabulary, an example of brevity and clarity.

So, the other day when a Surgery consult came to ask me to clarify what was written in the chart of a patient I had recently admitted I stared at him in sudden disbelief. Why it’s clear as night and day. The chart read, "64 y/o m was in USOH 2 d/ PTA, BIBEMS w/ c/o pain in LE and SOB, please r/o DVT/ PE. Obtain duplex, get a V/Q, D-dimer and spiral CT/ PE Protocol".

Where did this guy come from, Mars?

An oldie but goodie from the archive. Check the comment section for an explanation of the chart.

Grand Rounds

This week's Grand Rounds are at Dr. Andy's blog. I love Andy's blog and recently added him to the blogroll. About my entry he writes:

Doctor, nee Medical Madhouse Madman, complains about his difficulty in getting listed on Medlogs, which is a medical blog aggregator.

I always appreciate the effort set forth by Grand Rounds hosts. But sometimes am slightly disappointed by the introduction to my posts. I mean, I didn't just complain, I turned my complaint into an international incident. It was simply brilliant. The kind of creative feces people long to read. But with the introduction above, even I, wouldn't bother to click on the link.

Still, he's got a great blog, he's very intelligent and a great writer. so check him out!

Oh, and the COTV is at A DC Briding Blog this week.

How Do You Use Your Blogroll?

This vacation, although it is making my excellent coverage of medical issues slightly more difficult, is giving me a good chance to post about non-medicine related topics. Today, I would like to discuss the blogroll/link list, usually available on every blog. I guess it goes under blog etiquette but the behavior for one's blogroll is so variable and often not discussed.

It stems from the basics of internet that the best way to get people to your site is through links on other blogs. After all, the chance that a certain reader may click the link is higher than if he should search Google for that same topic directly discussed on your site. Google, as well, assigns a certain page rank to your blog/web site based on how many links it can find to your blog. The higher your "page rank" the more important your site is deemed to be and the more often your posts are archived and available for Google search results, meaning, that Google will scan your site more often if you have a higher page rank. Well, all that means in essence is that the higher your page rank, the more readers you are likely to receive.

This algorithm gets even more complicated as it's not just "how many" links are found to your site but also who those links are from. So a site with higher page rank "passes on" more importance to your page. Very interesting, but what the hell does any of this have to do with my post now?

It's so variable how bloggers use their blogroll, most of the times it's obvious as soon as one sees their page. If the link list is very long, chances are that this blogger exchanges links to boost readership and to increase Google standing. I believe it's a great strategy. Links don't cost anything, and although as your outgoing links increase your "page rank" decreases, this is a small decrease when calculated into overall page ranking. What seems to be most important is incoming links. I use this strategy here most of the time, unless the author requesting a link or their blog really doesn't interest me or has nothing to do with my topics. So yes, I do exchange links at times.

There are others who are very protective of their blogroll. I find this strategy very interesting as it is kind of counterproductive, but, I would guess that it stems from a feeling that your blog is an extension of yourself and so if you don't find another blog interesting you shouldn't add it to your list. I can accept that, although, I warn those same bloggers that they are likely not helping themselves as well.

And then there are those who use other approaches. They title the choice links "special" and others under "exchange/reciprocal links". This is instructive, as it really doesn't matter in terms of rank but achieves both motives at the same time. I think that it's probably a great approach although I don't use it here.

And then there are those who just get too big for their link list. For example, The Fug Girls, who used to have a link list until their readership became so huge that it disappeared off the page. So much for remembering the small people.

I'm not ashamed to request "exchange" links. An author is likely to blog off his list regardless of how the other blog got there. If you don't think so just check out Instapundit over the last two years and notice how the same authors are continually discussed. You'll find them in his blogroll as well, in case you were wondering. And he receives hundreds of submissions a day, so what does that tell you?

So the more links the better, links don't cost anything, they reduce your page rank marginally but can increase it substantially. Make your own calculation. My conclusion is kind of obvious, isn't it?

What's your link strategy?

For a better discussion of Google page rank check out Brad Fallon's blog. Drop me an e-mail about exchange links.

Update: I would just like to thank those who have been using the Amazon bar on the side to purchase their items. Needless to say, I haven't made a living out of it but the few dollars that have come my way as a result have been enough for a good movie and provided some motivation. Not to mention, gave me a good tickle. And to the one reader who actually used the "donate" button for a certain sum: I love you!

A Very Light Sunday Post

Today, Israel anounced the first steps in the disengagement from a Hamas led Palestenian governement. It is freezing the payment of millions of dollars to our murderers next door. Which is nice, to know that at least you are not paying for your own bullet.

Kind of heavy I guess.

So here's something a little lighter. Its just occured to me how sometimes you write what you believe is a fucking awesome post and yet it gets absolutely no response. Not one! and then you write another post, which you believe is the most boring compilation of text anyone ever combined into a paragraph, much less posted on the internet, and it gets tons of response.

Why?

Friday Intern Topic of the Day V: The Danish Cartoons

The following is an excerpt from an article published in this Friday's Newspaper by Uri Elitzur:

The violence over the Danish cartoons did not begin due to the cartoons just as the recent Intifadah was not caused by Ariel Sharons' visit to the dome. In 1939, many believed Hitler when he blamed the outbreak of war to "an incident" between German and Polish soldiers.

Normal people do not start wars over cartoons and Muslims are neither idiots nor retarded children. Most are not very religious either. The cartoons are not a reason but merely an excuse and when it will be exhausted they will move on to other excuses.

Do you really believe that Muslims are stupid? That they burn down embassies over cartoons? That they have been dying in the streets for five years because Ariel Sharon spent five minutes on the dome once? Do you think for one minute they don't realize that the cartoons are not really against Mohamed as much as they are a criticism of the violent nature of a so-called "peaceful" religion? "A spontaneous eruption of rage of an oppressed nation" the enlightened European says. Well, it's not.

It's not the cartoons, not the settlements and probably not the occupation either. There is a war brewing beneath the surface, burning like hot lava. It is looking for cracks in the ground where it can erupt.

Medlogs: A Terrorist Blog

Armed with the knowledge that only regular readers are familiar with my twisted sense of humor, I urge you to read the following piece with a tendency towards the comical

This weekend the Palestinian Authority (PA) is scheduled to elect their new Congressional Leader. Hamas, having won the majority of seats in congress, is preparing to take over the government. The current prime minister of Israel, Ehud Olmert, has stated that all ties with the Palestinians will cease.

In addition to stopping all payments to the Palestinian Authority Israel plans to freeze the payment of 50 million dollars of tax collections to the PA, take steps to prevent international foreign aid, and as a third step, possibly disconnect the supply of electricity to the Palestinian authority. This, according to published report in this mornings' newspaper.

Which made me think, since I am currently residing in the middle East (on vacation) and have promised my readers a certain "angle" over the next two weeks, I fully intend to carry out my obligations in all aspects related to this blog. And, as previously stated, I am currently facing difficulty getting this new blog listed on Medlogs. This after first having my feed denied multiple times and after sending numerous e-mails to the proprietor of the aforementioned blog.

In addition, this blog has made multiple attempts of diplomacy in the current situation, for example, posting a public plea for help with the matter. Even after an ally of this blog corrected the feed request with the correct feed request, which was accepted multiple times on Medlogs, the feed is yet to appear.

Unfortunately, at this juncture, more definitive steps must be taken to to achieve the desired result. Therefore, the author/s of Doctor is/are declaring that if the matter is not soon corrected the link to Medlogs (currently in the blogroll) may suddenly disappear. If the matter is still not corrected and the feed does not appear I/we may ask our current readers to boycott the current blog known as "Medlogs". This embargo will continue unilaterally for an unknown period of time at which point we may have to declare "Medlogs" and blogs related to the proprietor of Medlogs a "Terrorist blog" and enemy to the Doctor.

We may or may not take steps in the current "United Federation of Medical Blogs" (Which ironically, currently resides on Medlogs) to achieve our goals prior to beginning this process. Although, factoring in the inherent bias of this body, it is unlikely we will do so.

At this particular juncture we may take steps with our allies (all those mentioned in my/our blogroll) to levy sanctions against Medlogs and to remove all aid (including links to the above mentioned) from their blogs.

If all the steps previously mentioned still do not lead to a favorable outcome we will have no choice but to take forceful action and release our spam comment battalion into action. We anticipate that this will lead to a cessation of all quality postings of the so called author "Jacob Reider".

We/I feel that it is most unfortunate that it has come to this but we see no other means of negotiation at this point. Mr. Reider is solely responsible for the actions committed by the blog known as Medlogs as he is clearly listed at the top of the page as the owner and current leader of this questionable organization.

Updates to follow…

How Long Do You Have To Live?

It's slightly hard coming by good medical news here but this little nugget just happened to fall into my lap since the press here is having a field day with this one. It seems to me that anytime one can simplify the human condition into twelve easy to answer questions we, as the human race, are always for it.

And so, a new study from the VA in San Francisco (I am trying to translate from Hebrew so forgive me for any disparities), which included more than 11,000 individuals above the age of 50, attempts to predict survival over the next four years based on risk factors. According to the investigators the test is correct 81% of the time. It is designed for people over the age of fifty.

Follow the list, one at a time, and add the appropriate amount of points for each medical/human condition listed:

1. Age:
Below 50: No Points
60-64: 1 point
65-69: 2 points
70-74: 3 points
75-79: 4 points
80-84: 5 points
85 and above: 7 points

2. Sex:
Female: No point
Male: two points

3. BMI (weight in kg/height in meters squared):
below 25: no points
above 25: 1 point

4. If you have cancer: 2 points

5. Diabetes: 2 points

6. Chronic Lung Disease (asthma, COPD): 2 points

7. Congestive Heart Failure: 2 points

8. Smoker: 2 points

9. Unable to Shower alone resulting from difficulties in health or memory: 2 points

10. Unable to manage a checkbook or pay bills appropriately due to health or memory problems: 2 points

11. Unable to walk short distances due to medical condition: 2 points

12. Unable to carry heavy objects due to medical condition: 1 point

Result: add all points that you accumulate

0 to 5 points: less than 4% chance of death within the next 4 years
6-9 points: 15% risk of death within the next 4 years
10-13 points: 42% chance of death within the next 4 years
14 points or more: 64% chance of death within the next 4 years

Some Thoughts: Of the entire list only two risk factors (smoking and BMI) are amenable to lifestyle changes. The list includes a multitude of chronic diseases but does not address a change in prognosis on the basis of adherence to treatment. Of course, this is probably discussed in the original paper and not in the public media (my current only source of news), which tells a lot about how medical news is distributed.

Smoking carries the same weight as Congestive Heart Failure, chronic lung disease and dementia and is worse than currently having cancer. Do we need to continue driving home this particular point?

Middle East Angle: The study fails to address a change in prognosis based on current residence in the Middle East (in particular Israel). According to the news, Hamas is scheduled to take over the PA this week and Iran continues to enrich Uranium. My estimation states that this particular risk factor is worth something along the lines of 50 points, leading to a four year prognosis of "God can only save you now". The Rabbis around here tell me he's been doing it for quite a while now.

The Middle East Angle

It would be fun, I thought, that while I reside here on vacation that I should include a "Middle East Angle" in my current posts. So look for this at the end of all the posts over the next two weeks. It should make the whole thing more interesting, or depressing, or downright dangerous!

Maria, Will You Be My Valentine?

The "Internal Medicine" wife, the future intern and I arrived in Israel two days ago so that the in-laws can get a little glimpse of the skills that the intern has so far developed. I believe she may do a back-to-back Lumbar Puncture on both of them for her demonstration tonight.

It probably would have gone over so much better if she didn't catch a virus. This jetlag and a runny nose is a real deadly combination. Hamas would surely love to learn to cultivate this duo for the production of some sort of weapon of mass destruction.

While I dodge bullets on my way to a beach I suggest reading this week's Grand Rounds at Intueri. Maria wrote a very creative Valentine's Day edition. Makes you just want to cozy up next to a fireplace in the twenty feet of snow my parents are complaining about.

Friday Intern Topic of the Day IV: Say you Hate your patient?

As a follow up to the previous post I would like to throw out this as a topic of conversation.

My wife, who is an attorney, recently had to excuse herself from a case after finding out that one of the clients involved is a relative of ours. The law, fearing this could lead to bias, demands that lawyers disclose such information to their clients and, when possible, excuse themselves from the case when such a situation develops.

I often wondered what goes through the mind of Israeli doctors when they are forced to attempt to save the life of a suicide bomber after he has just murdered so many other innocent lives. It happened to this doctor in Iraq and he describes the anger that was slowly building within him:

“The more of the story I heard, the more angry I got,” he said. “But I was still able to do my job and realized I am a professional and I’m going to take care of this guy.

It always ends that way doesn't it? "I'm a professional. I did my job". Well, but all professionals are also human beings who have feelings and exhibit anger and resentment. Can one really, honestly, say that those feelings will have no consequence on the type of care your patient recieves?

In other words, should physicians be forced to dislose when they feel anger towards their patients. And...should they then be forced to sign off the case? After all, we don't even trust lawyers when it comes to simple money matters. Should we trust physicians when it comes to human life?

Seeing Red

The first time we were robbed I was only eleven years old and new to this country. My parents worked harder than they ever have in my short lifetime and they were gone most of the day. We understood that they were trying to build a better future for their kids. Personally, I had special admiration for them.

It’s why my heart wept for them when we walked in on our belongings strewn about on the floor. They had spent a good fraction of their weeks’ earnings that day to take us out to an amusement park in the area. We had a great time. And then we came home.

Money was missing. Our house was a mess. They broke precious items from our past, invaluable diaries of our childhood. I could not imagine anyone doing this to my parents intentionally. They are such well intentioned people.

The second time was even more dramatic. It was another apartment we had moved to and we just came home from vacation. We feared going into the house once we opened the door in case the burglar was still inside but my fathers’ temper got the better of him and he raged inward hoping to take his anger out on a possibly extremely dangerous thief. Looking back on it now, I’m not sure I would ever do that but, at the time, I definitely admired him for it.

The last time was by far the scariest. After a long day visiting family we had arrived absolutely exhausted. My brothers and I headed straight to our bedroom while my parents kept busy arranging the house. As my mother proceeded to the restroom she heard a strange voice from within. She called our names one at a time, hoping for a reasonable answer, but only heard grunts from the inside of the room.

As she attempted to open the door a strong opposing force slammed it shut in her face. Instinctively, I believe she knew what was going on but waited until she called panic. Years later, she told me in confidence, that she did not want my father to attempt to catch him and felt we were all better off if he was simply allowed to escape through the same route through which he entered. And he did, jumping out our bathroom window to the ground outside.

My father chased out with a knife. I, now older, right behind him with knife numero dos. Luckily, the thief escaped and my father kept himself out of jail. We needed him a lot more anyways.

Our emergency room is situated relatively close to a large police precinct. The surrounding area is one regarded as having one of the highest percentages of drug usage and trafficking in the country. All in all, we get more than our fair share of intoxicated patients.

Often, patients addicted to opiates (heroin mainly) or those taking methadone who somehow managed to find themselves arrested end up in our emergency room. They are brought there by the local police who fear they may withdraw from their addiction while in custody. They are there to receive a, just small enough, quantity of methadone to prevent that very complication from happening.

This morning, as my shift was slowly coming to an end, one such character was carried in with a tag along cop for company. “I did tons of heroin in the last couple of weeks”. How much I may ask? “Six to eight bags a day”.

Looking at this poor soul, one hand cuffed to a stretcher railing, I asked the next most obvious question. “That must be really expensive, how do you afford it?”

He chuckled and grinned. Told me how he robs houses for money and valuables which he sells to supplement his healthy diet, which is how he now ended up with a badge for an escort.

But I only saw red.

Memories of fear, resentment, helplessness and hate flashed before my eyes and I felt my upper extremity exert an immense will upon the rest of my body to swing at this pathetic, chinless, wimp of a man. I wanted blood. His head now resembled a large target sign in my hallucination.

I found this part of the past buried within that was simply begging me to let the anxiety, nausea and vomiting that was about to commence erupt unobstructed. I wished for the pleasure of watching his heart race like a thoroughbred on the monitor, to see sweat and saliva engulf and swallow whatever little pride this man had left. Just for a little torture in the form of payback. Do you remember those people in the picture you broke, they were my parents and they didn’t deserve it!

But I didn’t.

Eventually, I gave him his measly dose of methadone, which secretly I hoped was not nearly enough. I sent him and the rest of the cops on their marry way to a cellar. And then I called my mom and she told me of all the cool ways my father made fun of her yesterday.

My parents rock!

Click here for signs of opiate withdrawal. The next post probes the question: Should physicians excuse themselves when caring for a patient whom they dislike?

A Great Doctor

The Cheerful Oncologist gives a speech to the appreciative audience above about the attributes of being a great doctor:

Thank you for that warm welcome. It’s a pleasure to be standing here today in front of such an attentive crowd. As you heard in the introduction our topic today concerns the traits that comprise a great doctor, or as Sammy Davis would say, what kind of fool am I to want to go into medicine?

I counted, I'm 0 for 6.

Grand Rounds

Fresh off the presses, this week's Grand Rounds are brought to you by a biologist.

No Wonder they Call it the Holy Land

Don't worry, the clip is in english.

Friday: Intern Topic of the Day III “Where does Grand Rounds Go from Here?”

An interesting post from this week’s Grand Rounds. It seems the Grand Rounds are getting a little, how shall we say,…Grand!

From California Medicine Man:

Is it possible that Grand Rounds are getting too big? Perhaps those that host it might consider paring down the number of entries that are actually published more? It's getting difficult to separate the wheat from the chaff!

Perhaps we need to decide what the purpose of Grand Rounds should be? To increase the traffic of all who submit entries or to elevate and educate those that come to Grand Rounds to read and learn and gather insight from the many different perspectives represented (Physicians, nurses, researchers, administrators, payers and of course patients).

Personally, I'd opt for the latter. The great thing about the blogosphere is its democratic nature. Traffic comes to those who write clearly and have something to say. Grand Rounds should be one more way of bringing readers to the "best" of the medical blogs. Far be it for me to define what the "best" is. I'm perfectly content to have the criteria for that decision vary from week to week depending on who the host is.

I'd simply recommend that those hosts limit the number of entries on each given week. It's unrealistic to expect that every entry (or given the explosion of medical blogs, even most entries) are of equivalent interest to readers. I'd like to see the hosts worry less about potentially offending bloggers whose entries on a given edition were rejected.

I'm not in any way advocating a form of elitism here. Each blog entry should be taken at its face value for consideration. Each participant in the world of medical blogging should be judged on an equal footing by the hosts.

I think this will move us away from the more superficial objective of simply increasing traffic to our own blogs.

I thought about it for a while and found that the proposal would pose a set of problems:

1. Those who write well, write well: Isn’t it possible, or even probable, that the same bloggers would get picked to be included every week. That instead of Grand Rounds reflecting the medical blogosphere that it would end up being a compilation of the ten, consistently, best bloggers. Wouldn’t that be a contradiction to why carnivals were created in the first place?

I always thought it was to give the small guys a little exposure and maybe, eventually, a bigger following.

2. The blogosphere depends on links: And although I have nothing but the highest respect for everyone involved in putting the rounds together each week. Could the prospect of a lucrative link (big blogger, lots of traffic) loom in the back of the hosts’ mind and, let’s just say, slightly bias the selection process? It’s not double blind you know.

This week’s host addressed the issue on his own blog after the carnival:

When determining what to include in Grand Rounds this week I decided to be ruthless in my exclusion decisions. I excluded posts from many bloggers including those who make up some of my most prominent sidebar links and are on my blogroll (my favorite bloggers). I hope that those whose posts were excluded don't take offense or think that I don't like your blogs. This certainly isn't the case.

No offense taken, my submission was omitted, so what? But I have a level head and knew that I’d been included in the Rounds before, many times. I have a readership, a pretty good one. So I wasn’t offended.

But what about the little guy? If this was the first or second time he/she submits and he gets rejected once or twice, he may just never submit again. Well, he wouldn’t link to Grand Rounds, he wouldn’t support it. Wouldn’t we then be losing readership?

So Nick, whataya gonna do now?

And, what do you think?

Consumer Watch Dog Video

Go check out this animation. It's great and funny, in a really disturbing sort of way. I recommended sending it to Micheal Moore for his upcoming documentary.

Thanks to Consumer Watch Dog for creating it.

Jumble of Falling Musicians

“Nearer, my God, to Thee” was not the hymn played by the ship as the Titanic went down…The band, a brave group if there ever was one, played the “Autumn”.

The hymn ended in a jumble of falling musicians and instruments.

I read this scenario a hundred times over. But that was a scenario and this is you. You are a mother, a wife, a daughter, a provider and many people love you and they don’t want you to die. And I don’t want you to die. And you are dying. Stop dying! Please?

When I entered the room you expected me to save the day. I looked paler than my white coat. Did that make you nervous? Guess what, I was nervous. Underneath this white coat I am only human and as many times as I poke myself it still hurts, I still bleed and continue to be every bit as human as you.

Have you made mistakes before? I’ve made mistakes and continue to make them. Did your mistakes cost another life? Did your mistakes cost someone an arm or an eye? Do you want that responsibility?

Neither do I! Every day I wake with heaviness in my chest. A pressure so immense I have problems differentiating if something is truly wrong. This is taking its toll. I seem slow, groggy? I’m not really. But once you’ve made costly mistakes you really understand the importance of oversight, negligence, error. There really sometimes is only one chance to get it right.

Every day this coat feels heavier and heavier. On occasions, I want to rip it off my shoulders and leave, never turn back. But too much is invested now.

Like watching captains go down with the ship. Cue the orchestra. In many ways this coat feels like a cage.

I feel trapped in my white coat.

I wrote this piece back in November of 2004 for the Chronicles. I am republishing it here as it reflects upon this weeks' previous post.

Woodruff and Vogt: an Update

Feb. 1, 2006 — Nearly three days after surviving a roadside bomb, "World News Tonight" co-anchor Bob Woodruff is slowly being brought out of sedation and will be weaned off a breathing tube in the coming days. The condition of cameraman Doug Vogt, who was also injured in the attack, continues to improve.

Vogt was said to be awake, alert and talking.

Woodruff has increasingly shown signs of consciousness. "He started to wake up more — move his arms and legs and just this morning started opening his eyes"

As per the same NEJM article discussed in the previous post:

At Walter Reed, the severity of a Traumatic Brain Injury (TBI) is assessed according to the duration of loss of consciousness and post-traumatic amnesia, according to Louis M. French, a neuropsychologist who is the DVBIC's clinical director. A mild TBI (which is usually not associated with visible abnormalities on brain imaging) is one that causes loss of consciousness lasting less than 1 hour or amnesia lasting less than 24 hours. A moderate TBI produces loss of consciousness lasting between 1 and 24 hours or post-traumatic amnesia for one to seven days. Injuries causing loss of consciousness for more than 24 hours or post-traumatic amnesia for more than a week are considered severe.

If Woodward is only beginning to regain conciousness now (and not as a consequence of being sedated) it point to a severe form of traumatic brain injury. Vogt sounds like he's in better shape, with reports stating that he is awake, alert and talking.