Saturday, July 14, 2007

Wednesday, June 13, 2007

Diagnosis Wenckebach

Another example of medical students with too much time on their hands.

Thursday, June 07, 2007

G4TV Prankster Sprays everybody

A laugh while you are on call

Sunday, June 03, 2007

TB or Not TB: Isn't That the Question?

The only thing more confusing to me than this tuberculosis (TB) fiasco is how I am still the first to use this line for my title. The antagonist in the international bacterial bruhaha is a young personal injury lawyer who either knowingly or unknowingly flew off to his honeymoon in Greece with a multi-drug-resistant strain of TB (MDR-TB). Actually, the Associated Press reported yesterday that he had an even more resistant strain of Mycobacterium tuberculosis, called extremely drug-resistant TB (XDR-TB). Infectious disease is not my specialty but since when did we start assigning diseases cool prefixes that make them sound like luxury cars? We have heard rumors circulating that the 2008 model will be the YF'd-TB?

So the story goes that an excited newlywed personal injury lawyer goes to the doctor a few days before his honeymoon and is told that he "has TB". Speaker has also said that he was advised by Fulton County, Ga., health authorities that he was not contagious or a danger to anyone. Officials told him they would prefer he didn't fly, but no one ordered him not to, he said.

Let's stop here for a minute. There are really 2 kinds of "have TB"s. There is the positive PPD test for TB in which your body has formed antibodies to Mycobacterium tuberculosis after you have been exposed to it but you are symptom free and otherwise healthy, i.e. latent TB (LTB). Then there is the really have TB in which you are symptomatic, with clinical manifetations usually associated with the pulmonary system. Patients typically present with cough, fever, chills, night sweats, weight loss, bloody sputum, anorexia, etc etc. In this form, one is capable of actively spreading the infection.

Many, many Americans, and even more internationals "have TB" in the former sense and a great deal of them are probably unaware as they have never had a PPD test to detect its presence. And if all of those fliers with latent TB were quarantined, it would probably require a holding room the size of Giants Stadium. But very few Americans with dormant TB ever develop the active form of the disease unless they become immunosuppressed, as in the case of patients with HIV/AIDS or chemotherapy. Moreover, these carriers are not infective to anyone unless the disease becomes active. Lastly, his XDR-TB status does not make his disease any more transmissable than your run-of-the-mill TB, it is just harder to eradicate.

The fact that his new wife and he traveled to Greece makes you think (and hope) that he wasn't hacking up blood-tinged hunks of sputum during his "I do's". Thus, we are making the assumption that Speaker only had the presence of XDR-TB in his blood, making him no different from thousands of other air passengers who travel with latent TB on a daily basis. So what's the big deal? That's what we're trying to figure out. We are guessing all the tumult is a result of him ignoring the Man who told him not to fly.

But where did he get such an uncommon strain of the mycobacteria, that is found much more commonly in Asia and the former Soviet Union? Several reports have claimed that he was exposed when he visited a health clinic last year in Vietnam. We are not disputing that this is a possibility, but it turns out his father-in-law, Robert Cooksey, is a microbiologist for the Centers for Disease Control (CDC) who actually specialized in TB. [The plot thickens...] The same CDC that initiated Mr.Speaker's quarantine - the first of a human being since 1968. In medicine, we have a saying that common things happen commonly and if we follow that theory than it seems less likely that one week in Vietnam accounted for his infection than his chronic and long-term exposure to his microbiological father-in-law.

This is a bold call but we're betting serious money that the wife's father will be investigated and it will turn out that he, too, has XDR-TB (*cue the Law & Order dun-dun). Oh yeah, the father-in-law is the source and he is going down for this in the very near future. Or is he?

Currently, Speaker is taking up residence in a Denver hospital until he is given the green light to travel again. Perhaps we will find out that he indeed does have active TB infection but that will bring up an entire set of additional questions like why a young, healthy man in his thirties develops active TB infection in the setting of a normal immune system. (Dun-dun)

Tuesday, May 29, 2007

Bing Bong, the Myth is Dead

Duuuude (said depressingly), college students across the country just let out a collective gasp (with some smoke) as the World Health Organization (WHO) released a statement today asserting that water pipes are probably as bad for you as cigarettes.

"Using a water pipe to smoke tobacco is not a safe alternative to cigarette smoking," the U.N. health agency said in a seven-page document on the practice. "Contrary to ancient lore and popular belief, the smoke that emerges from a water pipe contains numerous toxicants known to cause lung cancer, heart disease and other diseases."

What? You mean the smoke doesn't get "filtered" as it makes that bubbly sound coming through the water? That really smart dude at the end of my hall freshman year explained the whole thing. I remember because he kept talking through the best part of Fluffhead.

But all is not lost, because the WHO really only referred to tobacco products and the use of hookahs - not 3-foot glass tubes with witty names. So maybe it is still true.

Also, those scientists did deliver some positive news for those water-pipe smokers out there: The agency said a person can inhale more than 100 times more smoke in a hookah session than in a single cigarette.

This Is Really Your Life

Only one day after my site,, wrote about a busted Pakistani organ-harvesting ring, news comes from Holland that a new reality show is inflaming medical ethicists all over the world.

The bioethics committees of the world must be really sitting around those tables and philosophizing now. Discussing and mulling; reviewing and reiterating; talking and talking and talking -- all about kidney transplants.

What exactly has their undergarments in a bind? A Dutch reality show plans to have three people compete for the kidney of a terminally ill 37-year-old woman. While viewers at home can register their opinion as they learn about the hopeful recipients, the ultimate decision will be made by the donor herself. So what's the big fuss about? What is so strange about a woman dying of brain cancer auctioning off her kidney to three strangers all on Dutch national television?

Ok. We do see why it could be construed as objectionable of The Big Donorshow (that title is not a joke), but the show's network, BNN, argues that the show highlights the shortage of organ donors and is a tribute to its founder, Bart de Graaft, who died of kidney failure five years ago despite several transplants.

Dutch newspaper De Telegraaf felt differently: "It is a sickening attempt to turn a serious subject about life and death into a form of entertainment, rather than a serious new attempt to try and get more donors," they said in an editorial.

The government has also spoke up about kidney disease becoming the next reality star: "The intention of the program to get more attention for organ donation may be applaudable," quoted Dutch Education and Culture Minister Ronald Plasterk.

"However based on the information I now have, the program appears to me to be inappropriate and unethical because it is a competition," said Plasterk.

While we agree that any attention given to the subject of organ transplantation and donation is probably good attention, we also agree that this may not be the best way to spread the word. It may, in fact, have a negative impact on those who were considering donation as reality shows do not exactly lend credibility to their subjects (see: every reality show ever - except, maybe, The Biggest Loser).

Sunday, May 27, 2007

Organ Vendors

In Lahore, Pakistan yesterday, 6 people were arrested, including 3 doctors and the owner of a private hospital, after authorities identified them as key participants in an illegal kidney transplant "ring"? Can we even call it a "ring"? I'm not sure what one would call that.

Authorities in eastern Pakistan said that many men, like the ones seen here with healing nephrectomy scars, are selling their kidneys on the black market for about $1000 to pay off debts.

Turns out that rumors of people selling organs on the "Black Market" are quite true - as if there was a doubt. They may not be waking up in a bathtub with a note on the wall written in blood but whenever medicine is practiced secretively corners are cut (no pun intended) and there is usually little recourse for those under the knife.

It does bring up an interesting question, though. If done safely and properly, what is the harm of selling an organ that you can safely live without in return for monetary compensation? Before we continue the dialogue though, let me clarify that I would never, ever advocate such a practice - unless, of course, it was sanctioned by our federal government and overseen by a tightly controlling administrative body with all the proper governmental bells and whitsles, etc etc.

That said, the benefits to private citizens selling kidneys could, if done properly, save billions of dollars in the United States alone - not to mention thousands of lives. Hundreds of thousand of kidneys fail each year and patients often end up on chronic hemodialysis, despite the fact that renal transplant is the treatment of choice. Dozens of studies have shown that a successful kidney transplant improves the quality of life and reduces the mortality risk for most patients, when compared with maintenance dialysis. Chronic renal failure is a major cost burden on our health system and also brings with it or accelerates a slew of other concomittant diseases, like coronary artery disease, heart failure, hypertension, liver disease, stroke, and on and on and on.

In the US, there is an ever-rising incidence and prevalence of kidney failure and the number of patients enrolled in the end-stage renal disease (ESRD) Medicare-funded program has increased from approximately 10,000 beneficiaries in 1973 to 86,354 in 1983, and to 452,957 as of December 31, 2003. Impressive? How about this: The total cost of the ESRD program in the US was approximately $27 billion. Now, of course, not all of these patients who are maintained on dialysis would be candidates for a transplant, but if we had more kidneys, we would also be able to loosen our restrictions on who can and who cannot receive a kidney. Restoration of renal function to these patients not only changes the way theiur kidneys function but allows these patients to get back a significant portion of their life that is spent sitting in chairs receiving HD for 3-4 hours thrice weekly.

And what of the seller's role in all of this? Healthy kidney donors actually function quite well with one kidney. Is it better to have a back-up? Of course. But perhaps the seller really needs the money for his own health or children or whatever. We allow people to sell everything and anything in this country, why not body parts? In order for one to give up body parts , they actually have to be dead. And they don't even make any money from it? [Which brings up another interesting question? If they paid families for the organs of relatives that passed away, would the frequency of organ donation increase?] What about American football players? Are they not indirectly selling their body parts for a salary? A knee? A shoulder? A brain?

Another potential benefit to the practice of buying and selling kidneys on the free market would be the negative impact it would have on the so-called "black market". The desire to seek out dingy hospitals in the Third World to avoid waiting on the transplant list would be quelched if you could do the same thing at a strictly regulated American hospital.

In 2002, Charles Erin an John Harris put forth a rough sketch of how they thought this could work in the Bristich Medical Journal:

The bare bones of an ethical market would look like this: the market would be confined to a self governing geopolitical area such as a nation state or indeed the European Union. Only citizens resident within the union or state could sell into the system and they and their families would be equally eligible to receive organs. Thus organ vendors would know they were contributing to a system which would benefit them and their families and friends since their chances of receiving an organ in case of need would be increased by the existence of the market. (If this were not the case the main justification for the market would be defeated.) There would be only one purchaser, an agency like the National Health Service (NHS), which would buy all organs and distribute according to some fair conception of medical priority. There would be no direct sales or purchases, no exploitation of low income countries and their populations (no buying in Turkey or India to sell in Harley Street). The organs would be tested for HIV, etc, their provenance known, and there would be strict controls and penalties to prevent abuse.

So what is the argument against allowing citizens to sell organs in a controlled and organized fashion? I suppose that it might pose a significant health risk in that there is a surgical organ extraction and that later on down the line there might be an additive health risk associated with having one kidney or half of a liver. Actually the short-term complication rate of kidney donation has hovered around 20%, while the mortality rate is less than 1%. Moreover, the risk of chronic renal failure amongst those donating their kidneys is equal to that of the general population.

Perhaps people have a "moral" objection to the business of body parts? But synthetic or manufactured body parts are okay - just not organs that come form a living human?

Some have argued that the rich will benefit while the poor will continue to suffer and be more likely to represent the majority of organ sellers. And that differs from the current system how? No matter what schema or health care plan we use in this country, those with money will always obtain "better" (i.e. more expensive) care because they can pay for it, and ostensibly they have a higher level of education enabling them to ask the right questions and find the right people. However, if anything, legalized organ doantion levels the playing field as more organs will become available and a regulated system of organ procurement will prevent those with all of the advantages ftrom taking advantage.

Buying and selling of human organs is not a new topic of discussion. It is a popular topic of conversation in the medical literature - especially amongst those in the University and Hospital Ethics departments, where procrastination and idle discussions are a favorite pasttime.

The truth is, this would never happen in the U.S. - not becaue it is wrong, but because we value opinion and discussion and democracy. And there are just too many people that would make fighting this their cause. For what reason? Your guess is as good as mine, but if you doubt it, just look at how stem cell research - probably the most promising new technology of our century - has fared. Literally stifled by the President of the United States. And I have never heard him speak intelligently about that.

Thursday, May 24, 2007

Top 5 Worst Hospital Jobs

1. Sharps Box Changer Guy – This guy is just plain crazy. His task in life is to remove plastic containers overflowing with butterfly needles and discarded IV’s contaminated with Hep C, HIV, and God knows what else. These guys should have a reality show and carry anti-viral medications in their pocket. The funny thing is that these guys never seem to wear any protective gear - I’d be wearing steel gloves and a football helmet.

2. Nurse’s Aid -
It is difficult to imagine that there is a worse job in the world, let alone the hospital. A typical morning will involve weighing six to eight combative and/or demented patients. Then comes “bathing” time, in which the term “bathing” is used loosely; then re-cleaning them 30 minutes later when their Dulcolax has kicked in. This is often followed by the business end of the “Out of Bed to chair” order in which they get to lift the patient to a geri-chair. Finally, the shift ends with a round of vital signs. The only thing smaller than the qualifications needed for this job, is the pay that they receive. But at least they have their union.

ECG tech – Can you imagine a worse job than removing 20 patients’ gown(s), getting all up in their chest fat and breasts, and occasionally shaving excessively hairy individuals in order to paste on some stickers? Welcome to the wonderful world of the ECG technician. The best part? They get to it again 3 minutes later when they have to remove the stickers. And then come back the next day and repeat the process. Wanna really be grossed out? Stay tuned for our upcoming documentary: “Things Found in the Folds – the Story of one ECG tech and his battle to leave his job.”

4. Laundry –
Ever wonder where those melena-laden sheets go after they’re thrown in the soiled utility? These people don’t. They use to smell them coming down the laundry chute but lost their olfactory senses a long time ago as a protective measure. Blood, shit, puke, urine, and all other bodily secretions end up in the laundry and these brave souls remove them. God bless them.

5. Intern - Take all the jobs above and add phlebotomist, proctologist, transporter, and general, all-around hospital bitch. That's an intern.

Tuesday, May 22, 2007

Tough Break for Paula

Someone above is looking out for StopPagingMe. We have been looking for an excuse to talk about the upcoming finale between the Keane-like, beat-boxing Blake and the smiley, It-factor-laden Jordin.

Our excuse to come clean about our Idol affinity came in the form of a broken nose. Not just any nose either, the nose of our favorite supportive and sedated judge, Paula!

According to numerous reports, the oft-slurring Abdul was trying to avoid her dog and wound up taking a nasty spill, telling Extra that she tore cartilage in her nose and broke a toe. Ouch! The dog was okay, though.

Paula has a well-documented history history of pain killer affinity so hopefully she was premedicated.

Getting medical though, schnoz fracture is the 3rd most common break and the most commonly broken facial bone. As in Paula's case, blunt trauma is the most common cause (85% of cases) but the management is by no means straight-forward or easily agreed upon. One can be sure though, that if there was some significant damage, the physical exam portion was not comfortable for the former Laker Girl.

In case your interested, here are the indications for open and closed reduction of the nasal fracture from eMedicine (feel free to skip right by it):

Closed Reduction:
Unilateral or bilateral fracture of the nasal bones
Fracture of the nasal septal complex that is deviated less than one half of the width of the nasal bridge
Indications for open reduction are as follows:
Extensive fractures
Deviation of the nasal pyramid greater than one half of the width of the nasal bridge
Displaced fracture of the caudal septum
Open septal fracture
Persistent deformity after closed reduction

Ice packs and head elevation are the mainstay of treatment in the majority fo cases. If the reduction is not going to be done that day, then a period of 3-5 days precedes further evaluation. Fractures that are not displaced do not require treatment. Because as many as 30% of patients have a deviation that was present prior to injury, in many cases, obtaining photographs for review is helpful. God, woudl we love to see those pics - where's when you need them?

Other famous broken noses?

Remember when Geraldo sported his massive rhino-dressing?

Or how about when Cameron Diaz dinged her sniffer while surfing (she had a nice rhinoplasty following).

And then there's this guy. After a surgical repair for nasal trauma they used leeches when the graft was failing. Ok, it has nothing to do with Paula's accident but it's cool nonetheless (we are doctors, ya know?):

Tuesday, May 15, 2007

The Mighty Have Fallen

Crusading televangelist and father of the Christian Right, Jerry Falwell, has passed away.

CNN is reporting that Falwell was found unresponsive in his Liberty University office and despite aggressive resuscitative measures, could not be revived.

Falwell founded the Moral Majority in 1979 and is a nationally known voice for conservative Christian views.

The Associated Press reported that Dr. Carl Moore, Falwell's physician, said the evangelist had a heart rhythm abnormality. Most likely, this is atrial fibrillation for which Falwell probably took a blood thinner, i.e. warfarin (Coumadin).

While this may not have helped things, a-fib was almost certainly not the cause of death. Much more likely was the pastor’s history of coronary disease for which he had a stent placed in 2005.
When someone dies suddenly it is typically classified as a sudden cardiac death (SCD) and SCDs are usually the result of a very fast and unstable heart rhythm like ventricular tachycardia (VT) or ventricular fibrillation (VF).

Thursday, May 03, 2007

Doctors Sue Back

According to the Associated Press, a group of doctors has filed suit against the state of Louisiana seeking $100 million they say they are owed for providing free care to poor and uninsured patients following Hurricane Katrina.

In all, 381 physicians at West Jefferson Medical Center, says the state failed to reimburse them for treating indigent patients since the Aug. 29, 2005, hurricane closed the state-funded Charity Hospital in New Orleans.

Despite many years of poorly reimbursed training, excessively long hours, and thousands of dollars in loans, you would be hard-pressed to find anyone crying for doctors. And I’m not saying we should start the water works just yet. But I am proud of my fellow colleagues for standing up for themselves and not simply accepting the role of martyr while everyone else collects a paycheck. I am quite sure the rest of the hospital staffers and administrators got their compensation – the union would make sure of it.

For years, physicians have taken a passive role in their reimbursement for a number of reasons. Firstly, they rightfully believe that people must be cared for regardless of compensation and like me, have a slight complex about “fighting” for money. Next, by convention, doctors are hard-working individualists who have to deal with complex billing systems and shrewd insurance companies. This makes for big trouble when trying to advocate on their behalf. Lastly, no one cries for doctors as most are quite comfortable.

It was probably a very difficult decision to sue the state of Louisiana after such a tragedy and I am sure it was not an easy undertaking to get these physicians to sign on. Many will scowl at the thought of doctors suing – as if they need the money. Evidently, they do. And they are not suing the indigent who received care, they are suing the state that is supposed to provide for their constituents – rich and poor, black and white, blue collar, white collar or no collar.

I am (quietly) proud of these physicians for taking a stand and not becoming the good martyrs in this instance. They trained long and hard for their degree and the privilege to call themselves physicians and they deserve compensation like everyone else. Chalk one up for the white coats – at least until the next billing scandal.

Friday, April 27, 2007

Top 5 Medical Movies

From St.Elsewhere to Grey's Anatomny, and all the o­nes in between (see: Chicago Hope, Strong Medicine, ER, etc, etc), television MDs have been all the rage for as long as we can remember. But how about their silver screen equivalent? While medical TV has been a staple o­n Primetime year after year, the Big Screen has been suspiciously devoid of doctoral cinema? There have been a few good o­nes over the years, and the staff at have combed through hundreds of movie titles to give you the best that Hollywood has to offer.

1. M*A*S*H (1970). No, not the TV show! Most people don't realize that this is o­ne of the few instances where a movie's small-screen spin-off overshadowed its hilarious, Oscar-nominated, big-screen original. Elliot Gould (Trapper), Donald Sutherland (Hawkeye) and Robert Duvall (Frank), play surgeons during the Korean War in an era where politically incorrect was correct, and doctors and nurses stilll "fraternized." Finally hear the words to the famous theme song, laugh continuously, and think of your own Methylene Blue prank.

2. AWAKENINGS (1990). Robert DeNiro plays a catatonic schizophrenic, and Robin Williams play his socially phobic psychiatrist in this emotional roller coaster of a movie. When Williams' character discovers a drug that brings his patients back to life, irony ensues, as DeNiro teaches the doctor about what living really means. Having been "awakened" for o­nly a few weeks, DeNiro swims in the Bronx waters, falls in love, and nearly starts a rebellion within the institution. The drug's effects are short-lasting, making for a Algernonian ending, but the lessons he teaches the psychiatrist are forever.

3. FLATLINERS (1990). What do you get when you cross Kiefer Sutherland, Kevin Bacon and Julia Roberts with Billy Baldwin? 3 future A-list celebs and 1 celebrity mole. See these actors before they were truly big-time in this thriller about medical students who are killing, and then reviving themselves, all in the name of research- and "thrillerology." Although, I didn't exhaust Medline, I'm pretty sure I never saw an abstract like that. I'll bet it would make for interesting conversation during your fellowship interview, though.

4. DEAD RINGERS (1988). As if o­ne Jeremy Irons character isn't weird enough, he plays TWO identical twin gynecologists in this bizarre, and highly-acclaimed film. This suspense/horror/fetish flick makes the list o­n its originality alone. And it's got nudity.

5. GROSS ANATOMY (1989). Not since Vision Quest, has Matt Modine inspired me so much. Although he's not wrestling "Shoot" for the state title and runnning in a shiny silver suit to make the weight, he's studying his way to his MD in this Saturday Afternoon Movie-type flick. A boy from the wrong side of the tracks rejects the ways of his stressed out, cut-throat colleagues, and shows them how it can be done without being such toolboxes. Some eerily accurate, and identifiable, pre-test stress is portrayed- but Modine's character represents the guy/girl that every college freshmen wants to be until they realize that, in med school, you need to be a tool box to get by.

Monday, April 23, 2007

Sky Mall "Medikal" Merchandise

On a recent plane trip home from Hot-lanta, where we endured 3 days of non-stop lecture about cardiac ultrasound, our brains were not up to discussing any politically incendiary health issues. However, we did get a good laugh from the ever-entertaining SkyMall catalogue. Please to enjoy...

1. Millenium Water Oxygenator - Wow. This one is a truly special medikle bargain. For just under $900 you can have all your water with extra oxygen. Because H2O needs more O? HealthyConnections, which asserts to bring you the very best in wellness is bringing you a lot of hot air with this item. I can just picture the somatizers of the world gathering together to praise the wonders of hyper-oxygenated water - and kabbalah. It's worse than those oxygen bars where people hook themselves up to a nasal cannula as if it's doing anything. Maybe our failing hospital systems should start offering cheap oxygen to these hipster doofuses that beleive it actually has an effect?

2. The Headache Glove - HealthyConnections has evidently been hitting the O2-water pretty hard. They also offer a bona fide headache cure based on "ancient Chinese acupressure techniques with modern technology." Intrigued? Don't be. It is a $100 inflatable glove with a pump attached that squeezes your hand when you have a headache. For $15, will call your friend to come over and kick you in the groin next time you have a headache. We promise similar effects.

3. Head Spa Massager - The catalogue's title for this item compels you to "enter a state of euphoria". Gadget Universe, clearly a dynamo of quality products, rubs our editors the wrong way with this helmet-esque device that promises to "relax and soothe your problems away." Let us just say that, medically, if you are buying a metallic Viking helmet that plugs into a wall to make your problems go away, you might have bigger issues, i.e. think about trying drugs. The blurb next to the item claims that it's like thousands of tiny fingers massaging your scalp at once. Ewwww.

Link to a YouTube video of a demonstration:

4. iCarta Stereo Dock - Talk about crappy music! This Charmin-holding iPod dock hails from the illustrious Sky Mall Collection and the description proclaims it the "King of All iPod Docking Stations". Firstly, we were not even aware there was a monarchy associated with iPod docks; if there were, what a sad world where the King has to also hold toilet paper. For $99.99, you can take your iPod to places where few have gone before - just make sure to disinfect it frequently.

5. Inversion Stretch Station - Found in the FootSmart department of the SkyMall is one of our favorite "medikel" items - which is our euphemism for anything that presents itself as a therapeutic device, has no proof of its benefit to humans, and probably does more harm than good. The Inversion Station is a first rate example of this. They boast that Hippocrates, himself, prescribed this noninvasive method of treating back pain. Wow, you mean an ancient physician from 400 BC said that hanging upside down on a metal triangle was good? He also held that all illness was from an imbalance of the four humors in the body - blood, black bile, yellow bile and phlegm. Nice.


Pop-up Hot Dog Cooker - Ok. It has nothing to do with medicine or health care but it's a classic. Hammacher Schlemmer cooks up this Sky Mall treatfor the tasty sum of $49.95. It's graced the pages almost as long as the Giant Crossword Puzzle and is about as useful. If you are someone who has trouble boiling water or using a standard toaster-oven than this is the device for you. It has two circular slots for hot dogs and two oblong slots for buns - be careful not to confuse them and cram the buns where the meat should go.

Friday, April 13, 2007

Surgeons Repair Croc-Severed Arm

That is a real 400 lb crocodile. And someone's real coarsely amputated arm. The crocodile is a resident of the Shoushan zoo, in the southern Taiwanese city of Kaohsiung, and the arm belongs to Chang Po-yu, the zoo's veterinarian.
The croc doc had not recognized that his patient was not completely anesthicized and when he tried to retreive a syringe from the reptile's hide - whammo. The vet was rushed to the OR table and his arm was clode behind, as shown in this fairly intense video.

After six hours of surgery, the skilled Taipei surgeons successfully reattached the Po-yu's arm. It is really cases like these that make you proud to be a physician. That doctors and emergency staff can work so efficiently and effectively togther as to reconnect a man's arm that was torn off by a friggin aligator (crocodile, whatever) - it is amazing!

Bacterial contamination of the arm has got to be a serious concern as it was recently sitting in the mouth of a huge-toothed beast that routinely eats raw flesh and wades around about 3 inches off the ground. Also, the life span of nervous and vascular tissue exposed to the air (and that mouth) cannot be very long.

That is not even taking into consideration the massive surgical cahones you have to have even to be able to re-anastamose shredded arteries and veins and muscle and bone and skin!! How great are those guys!

I think we should start efforting for an interview with these surgeons to ask them exactly how they performed this medical feat. We're on it. Does anyone know Taiwanese, though?

Wednesday, April 11, 2007

StopPagingMe's Kick in the RSS

Bush: A Champion of Inhibiting Science

He did it before and he'll do it again. Ask out President for anything and he will say 'yes'. But ask him to allow federal spending on the hottest field in scientific research and he will dust that veto card off quicker than you can say 'Christian Right.'

For only the second time in his two terms, Dubya is poised to block a Senate-supported bill that would lighten up on embryonic stem cell research restrictions.

I am so curious to know whether this vendetta against embryonic stem cell research is Dubya's personal opinion or urging by his party? When the leaders of virtually every major scientific institution and academy, including the guy he picked to head the NIH, agree that more federal monies should be spent, how much guts (or stupidity) do you have to have to say 'Eh, what do they know.'

Imclone Gets Theirs

Imclone, a compnay that has based the majority of its eraning potential on one chemotherapeutic agent, Erbitux, presented disappointing study data with regard to treating metastatic and nonsurgical pancreatic CA.

The stock was down more than 7% on those results.

"We still consider pancreatic cancer to be of the utmost priority, and we intend to pursue additional evaluations with Erbitux including a pilot study of Erbitux and bevacizumab with or without gemcitabine, as well as our pipeline agents, to improve the outcome for patients with pancreatic cancer," stated Eric K. Rowinsky, chief medical officer and senior vice president at ImClone. always ragged on Imclone's prospects as a viable investment since Erbitux seemed to be their one and only earner - without any evidence of a viable pipeline. This might be the beginning of the end for the company that put Martha Stewart in the clink.

Add Chocolate to the List of Foods That Heal?

Every day there is a new story about some food that is either helpful or harmful. For some reason, the media selects these small and often clinically irrelevant studies because it relates to food. Today, the healing food du jour was cocoa. An article in the Archives of Internal Medicine reported that those patients who ate chocolate for at least 2 weeks experienced a drop in blood pressure that was significant compared with those who did not.

If this is what you need to go ahead and eat that KitKat, then justify away. But don't think that you are doing a good thing. For every millimeter of mercury that you drop in blood pressure you will have an equal rise in blood sugar, fat grams, and likelihood of developing Type 2 DM - not to mention waste size and fold number.

Smoking Out Dementia

So, if you trust the RSS feeds, chocolate is good for you in the middle of life when you're battling hypertension but how are you going to stave off the pill-rolling tremors, masked facies and dementia of Parkinson's Disease (PD)?

Easy - smoke up Johnny!

The big brains at Duke University studied relatives of Parkinson's patients and discovered that those who smoked regularly and drank coffee were less likely to develop PD then their squarer relations.

Coffee we are not really too concerned about, but giving positive reinforcement to smoking to avoid PD is like supporting guns to avoid stabbings. While not based on any scientific evidence one has to be curious whether long-term smokers who make it to a Parkinsonian age without developing other significant (smoking-related) diseases might be genetically superior in some fashion?

And Finally...

In case you missed it, Larry Birkhead is the dad. And was anyone else as disturbed as we were by that picture of him with his arms raised in a 'V' like Johnny Drama? What exactly did he win that he should be celebrating? 'See America? I am the father of a tragic, deceased, diet-pill-model's daughter. And I will spend the rest of my days chasing money in courts. I am the champion."?

Saturday, April 07, 2007

Enough is Enough: Cruise Goes from Bizarre to Retarded

What is going on in this world? It's not enough that Tom Cruise has more money than most small countries, but now Maverick is using it to exploit some scientology-based, bullshit treatment for 9/11 workers.

And no one is writing a thing.

The self-proclaimed president of the L. Ron Hubbard fan club (aka Hubheads) is on a fundraising mission as co-founder of the New York Rescue Workers Detoxifixation Project. Sounds legit, huh? They are advocating an untested, unreported, pseudo-medical, regimen created the by Hubbard, himself, who is about as qualified to treat toxic exposure patients as Snoop Dogg. Tickets for the April 19th gala, which will star Cruise, run as high as $100,000 for a table for eight.

And still, no one is saying a thing!

It would be one thing if Cruise preached this crap in Los Angeles where star status sometimes takes precedence over common sense and practical thinking. But he is spewing this garbage all over what I consider to be the greatest (and toughest) city in the world - a city that suffered a great tragedy but rebounded magnificently. A city that is world-renowned for its medical prowess and internationally-touted physicians and surgeons. A city that does not hide its opinion or tolerate crap from anybody.

And despite all of that - not a peep.

This detoxification process that Cruise is hawking consists of high doses of niacin, moderate aerobic exercise, intermittent dry saunas to "force sweating", and of course, vitamin supplementation. As medically sound as it seems (can you hear the sarcasm?), the detox regimen has never, ever been reported to yield any positive health effects. It is not cited in PubMed, you will not read about it in any medical journal, and it has never been reported in a case series, let alone a randomized control trial, demonstrating any therapeutic or clinical benefit.

Yet no one has come out publicly to say that this might even be harmful to men and women who made a great sacrifice for our great city.

Well, let us be the first with a medical background to shout loudly that this is a huge load of Scientologic excrement. If Travolta and Cruise and all of the other Hubheads want to donate money to the 9/11 workers, why not consult with the Mayor and ask where their dollars could be most helpful? And why hasn't Bloomberg, who usually does not hesitate to share his pragmatic opinions, weigh in on this matter?
It is completely irresponsible to offer a sham therapy in the hopes of converting some desperate folks and Cruise should be admonished for hocking his Scientologic mumbo jumbo. If he could offer even a shred of scientific evidence that this would benefit 9/11 workers we would not be so outraged but the only proof he can offer is his vacant grinning face and a wealth of scientology preachings.

Medicine in this country has shifted over the past twenty years to lean heavily on the evidence and base treatment on what has shown clincal benefit in large, multicenter trials. As physicians we have a responsibility to have an open mind but always fall back on the evidence. I have no problem with holistic forms of therapy and even placebo has shown actual clincal benefit in many forms - but using a hypothetical detoxification program to recruit new members and make promises of wellness reeks of dishonesty and ignorance.

So we said something.

Wednesday, April 04, 2007

The Price of Doctoring

What the f$#% is up with the ever-increasing price of study materials, test prep courses and the exam fees? Can we get a break anywhere? The test-taking business has become a lucrative for-profit industry that has ended up costing medical students and residents, already strapped by ridiculous loans, huge amounts of money.

Aren't preparation for national Board exams and USMLE tests the responsibility of medical schools and residency/fellowship programs? That's the deal we make with our benevolent program directors - we work like dogs for crappy pay and they provide us enough education to pass our tests. Lately, one party is not living up to their half of the bargain - and last time I looked residents' pay still sucked.

Prior to becoming the financial boon that it has become, the purpose of these tests were to assess the knowledge base of graduates and assure that those graduating physicians were studied enough to make reasonable decisions. Now they have become just another money-draining requirement along the way to becoming a "real" doctor. Why we need to pay hundreds of dollars just to take the test and thousands more for the numerous books, courses and additional fees is beyond me. Essentially, we're paying to be tested after paying to be educated.

When the vast majority of medical trainees are taking out more than $100,000 in loans just to attend medical school and then scraping buy during residency, they should not have to pay additional money out of their own pocket just to pass a test.

Perhaps no one ever talks about this because so many professors actually get paid by these test prep courses to teach these prep classes. But education has become exhorbitantly expensive and many of the readers of our website, an online community of medical students and residents called, have echoed similar sentiments. Which is a nice way of saying that they don't stop bitching about paying $700 to take their medical licensing exam.

One partial solution could lie in our fantastically logical idea we fondly named: The Generous Professor Series. What is this, you ask? We have begun asking our (and your) favorite professors to make donations in the form of Boards-style test questions in their respective specialty. Of course, we credit them for their generosity and they are listed as one of the authors of this altruistic endeavor. When we have gathered enough questions in a particular residency or medical school specialty (e.g. anatomy, pathology, internal medicine) we will sell them online for super-cheap and force all of those overpriced study guides and Q&A books to match our quality and our price. This will get done much faster with your help, so if you think you're into the Generous Professor project, click here to WRITE us and start contributing questions ASAP.

The outcry against pharm reps has been a grassroots success against a major industry trying to penetrate the medical training field. Our opinion aside, a united medical student and resident voice has shooed may reps right out of their hospitals. Perhaps affordable and responsible education should be the next great cause. We don't even have to give up free lunch for it.

Monday, April 02, 2007

Medical Hospital from "Acceptable TV"

Fantastic parody from the peeps at Acceptable TV. Best line: "He's bleeding from a gunshot wound. I need 20 cc's of medicine."

Monday, March 19, 2007

The Real March Madness

Forget bracketology and Dickie V's Final Four-cast - this madness is for real. Real jobs, real patients, real pain and suffering in the near future as the dreaded internship year begins to come into focus.
Monday, March 19th was a huge day for more than 20,000 medical students across the U.S. These future physicians learned at which hospitals around the United States they would be tortured for the next 3 to 8 years.
All the pictures we find on Google Images are of people hugging and smiling and laughing so we want to let those of you who are not doing those things that it is okay and you will be fine. The majority of applicants do not get their 1st choice and still end up doing wonderful things. I've always thought that it would be an interesting study to survey each specialties' thought leadrers to see how they fared in the The Match.
If you did not get your first pick or even your third pick, take it form us: it all works out in the end. What you thought was the best thing as a MS4 may not really be the best thing as a PGY-4,5 or 8. Residency, like everything else in medical training (and in life is what you put into it and you will find good and bad people whereever you go. If it turns out that you hate your instituion after a full year, you can always change.

So congratulations to all of you newly minted interns and let us be the first to inform you that there are some very psyched soon-to-be-PGY-2's ready to exert some influence.
Unfortunately more than 6,500 students, mostly at schools based outside of the United States got the news that they did not match earlier in the week. They were forced to suffer through the aptly named "Scramble" where the unmatched call, e-mail, and beg programs with unfilled vacancies to accept them - hardly a prideful moment for students who have worked so hard. Some succeed, but the process is pure torture regardless and seems quite antiquated considering the current state of technology and the fact that we are no longer scribbling on rock tablets.

Remember one thing, newly minted residents: the field you have chosen may look very different 18 months from now. If that should happen, you CAN change your specialty. Have the courage of your convictions. You can check out OpenSpots and have a look-see. You will not be alone. Chances are, you will stay in your specialty, you just have to get through the grueling years of long hours and no respect from higher-ups, nurses and patients. But remember, your mother loves you no matter what!
Now go out, get drunk, and play doctor!

Saturday, March 17, 2007

Larry King Recovers from Cartoid Surgery

When it rains, it pours. And this week it was pouring 70-something talk show hosts with serious vascular issues. First Regis and now Larry King. Charles Grodin and Charlie Rose better pack a bag.

While Reege is hopefully thinking about discharge, the 73 yo King is fresh out of a carotid endarterectomy (CEA) and his camp says he'll be back by Monday to interview Sen. Barack Hussein Obama (that name is like a SNL joke - he couldn't have worse luck if his name was Stalin Bitler).

Larry King is no stranger to vasculopathy and has a history of 4-vessel CABG way back in 1987. Which also implies that he has probably had subsequent cardiac caths to open of some grafts or possibly even an ancient native vessel. King's propensity for vascular disease makes one wonder what risk factors he wields.

It is very likely he is hypertensive and most certainly takes a statin for high cholesterol. Is he diabetic, too? Probably not - all those years of poorly controlled blood pressure, cigarettes, drugs?, and booze is most certainly enough to give you the old coronary-carotid double feature.

Prior to surgery King definitely had a carotid ultrasound to assess the degree of stenosis. The question is, did symptoms prompt this vascular study or was it a smart doc who knew the talk show host's propensity for vascular atherosclerosis? Either way, he had enough of a lesion to dictate that medical therapy, compared with surgical revascularization, would be more likely to result in a stroke or even death.

What about his outcome? Well, all of the following characteristics have been associated with an increased risk of poor outcome (stroke, myocardial infarction, or death) at 30 days after CEA:

  • Age 80 or older
  • Severe heart disease
  • Severe pulmonary dysfunction
  • Renal insufficiency or failure
  • Stroke as the indication for endarterectomy
  • Anatomical issues including limited surgical access, prior cervical irradiation, prior ipsilateral CEA, and contralateral carotid occlusion
Surgical Methods

Carotid endarterectomy (CEA) is most often done through a neck incision either bordering the sternocleidomastoid muscle, or more esthetically, with a horizontal incision in a skin crease at the level of carotid bulb. Either way, the scar will be small and discrete enough to be covered by a good layer of pancake, so don't expect to see it on Monday unless King wants you to.

The underlying platysma (muscle) and sub-Q tissues are dissected and the carotid artery is isolated, from the common carotid to well beyond the bifurcation of its internal and external branches. After proximal and distal control of the artery is obtained, the patient is given anticoagulated. The internal, common, and external arteries are then clamped sequentially and a the artery is opened at the level of the bifurcation and extended proximally and distally. Some surgeons use a cerebral shunt which is inserted at this time.

The carotid plaque, consistently found at the carotid bifurcation and the origin of the internal carotid artery, is dissected out and removed through a dissection plane developed between the media and intima. Surgeons take great pains to create a smoothly tapered transition between the endarterectomized portion of the artery and its normal distal extent. This maneuver avoids intimal flaps which might lead to arterial dissection after flow is reestablished or perhaps become a nidus for platelet adhesion and thrombogenesis.

After careful inspection of the now clot-free surface, special attention is directed at repair. Some surgeons choose to repair primarily, while others patch the artery with saphenous vein or prosthetic material such as Dacron or polytetrafluoroethylene (PTFE).

Before the artery is closed, the internal carotid artery (ICA) is unclamped distally and flushed free of debris in a retrograde fashion. This vessel is then reclamped and the common and external arteries are opened. This way, all the left over aretreial "gunk" is jettisoned via the external carotid artery prior to restarting antegrade flow, i.e. that blood which goes to the brain. This technique is based on prior experience showing that patients were coming out of surgery with new neurologic events despite the best efforts of the surgeons to remove all the plaque adhered to the wall of the artery. [Interestingly, when carotid stenoses are done percuatneously, i.e. by catheter, interventionalists use a distal occlusion device to prevent embolic events. However, the interventional community is having a tough time showing benefit, or even equivalence to CEA.]

Once hemostasis is achieved, a Jackson Pratt drain is left in the wound to minimize neck hematomas and the muscle and skin are closed. when King was waking from his anesthesia, a neuro check was performed and repeated probably every 10 mins for the first hour and then every hour during recovery to make sure the talking head wasn't slurring as a result of the arterial manipulation.

Below is a sweet slide presentation we found that provides a step-by-step approach to carotid surgery.

Wednesday, March 14, 2007

Cure for Your Match Day Blues

Here's what happened when we searched Google images for "The Match". Hopefully, you felt - not necessarily looked - like this guy on Monday, and not like the pic we didn't post of the girl with her head in her hands.

On Monday, March 12th, 4th year medical students all over the United States logged on to find out whether they did, or did not, match into any residency program.

For those of you who did not raise your arms with joy, keep the faith - at least you're not that dude in the picture. Also, if you want it bad enough, there are plenty of things you can do to improve your chances of matching next year or even filling an OpenSpot later on this year. Here are 4 courses of action to start:

1. Find somewhere to do research. But do your research first. Unfortunately, toiling under the assistant biochem tecaher's assistant most of the year will not serve you well. However, working for the assistant program director may yield great results.

2. Call Around - Every program that has OpenSpots does not necessarily advertise them well or enter the scramble or even try very hard to fill them. So, how hard is it to make 25 phone calls to programs in and around your area and in your specialty. Also, you might consider calling programs from a specialty that you could see yourself doing but may not have been your first choice.

3. Call a Trusted Mentor - This might be a good time to call that teacher or professor in your life that has some connections and work it! You would be amazed how much can change with a phone call from a friend. Swallow your pride, hide that ego and use every possible connection you have to see if you can get a break. Believe us, others did it!

4. Go to - Yeahg, it's a shameless plug but it's the most helpful webiste out there if you are post-scramble and pre-unemployment. We spend all the time finding these poorly advertised spots and you can view them for a paltry fee (just enuf to keep our servers functioning).

Tuesday, March 13, 2007

Regis on the OR Schedule for CABG

Celebrity tak show host Regis Philbin dropped a bomb on his audience yesterday when he informed them that he would soon undergo coronary artery bypass surgery (CABG).

"I got to do it," Philbin said at the start of "Live With Regis & Kelly." "Darn it, I don't want to do it. Nobody wants to do it, I guess."

The diminutive but spry 75 yo male had been on a short hiatus, most likely to evaluate some ongoing chest pain issues that he had admitted to: "I had been feeling chest pains, you know, and, uh, shortness of breath and all those little symptoms that you hear about."

Philbin's refreshing candor about such a serious operation will most likely go a long way to educating his viewers about coronary artery disease and its treatment options. It also cuts out a lot of the investigative and speculative fun of our Celebrity Illness article, but don't worry, there's plenty to discuss.

Reege, as he is affectionately known, most likely presented to his PMD with c/o chest pain and fatigue and who knows what else. The guy is a huge college football fan and constantly boasts about his superior physical shape which will serve him well during this process.

Upon hearing his symptoms, it is possible that Reege was sent directly for cath, (i.e. cardiac catheterization) but more likely had a exercise-nuclear stress test first which should have suggested significant ischemia. Either way, coronary angiography was performed.

Why isn't he going for stent you ask? Currently, there are only a few hard and fast indications for CABG: 1) Left main (LM) coronary artery blockage >50%; 2)Triple vessel disease or 2-vessel disease involving the early portion of the left anterior descending artery (LAD).

If it was the former, there would have been no discussion and Reege would have most likely already been on the OR table by now. Thus, it is much more likely that he has stable multivessel disease and will have a left internal mammary artery (LIMA) graft to the LAD as well as some saphenous vein grafts harvested form his legs.

Coronary artery bypass graft surgery is associated with significant morbidity. Major complications include death, myocardial infarction (MI), stroke, wound infection, prolonged requirement for mechanical ventilation, acute renal failure, and bleeding requiring reoperation. This doesn't even include the nearly 50% incidence of post-op atrial fibrillation and all fo the complications inherent in AF. Using registry data in the United States, the perioperative and in-hospital mortality rate after CABG averages about 1% for the lowest risk elective patients, and 2-5% for all patients.

There are a few risk-predicting algorithms as outcome is hinged on comorbids but we're not gonna go there. Here are some factors that have a major impact on survival and complications:

- Pre-op LV function
- Age
- Kidney function
- Coronary diameter
- Operator experience

Are we getting too data-y for you? It's a tough surgery and you should know this before you send patients (or go for it as a patient) for what has become thought of as a fairly routine deal. It is also important to keep in mind that it has amazing benefits in almost 98% of patients.

Philbin will be facing a difficult recovery as his sternum will be sawed open to expose the heart and although he will be under general anesthesia at the time - he hopefully won't stay that way. After the recovery room, he'll be monitored in a special cardiac surgery ICU where they will hope to extubate him as soon as he can tolerate it. He will also have chest tubes and a pericardial drain following the surgery, all which will hopefully come out after POD#3. He should be out of the hospital b/n 5-7 days where he will gently recuperate and be maintained on good pain meds.

After about a month, Reege will be able to get his groove on again and we predict a late April/early May return for the daytime maven of talk.

We wish Philbin a speedy recovery and hope that he uses this opportunity to educate his audience about his experience and the preventive measures that can take in order to avoid a similar prognosis.

Friday, March 09, 2007

Here's a Laugh When You're On Call

Depp's Daughter Recovering After Foot Puncture Infection

The Associated Press is reporting that Johnny Depp's 7-year-old daughter with longterm partner Vanessa Paradis is "doing much better" after a nine day hospital stay in London.

Several articles report that Lilly Rose was originally admitted for "blood poisoning" after stepping on a rusty nail at Depp's country home.

'Blood poisoning?' Another one of our favorite media pseudo-medical phrases. Why can't they use bacteremia, or infection, or even blood infection.

We decipher "blood poisoning" to mean bacterial infection disseminated to the blood causing a sepsis like picture. And considering the circumstances, i.e. rusty nail, one would have to assume that the offending bug would be Clostridium tetani, or tetanus. Or is it?

Actually, probably not. While more than 90% of pedal puncture wounds result from stepping on a nail. The most common organisms implicated in penetrating wounds are Staph aureus, beta-hemolytic streptococci, and then various anaerobic bacteria. Also, Pseudomonas aeruginosa is often responsible for infection when the injury is due to object penetration through shoes and socks.

Importantly, puncture wounds have the capability to infect deep spaces of the foot, including bones, joints, tendons, and deep fascia, and serious complications can arise. Therefore, the depth of penetration is hugely important.

The signs of more extensive injury are those typical of any infection, i.e. redness, warmth, pain, and swelling. If the offending object is still partly in there, e.g. broken glass or sea shell, it must be removed and the wound must be extensively debrided. Empiric ABx should be started to cover the most common bugs, i.e. S. aureus but anti-pseduomonals should be strongly considered as psudomonal osteomyelitis/-chondritis can be catastrophic.

It is our suspicion that Depp's daughter probably was treated inadequately or conservatively at first or perhaps even his the injury from her parents as kids can do and then presented 2-3 days after the injury with a warm, red, swollen foot. Imaging studies were performed for sure which included plain old x-rays to look for air and possibly a CT. CBC, Chem, and ESR were quite important in documenting infection and blood cultures were probably being sent every time the little one spiked a fever.

When she manifested systemic evidence of infection, broad spectrum IV antibiotics were certainly started and the wound was opened, any pus was removed, and the wound was most likely left open to heal on its own rather than sew it shut again.

Typically, in systemic bacterial infection, i.e. bacteria in the blood (bacteremia) patients will experience signs of sepsis: hypotension, tachycardia, fever, increased WBC. In addition to stroing anti-microbial therapy, IV fluids were probably used and maybe even pressors for blood pressure support.

This is a very scary situation for a little girl and her parents. We are happy to hear that she is out of the hospital and recovering. An interesting infectious disease topic nevertheless which proves our mantra: It sucks to be an interesting patient, but it's great to have an uneventful recovery.

Baldwin G, Colbourne M: Puncture wounds. Pediatr Rev 1999 Jan; 20(1): 21-3[Medline].

Patzakis MJ, Wilkins J, Brien WW, Carter VS: Wound site as a predictor of complications following deep nail punctures to the foot. West J Med 1989 May; 150(5): 545-7[Medline].

Wednesday, March 07, 2007

It's Joost The Next Huge Thing

joost1.jpgFirst there was Friendster. Then there was MySpace. Now there is YouTube. And coming soon, there will be Joost. Beleive us now and hear us later this will be the next huge thing to hit the Internet. How hot is it? Well, the guys that designed it also are the duo repsonsible for Kazaa and Skype. That alone should have you dabbing the salivation from corners of your mouth. But what exactly is it? We'll let them tell you:

What is Joost™?

Joost™ is a new way of watching TV on the internet, which uses new and established technologies to provide the bestjoost2.jpg of both the internet and TV worlds. We're in the process of making it as TV-like as we can, with programmes, channels and adverts. You can also see some things that we think will enhance the TV experience: searching for programmes and channels, for example, as well as social features like chat. There are many more new features to come!

How does it work?

Joost™ uses secure peer-to-peer technology to stream programmes to your computer. Unlike other TV and video-based web applications, it does not require users to download any files to their computers or browse through complicated websites.

Unfortunately, not everyone can enjoy this awesome new service as they are still in Beta testing but if you are lucky enough to know someone who has access, they can send you an entry ticket. Or, you can go to and apply yourself. Good luck.

Tuesday, March 06, 2007

This is too Cool

A Day at the Beach

I was really looking for an excuse to include this pic of me and my son, Sammy, at the beach in Naples, Florida. If you have not been to the west coast of FLA, I highly recommend it. There is something a lot more laid back and relaxed about this area.

It does have the money of Palm Beach and Miami but it doesn't have all the cheese. And there's alot of cheese on the East Coast of FLA. For the prices, I just do not see the sense of going to played out, overcrowded, overrated bars and restaurants when I'm on vacation. If I wanted to do that, I could wait unitl the summer and go to the Hamptons.

This picture very accurately depicts the relaxing, mellow vive of Old Naples and I would go back any time.

Monday, March 05, 2007

Deep Chene Thrombosis

cheneynaps.jpgAdd another item to Dick Cheney's long list of medical issues. In addition to his 4 heart attacks (first being at a sprite 37 yrs of age), 2 bypass surgeries, multiple coronary interventions, popliteal aneurysms, ischemic cardiomyopathy, and subsequent implantation of a cardiac defibrillator - the vasculopath has staved off death yet again.

The cat-like veep has amazing luck or a ridiculously attentive medical staff. Following an around-the-world trip which included more than 60 hrs of air travel, Cheney complained of slight calf pain which elucidated the DVT.

Cheney visited his doc at George Washington University hospital and a duplex revealed the clot, prompting his MD to start him on warfarin. In a statement today, Mr. Cheney’s office said he would be treated with “blood thinning medication for several months.”

We can only assume that Cheney is already on standard anti-platelet therapy, aspirin and Plavix, considering his multiple stent history. Throw in some warfarin for this latest diagnosis and his blood will be "thinner" than Nicole Richie. Speaking of "thin blood", why do we use this euphemism and who came up with it? The blood's viscosity does not change at all. Is it really that hard to explain or understand that platelets help clots to form and these medications prevent the bonding of platelets to each other? It is due time that the media and PR flack start speaking of medical treatments in real terms rather than 3rd grade metaphors. If advertisors can advertise directly to consumers than consumers should understand medical terminology rather than psedo-scientific analogies.

Back to Cheney's hard-to-believe medical history, Dr. Cameron Akbari, a senior vascular surgeon at Washington Hospital Center in the District of Columbia, said Mr. Cheney’s history of heart disease puts him at only “a very slightly increased risk” of developing a deep venous thrombosis.

“Reasons No. 1, 2, 3, 4 and 5 why he developed this are he was on a very long plane ride,” Dr. Akbari said.

Ok. But why does he keep clotting every portion of his vascular bed. I am quite sure that Cheney has had the over-ordered hypercoagulable work-up, but he should also be tested for aspirin and clopidogrel resistance.

To clarify, it is unlikely that the clot lodged in Cheney's left leg is actually sitting in his calf. The vast majority of these thrombi sit in the larger, more proximal venous system. And lastly, Coumadin or Warfarin, will prevent further propagation of this clot but will not dissolve the clot - so the risk of PE is still there all you anti-Chenites.

One more interesting historical note: Warfarin was named in honor of the Wisconsin Alumni Research Foundation who discovered that coumarin, a byproduct of moldy silage, was a potent anticoagulant and the cause of bleeding cows. Warfarin was first registered for use as a rodenticide in the US in 1952, but its true mechanism of action, the inhibtion of vitamin K-dependent cofactors was not elucidated until 1978.

Sunday, March 04, 2007

Hepatitis A Scare for Beyonce's Party

beyonce2.jpgAn unlucky employee of Wolfgang Puck Catering diagnosed with hepatitis A may have donated his virus to guests at several high-profile functions, including Sports Illustrated's swimsuit issue party attended by Beyonce Knowles and other pseudo-celebs, officials said.

The risk of illness was 'quite low,' but anyone who ate raw food at the magazine's Feb. 14 party was urged to receive a preventive shot by Wednesday, the LA County Department of Public Health said Tuesday.

The affected employee was placed on medical leave, said Carl Schuster, president of Wolfgang Puck Catering.

'We immediately worked to take every precaution to further safeguard our patrons and other employees,' Schuster said in a statement.

Sports Illustrated said in a statement that it was taking the situation very seriously and was working directly with county health authorities.

'We are alerting our guests and staff as quickly as possible to ensure they receive the relevant health warnings,' the statement said.

Hep A (HAV) is usually spread via the fecal-oral route, i.e. infected people share the yellowing virus through food and water that they handle – after touching their ass. It is more prevalent in low socioeconomic areas in which a lack of adequate sanitation and poor hygienic practices facilitate spread of the infection.

To get technical on your ass, (and for those of you prepping for Boards) Hepatitis A is a 27 nm, nonenveloped, icosahedral, positive-stranded RNA virus classified in the Heparnavirus genus of the Picornaviridae. But you knew that.

According to our favorite medical resource,, community outbreaks due to contaminated water or food have also been described, shellfish being the most popular offender. However, several outbreaks related to consumption of “contaminated” green onions have been reported in the literature.

HAV infection usually results in an acute, self-limited illness and only rarely leads to fulminant hepatic failure.

The two most common physical examination findings are jaundice and hepatomegaly, which occur in 70% and 80% of symptomatic patients, respectively. Less common findings include splenomegaly, cervical lymphadenopathy, evanescent rash, arthritis, and, rarely, a leukocytoclastic vasculitis.

Laboratory findings in symptomatic patients are notable for marked elevations of LFTs (usually >1000 IU/dL), serum total and direct bili, and alk phos. Typically, ALT is higher than the AST and bilirubin levels above 10 mg/dL are not uncommon.

The diagnosis of acute HAV infection is made by the detection of anti-HAV antibodies in a patient with the typical clinical presentation. Serum IgM anti-HAV is the gold standard for the detection of acute illness.

Because the disease is usually self-limited, the treatment is supportive.

But believe us, it would be a lot more than supportive if one of the celebs turned yellow.

Sunday, February 25, 2007

The IN's and OUT's of Hospital Style

While your choice of hospital shoes still says a lot about who you are, trends are moving up the body and now scrubs and accessories have started to become more fashionable. In this version of In’s & Out’s, we declare what is hot and what is not on the floors, in the OR, and beyond.


racingstripesscrubs.JPG1. Racing Stripe Scrubs –
The old days of shapeless, burlap-like, draw-string scrubs are done. Taking a cue from Dr. 90210’s freakish Robert Rey who tailors his OR apparel to show off his biceps, more and more hospital staffers are customizing their scrubs. While we have not seen the Rey-esque tank-top scrubs yet, we have seen quite a bit of the snazzy scrubs with bold racing stripes down the legs. They come in all sorts of non-hospital-like colors, e.g. navy blue, dark green and even brown. They also come in male and female varieties and unlike their predecessors, are able to highlight those hospital workers with nice features.

2, Low-rise Scrubs (a.k.a. Hipsters) – Following the trends from the denim world, now you can see your favorite nurse or doc’s coin slot with the evolution of low-rise scrub pants. Points to the RN’s and MD’s who can find low-rise scrub pants with racing stripes.

mules.jpg3. Schlogs –
They’re part shoe, part clog. When you see them from the front, you might think that they’re standard leather shoes of the Ecco variety but pull up that scrub leg and they are backless with a cushiony insole. Oooh la la, comfort and style. More impressively, these shoes have actually done the rare cross-over as both surgeons and medicinites are donning the schlogs.


1. Crocs – Here’s a tip: when it crosses over into the general public, it is no longer cool (see: red leathercrocs.jpg Dansko clogs circa ’01). Hence, as soon as 7-year-old boys were skipping around in crocs, they no longer were considered cool hospital footwear. They’re done.

2. iPod –
This is one of those rare fads that was out as soon as it was in - sorta like neck tattoos. It seems to be most popular amongst the interns, particularly the prelims and transitionals who may be using it as a subtle ‘F--- You’ to their seniors. We love gadgets as much as the next guy but do you really need to listen to music while you change that wound dressing or write orders? If you want to demonstrate your bitterness about being low man on the totem pole, do what every other intern does - ignore pages. Huh?

3. Fanny Packs – Just a reminder: fanny packs have never been and never will be an acceptable accessory! Ever.

4. BlueTooth headset – This trend lasted all of 5 minutes and belonged exclusively to the attendings. Now that they sell the ear-gadgets at gas stations, it is definitely over. However, it has now become a simple way to identify those doctors who you would never want treating your family.

Monday, February 19, 2007

Top 5 Differential Diagnoses for Britney's Break

baldbrit.jpgDespite the appearance of physical health - at least, until she shaved her head - Britney is not well. To enlighten our writers and readers we decided to enlist the help of an Ivy League-trained clincal psychologist for this special edition of Celebrity Illness. Enjoy.

1. Substance Abuse Disorder - Addiction. That’s right, you guessed it. Like we said about so many young celebs in this article: if it smells like drugs, and looks like drugs.... it’s drugs! Coke, Meth, Crack, X, Alcohol…whatever. That’s my call.

2. Borderline Personality with Psychotic Features -
Altogether likely. Given the labile mood, strange and extreme behavior and chronic emptiness coupled and with pre-morbid narcissism, pattern of unstable relationships and shallow affect, BPD with psychotic features is definitely a contender for the diagnosis. It is almost a requirement for to be a Hollywood/performer type.

3. Psychotic Disorder NOS - Purely based on strange behavior and poor judgment, we don’t actually know if she has lost touch with reality (like hearing voices, seeing and/or smelling things, delusions). Unlikely since she is a bit old for a psychotic break..though still within the age range for women.

4. Postpartum Depression with Psychotic features -
Britney did just have a child within the past six months so we can’t totally remove it from the differential; it is unlikely because this diagnosis is usually diagnosed within the first 6 weeks postpartum…and it is kind of like she doesn’t have any children at all…so what is she depressed about? Hormones.

5. Bipolar Disorder - High on the differential because it is so hot and hip these days with the famous set. Britney’s impulsive behavior..partying (i.e. self-medicating), flying all over the country, checking in and out of rehab within a day, hyper -sexuality, shopping, irritability. True bipolar will generally see an approx 3 months manic period followed by deep depressive period for approx 9 months. So, we could be in the downward spiral anytime.

Friday, February 16, 2007

Notre Dame Head Coach Sues for Botched Bypass

Charlie Weis, head coach of the Notre Dame Fighting Irish and former Super Bowl winning offensive coordinator, testified yesterday in his lawsuit against two surgeons from prestigious Massachusetts General, who he claims were negligent following his gastric bypass surgery.

According to, the now svelte Weis said he spent more than a month in various hospitals, and following his release, had problems walking and could get around only with the help of a wheelchair or electric cart. His lawyer, Michael Mone, told the jury during opening statements Tuesday that Weis still suffers nerve damage in his legs.

How was his ambulation when he tipped the scales at 400 lbs? And his diabetes? And HTN? And obstructive sleep apnea, etc etc?

I am astonished that someone who signed a contract for $30-40 million over 10 years and is now healthy enough toWeis2.jpg walk the sidelines and handle a high-stress job like his, would sue doctors who are at the top of their field and clearly did not mean any harm.

Gastric bypass is inherently a complicated procedure and when a morbidly obese individually undergoes the surgery, this is explained to him or her. If the physicians made a erred during the surgery and corrected their error enabling him to successfully drop weight and return to coaching, what is he suing for?

Obviously, we are not privy to the details of the case but we do know he is coaching and that hey are Harvard surgeons who want the bet for their patients - especially high-profile ones like Weis.

Can the Fighting Irish fans sue Weis every time he makes a bad call or for their pitiful performance in Bowl games?

Doctors explained to Weis the risk of the surgery and he, in fact, waived a psychological assessment period so that he could be ready in time for football season. Now he is suing them?

Weis, as a head football coach, and a man who is familiar with risk-benefit analysis, whould recognize the complications inherent in such an invasive procedure - particularly in such an unhealthy individual. Big rewards can be gained form big risks - but like the deep pass and the double reverse, catastrophe can also occur. Weis is lucky that he is alive, healthier than before, and actively coaching a marquee program. And who does he have to thank for that? His team? His family?

No. His doctors.