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!

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.

http://www.pvss.org/Cases/CartEnd/car3.htm

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 OpenSpots.com - 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).

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.

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].

It's Joost The Next Huge Thing

First 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 best 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 Joost.com and apply yourself. Good luck.

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.

Deep Chene Thrombosis

Add 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.

Hepatitis A Scare for Beyonce's Party

An 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, UpToDate.com, 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.

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.

WHAT'S IN:
1. 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.

3. 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.









WHAT'S OUT:

1. Crocs – Here’s a tip: when it crosses over into the general public, it is no longer cool (see: red leather 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.

Top 5 Differential Diagnoses for Britney's Break

Despite 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.

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 ESPN.com, 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.

Money for Nothing

An interesting article appeared in today’s New York Post. Turns out that the recently elected Governor Eliot Spitzer has caught on to the fact that several NY area hospitals were being paid for residents and fellows that were not actually training in the paid institution.

This is laughable to anyone who trains in a large city as hospitals are changing leadership and affiliations so frequently these days but medical education is rarely, if ever a real consideration in the transition.


Since hospitals are now run by administrators whose concern is to make money, they are much more concerned with the bottom line rather than medical education or the quality of academics at their hospital.

The Centers for Medicaid and Medicare Services (CMS) have been given the responsibility of paying hospitals for educating medical students and house staff based on the number of medical residents and doctors in training.
In New York, Spitzer and his staff discovered that for years, the state budget provided funding based on antiquated data. Through 2004, the state paid for resident-interns based on staff figures from 1981 and 1990. Does this surprise anybody?

"This [physician] education is critically important, but we're currently funding it in an excessive and irrational way that isn't directly correlated to the actual students being taught - thus costing the state exorbitant amounts of money in what amounts to general subsidies to teaching hospitals," Spitzer said.

"In fact, when we looked closer at this broken formula, we discovered that many of those dollars are going to pay for phantom residents and doctors who don't even exist. We will no longer pay for graduate medical residents who don't exist."
The problem is even more drastic then Spitzer knows. Hundreds of residency and fellowship vacancies exist in medical training each year. From esoteric heart failure fellowships to OB/GYN residency spots, ACGME-accredited spots go unfilled and there is no national database to feature them.

Instead, all of these medical training opportunities, which hospitals often get additional funding for, remain unfilled. Perhaps if training doctors were better informed of these existing training spots, they might be encouraged to apply for additional training or, training at all.

Often, medical training is the last consideration in the day-to-day running of a hospital which is ironic since so much of the care provided, particularly at large academic centers, is by those same residents, fellows and even medical students.

Top 5 Most Annoying Hospital Noises

1. Telemetry – Beep, beep, beep, beep, Booonng! Booonng! Booonng! Annoyed yet? Multiply that times 400,000 and you have recreated the telemetry floor experience. Sitting next to alarming monitors and trying to write your notes is almost as torturous as resisting the urge to put your foot through one of them.

2. The Unanswered Phone – Will no one pick up that friggin phone? Nurses and ward clerks have developed some weird defense mechanism to a ringing phone. Not only do they lack the natural guilt that should go along with ignoring someone’s call but they almost relish the annoyance that others feel after the 9th, 10th and even 11th ring.

3. The Repeating Patient – I know, this one will not make the Top 5 Politically Correct list but at least we’re honest. Whether it is the aye-fibbers (“aye-aye-aye-aye”) or the Help-Me’s (no explanation needed), hearing a patient yell anything over and over and over again often makes you want to gauge your own eyes (or ears) out. If you’re lucky, they might throw in an inappropriate phrase occasionally to keep you on your toes.

4. Suction – Do we really need to elaborate on this one?

5. Pager – This website didn’t get its name for nothing. Go ahead and switch the beeper tone all you want, it won’t help. Even more annoying is when someone’s pager goes off in grand rounds and everyone in the room checks their pager, even if they are 100 yards away. Putting your pager on vibrate solves all of the above problems, except of course the annoyingness of being paged. We fear the day of downloadable pager tones.

Rank and Guile

For many of you medical students out there, January 15th marks the birth of a new stage in your career. One that will lead you to hours and hours (and hours) of gratifying time spent in a specialty of your choice. It will signal the beginning of the end of kissing residents’ misshapely asses, scutting for good evaluations, and the education-comes-first mentality. Less than half a year from now, you will actually receive a paycheck, call yourself “Doctor” and you may even live in a different state - all contingent on that RANK LIST. The Rank is a curious creature and many medical students have made crucial mistakes that put them in specialties and/or states that were not for them. Thus, StopPagingMe.com has selflessly created a list of 5 rules for you to remember when constructing your ultimate Rank.

1. More is better. NRMP says: Applicants are advised to rank all of the programs deemed acceptable, i.e., programs where they would be happy to undertake residency training. Get it? If you could picture yourself at a place, put it on your list. And when you are hemming and hawing about whether you really would be happy at County, make sure the alternative you are comparing it with is no-place and it will make your decision a lot easier.


2. More is better. NRMP also says: “Unmatched applicants have shorter lists on the average than matched applicants. Short lists increase the likelihood of being unmatched.” Have we hammered this point home enough? Just in case we haven’t, think of how you’ll feel on Match Day when all of your friends are hugging and kissing and you’re worried about scrambling because you couldn’t picture yourself with all of those residents at County. Get over it and put everywhere you interview on your list!



3. Rank in order of your preference. This is also straight form NRMP.org. The position of a program on your rank order list will not affect your position on the program's rank order list, and therefore will not affect the program's preference for matching with you as compared with any other applicants to the program. Translation: They don’t know where you put them so it cannot affect where they put you. That brings us to another interesting point: Tell every interviewer that they are your number one choice! Act happy to be there and convince them that this really is the place for you with some unique observation about wherever it is that you’re interviewing.



4. Don’t Believe the Hype. Choices should not be influenced by what an interviewer might say to you – positive or negative. One never knows who is interviewing after you and we don’t just mean that they might be smarter and have better USMLE scores. They might be the Chief’s nephew or the daughter of the program director’s secretary, or be high-rankingly hot. Interviewers are human and humans have feelings, wants, needs, likes, dislikes and issues. Thus, take all interviewers’ promises with a large grain of salt and refer to Rule #3.



5. Do your due diligence. First, go to www.NRMP.org and read how the match algorithm works. Now that you have included all of your possible programs and are stuck on the order of what you like best and least – it’s time to research your options. Find out who the program director and Chairman are; Google the hell out of your department; consider lifestyle aspects like where you’ll live (and for how much); do they publish; so they go on to fellowships; etc etc. You get it now – so get to it and best of luck Ranking your List.

Appendiceal Surprise or Big Pack of Lies?

Appendiceal Surprise or Big Pack of Lies?

Our favorite VIP patient and frequent topic of this column, La Lohan, has been admitted again!

It’s really a shame that it happened during such a tender time for the 20-year-old party girl-turned-AA-member. She was just getting used to normal blood alcohol levels and then wham! – an acute abdomen.

The details of how and when she got admitted are hazy, as per usual, but piecing together various stories, the most likely scenario sounds like she saw a doctor sometime Wednesday who diagnosed her with a hot appendix and sent her to Century City Hospital in Los Angeles to have it snipped out, where she most likely stayed in one of their luxe VIP suites (seen in pic). Ooooh la Lohan.

We’re quite sure she’s a good judge of hospital VIP suites by now. Maybe she would consider doing a Top 5 Best Hospital VIP Suites for StopPagingMe.com?

Why is it that Lindsay keeps returning as an inpatient? Is it the young interns? The pain meds? The swing-arm TV?

Now, we would have given Blohan the benefit of the doubt had we not seen TMZ.com’s new video clip of her jaunting out of the hospital on post-op day #1 (POD#1).

There is no question that the party princess would have had her appy done by laparoscopic approach. This way, surgeons could easily hide the 1-2 cm scars below her ischial spines and inside her umbilicus (belly button). And yes, that is less painful and often results in quicker recovery – but 24 hours??? That is really pushing it from a pain tolerance and medical standpoint. It just seems silly that she would not give the trocar incision sites at least until the evening to heal up a little. Which brings up another interesting quandary: what type of pain meds did she get, being that sh is trying to clean up her act?

Typically, surgical patients, even those as young as 20, are observed for at least 24 hours to watch for any signs of infection (fever, chills, nausea, vomiting) and to make sure their gut is active again. That’s the best part. Gut activity is determined by the resumption of bowel peristalsis, or muscle contraction, forcing stool and air down the gut towards the rectum. Thus, docs determine if the gut is active by asking patients about flatus, aka ass-wind. I can just imagine the doctors asking LaLo if she beefed yet? Lucky bastards.

But if it was not her vestigial appendix what could it be? There are too many possibilities for what really could have happened, but here’s a short list:
- More “fatigue/exhaustion/anxiety/cocaine hangover
- Elective abortion – It’s a same-day procedure that is often well-tolerated and quite safe
- Some minor plastic surgical procedure
- UTI
- Gastroenteritis


Regardless of whether the Queen of Teen had an inflamed appendix or not, we would like to thank her for providing this column with so much fodder this past year. We wish Lohan the best of luck and health in the future and look forward to her returning several times in 2007.

Top 5 Reasons for the Short Coat

1. Target Practice – In the complicated hierarchy of academic medicine, attendings beat on residents, residents beat on interns, patients beat on interns, and nurses beat on interns (and anyone else that show signs of weakness). Since the interns are so grateful to have help, most do not transfer their abuse to the medical students who serve to a) scut, and b) deflect some of the nursial abuse. When nurses see a short coat, their eyes light up like it was free food day in the cafeteria and that lack of white fabric might as well be a bullseye or a sign that says: 'Yell at me for sitting in your chair.'

2. Limits Responsibility – Despite the lack of experience and knowledge connoted by the short coat, it brings with it a certain freedom, i.e. those who don the half-length jacket are not liable for any missed labs, failed blood draws or late discharges. Ah, the life of the blameless.

3. Still Works with the Chicks – When residents see the short coats, we secretly smirk at the awkward presentations, constant ass kissing and lack of hospital savvy that wear the mini-coat. We hearken back to times when a test at the end of the rotation was our greatest responsibility. They are the pledges of the medical hierarchy, the plankton of the medical food chain. But to non-medical people, they are future earners and the next potential Dr. 90210. The white coat equals doctor and to those who care about such things, that is the long and the short of it.

4. Bottoms Up – Myth has it that the long white coat was invented to cover up the expanding asses of residents and attendings unable to make it to the gym because of their hectic schedules. Still able to hit the treadmill regularly, med students can proudly display their backside, and help bring down their higher-ups just a notch. Fashion Sense – The sport coat is back, baby. Go to any club/lounge/bar in NYC and see for yourself. No longer reserved for the 35 and older crowd, the jacket and jeans look affords the wearer a unique sense of casual-formalness never seen before. Donning that short white coat with jeans and a loose tie could land you ahead of the fashion game. Or the victim of an ass kicking.

5. Fashion Sense – The sport coat is back, baby. Go to any club/lounge/bar in NYC and see for yourself. No longer reserved for the 35 and older crowd, the jacket and jeans look affords the wearer a unique sense of casual-formalness never seen before. Donning that short white coat with jeans and a loose tie could land you ahead of the fashion game. Or the victim of an ass kicking.

Why This Reality Show Might Save America

Say what you want about Dancing With the Stars or The Surreal Life. Go ahead and mock that Flavor Flav show and the inane lives of teenage rich kids as seen on MTV’s Laguna Beach. But don’t you dare include any of those shows in the same breath as The Biggest Loser, possibly the most important show to hit primetime in the past 50 years.

Reality programming has become TV’s version of crack. It’s easy to make and equally addictive. Put a bunch of camera hogs with personality disorders together in the same house and watch the entertainment ensue. Just imagine if you could use the dependency for good rather than evil - that’s right, healthy crack.

If you have not seen Loser, the basic premise is to get 14 morbidly obese people to lose as much weight as humanly possible in 100 days. They are divided into two teams and each team is given a personal trainer that works them like they have never been worked – and many of them really have never worked out. They are also taught important lessons about diet e.g. what is healthy and what is fat-inducing. They are taught how to order at a restaurant, how to prepare healthy family meals, how to count calories and so much more. Sure, there are blatant product placements and shameless ads for everything from low-fat turkey to exercise bikes but it’s all in good fat, er, fun. And the best part about all these life lessons that the losers get is that they are televised and even charted for the millions of obese watchers at home.

America is the fattest country in the world with more than ¼ of our population classified as obese. Our BMI’s are only matched by our insatiable hunger for TV, and reality TV in specific goes together with couch potatoes like special sauce on a Whopper. Who better to make you feel OK about yourself than 15 semi-retarded women literally fighting to marry a 5’3” ex-rapper with gold teeth and a giant clock around his neck?

The Biggest Loser is more effective than any institution or individual physician in combating the growing obesity epidemic. Not even the best of academia can affect as many lives over the course of a month as Loser does in one night. What doctor do you know talks to millions of households every week and shows demonstrable evidence that simple diet and exercise does indeed bare out results?

Week after week, the losers drop weight and improve physically and emotionally. There is a minimum of 10 crying scenes, 12-14 shots of massively sweaty tank tops and 6-8 mentions of how they are “doing it for their children”. As with any good reality show, there is bickering, badgering, complaining and just enough scheming to remind you that someone has to be sent home. But the proof is in the fat-free pudding for this bunch, as most often the person who lost the least weight is sent home to combat their eating issues alone.

Perhaps we like reality shows too much and are stretching to find the good in an otherwise crappy genre of TV. But if just one person at home learns that eating a short stack with two eggs on the side with bacon is not a typical breakfast then this show has succeeded in making people better. And isn’t that what we all want to do?

Check out this website to see some great before and after action http://www.biggestloserclub.com/.