After a month without television, I've done some catching up since Christmas. And I've seen TV do some catching up with current events.

The Indian Ocean tsunami disaster was something I heard about first as an afterthought during afternoon football games, and placed at low priority on the local nightly news (a snowstorm was settling in, and the post-holiday mall blitz was underway). But the initial report of 7000 dead, with assorted clips of foreign harbors, seemed absurdly out of place sandwiched between sports highlights and snowfall totals. It was anomalous, and I'd think about it later.

Now the number they're throwing around is 60,000. I try to imagine my town being wiped off the map, or a dozen 9/11's, but nothing really registers. Yet the disaster has gone from a neatly compartmentalized, abstract story, to something I can't stop thinking about.

The TV's coverage has reflected this change -- they've gone to full-court press. Is it because the networks finally got correspondents in place? Did they underestimate the story's traction? Or did they, too, have a hard time processing this far-away disaster? For all the suddenness of the tsunami, it seems to have taken a few days to realize this might be the most widespread catastrophe in our experience.

If it helps to think of the concrete, there's a second crisis looming as the disrupted water systems in 11 countries succumb to contamination. This time, at least, there's some warning, and an opportunity to intervene. It's at least something to do.

Taxi Cab Confessions

I was running late to an interview (meaning that, I wasn't certain I'd be 15 minutes early), so I decided to skip the subway in favor of a cab. I flagged one right outside my apartment and asked the driver to take me to a place we'll call Hospital X.

"Hospital X? I love that place. You work there?" he said, eyeing my suit.
"No, just interviewing," I replied. "So what's so great about Hospital X?" I figured I might get some first-hand insight into the operations of the emergency room, or an off-service department like ortho or surgery.
The cabbie replied, "It's the best psychiatry unit in the city. I've been there many times. I love it when they take me there."

I try to take things in stride, really. And I try to be conscious of prejudice with mental illness. I read Shrinkette, dammit. But I can't deny my general state of alarm, as visions of "Taxi Driver" danced through my head. So I turned to my trusty smalltalk skills, and asked him why he didn't like the psychiatry at Hospital Y, often reputed to be the best.

"Last time I was there, they had me next to these murderers from Riker's Island. I don't need that. I'm not a criminal, I just get confused sometimes."

OK, I thought. And a nice epitaph, to boot. I'm calming down. But then:

"Aww, look at THIS! Traffic on the FDR at this time of day? Of all the @%#(&#(*$&# luck to *#%($#(*# me upside the #$%@#* in the *$&##$*%. It kills me when we're in traffic. I make #@%&*!* money. It KILLS me. I oughtta drop you off RIGHT HERE for getting me into this *(#%&(*#%."
At the conclusion of his tirade, I realized I had stopped breathing. I forced some air out to say "Ha," weakly, as I tried to smile.

"Just kidding, buddy. Don't worry, I'm on seroquel."

A finer endorsement, I cannot imagine. The traffic quickly cleared, and as we zoomed along the edge of Manhattan, I knew I could handle the upcoming interviews.

Bring a Torch

REM's latest single notes that leaving New York is never easy. You might think they're talking about giving up on a relationship, moving on. In fact, they're singing about the Port Authority Bus Terminal at Christmastime. The ten o'clock riot at Gate 83 was more harrowing than anything I dealt with in the SICU.

A happier memory from New York came from a week earlier, when I attended a poetry reading to hear an accomplished medical student. Good stuff! And I'm sure we'll be seeing more of it in print, soon.

After the readings, there was an audience-participation haiku contest based on this story:

A 74-year-old Georgia woman is in serious condition after a man dressed as Santa Claus hit her in the face and head with a large piece of wood for no apparent reason, according to Local 6 News.

Police in Atlanta, Ga., said Elkin Donnie Clarke, 49, attacked Annie Ruth Nelson, 74, with a two-by-four piece of wood as she walked down a downtown street this weekend.

So inspired, I jotted down the following:

Santa rearranged
Old St. Nick with a yule log
could it be ... Satan?

Alas, I lost the haiku competition. I can't recall the winning entry, other than it contained the term "glory hole." Tough crowd. Almost as tough as those holiday bus passengers.

Maybe next year.


CodeBlueBlog is hosting this week's Grand Rounds. He advances the notion that the growth of medical blogging isn't simply geometric, but rather...

...A sort of medical blog meiosis that assures the mixing of information, the distribution of characteristics, and the spontaneity provided by point mutations.

There are not just clones budding throughout the medical blogosphere; rather, we are watching unique individuals produced with information crossed, passed, and punctuated by individuals who live all throughout the map of modern healthcare.

Well said. But then later he dubs me the progenitor, which probably has more to do with my name than anything else. The first medical weblogger is Dr. Jacob Reider, who continues to advance the field with his academic approach to blogging, and his useful medlogs.com aggregator. Medical blogging would simply not be where it is today without him, and his colleague David Ross.

As for where it's going, well, beats me. The weekly linkfest continues to feature a nice mix of established writers and newbies, with interesting and different perspectives. Compared to automated aggregators, or year-end Web awards, I think the format of Grand Rounds -- with its rotating host / editors -- is most likely to bring good writing to the attention of regular readers.

But I might be biased.

Tune in next week when Codeblog: Tales of A Nurse gets a turn.

Over there

I sometimes wonder if this blog should devote itself exclusively to the writings of surgeon Atul Gawande. The big concern is that I wouldn't be able to keep up (I already missed the boat covering his latest New Yorker piece).

In last week's NEJM, Gawande wrote on combat medicine, providing some blockbuster statistics in his usual understated, enlightening manner:

When U.S. combat deaths in Iraq reached the 1000 mark in September, the event captured worldwide attention. Combat deaths are seen as a measure of the magnitude and dangerousness of war, just as murder rates are seen as a measure of the magnitude and dangerousness of violence in our communities. Both, however, are weak proxies. Little recognized is how fundamentally important the medical system is — and not just the enemy's weaponry — in determining whether or not someone dies. U.S. homicide rates, for example, have dropped in recent years to levels unseen since the mid-1960s. Yet aggravated assaults, particularly with firearms, have more than tripled during that period.2 The difference appears to be our trauma care system: mortality from gun assaults has fallen from 16 percent in 1964 to 5 percent today.

We have seen a similar evolution in war. Though firepower has increased, lethality has decreased. In World War II, 30 percent of the Americans injured in combat died.3 In Vietnam, the proportion dropped to 24 percent. In the war in Iraq and Afghanistan, about 10 percent of those injured have died. At least as many U.S. soldiers have been injured in combat in this war as in the Revolutionary War, the War of 1812, or the first five years of the Vietnam conflict, from 1961 through 1965 (see table). This can no longer be described as a small or contained conflict. But a far larger proportion of soldiers are surviving their injuries.

He goes on to discuss the transformation of front-line trauma care since Vietnam, and some of the remarkable people behind it. One comes away with a greater appreciation of what the tiny number of army physicians and surgeons have accomplished in Iraq. There are implications for our civilian trauma management, as well (lengthy stabilization in the field or community hospital may not be in the patient's best interest).

I understand there was some controversy over how his article was presented, because he's not a trauma surgeon and is not involved with the war. But to me, his points are so clear and salient, I can't see how readers are disserviced. Plus, as becomes obvious from his reporting, the doctors in Iraq don't currently have the time to write.

Sports Medicine

For years, the Boston Red Sox received care from UMass Medical (despite the fact that the campus is not particularly close to Fenway Park). After team physician Arthur Pappas* retired, Sox care fell to Dr. Bill Morgan. He made a lucrative deal with St. Elizabeth's in Brighton, and sent the Sox players to his new sports medicine center there. Then, a few years ago, Beth Israel-Deaconness became the Sox care center, though Bill Morgan stayed on as team physician.

Now, the winds of change are blowing again:

The Red Sox are reportedly negotiating with Massachusetts General Hospital and Beth Israel Hospital for the care of their players. Morgan is employed in Brighton at St. Elizabeth's Hospital, which is also believed to be bidding to care for Sox players.

Though the Sox established a relationship with Beth Israel shortly after the current ownership took control of the team, recent indications suggest Sox players will end up under the care of doctors at Mass. General.

These maneuvers are big business, even here in New York (where Sox cap sightings currently outnumber Yankees caps 3:1). NYU Med Center apparently paid the Mets a lot to be the caretakers of New York's other baseball team. And even though they advertise it prominently, even this relationship isn't clear cut:

The widely respected Altcheck, who is associated with the Hospital for Special Surgery, was replaced in 2001 when NYU and the Hospital for Joint Diseases paid the Mets for the right to provide the team physicians.

In a carefully worded release, the Mets claimed the two sides amicably ended their association. But the Mets were a medical mess last season.

Obviously sports teams want the best physicians and resources to get their injured athletes back on the field. And obviously hospitals want to show people that they've got such physicians in their ranks.

I only bring this up because, at some level, the privilege of caring for sports figures amounts to hired celebrity endorsements for hospitals. There are many ways to attract patients to a particular hospital, but this method isn't particularly grounded in the patient's best interests. Why not tout improved outcomes or other evidence-based data? Wouldn't you rather have surgery at a place with the lowest complication rates, instead of just going where Pedro goes? Wouldn't your answer be influenced if Pedro's team was reimbursed for the chance to care for him?

People routinely criticize pharmaceutical companies for vague direct-to-consumer advertising. They say it's wasteful spending and gives patients false impressions. I have yet to hear these people, however, speak out against hospitals involved in a similar practice. This issue will only grow larger as more hospitals seek, and advertise, relationships with sports teams and celebrities.

*Full disclosure: I once rode in an elevator with Dr. Arthur Pappas.

The next generation

Here's something I noticed about my team a few weeks back:

Everyone was either a child of a physician... or a child of immigrants. One guy was both.

I suppose that says something about the pools that medicine draws from. Assume that, if you go into medicine, you have to think you'll love it. That expectation seems to come from either growing up around doctors, or from a residual old-country respect for physicians.

These are deep-seated influences, to be sure. And it's encouraging to think that future physicians are inspired by a familiarity with, or notion of, the importance of doctoring.

But maybe carrying these notions with us is the only way to get through the process of becoming a doctor. No other motivation seems to be doing the trick as reliably.


Head on over to Dr. Emer's Parallel Universes to see this week's Grand Rounds. He's done a great job organizing the best posts from the growing number of medical blogs.

Thanks to all for the comments and emails after my last post, about future Grand Round hosting. Sorry if I haven't gotten back to you all. The time I'm spending on interviews, the SICU, and the diversions of this island has really cut into blog-related activities. And sleep. Suffice to say, we've got a lot of new interested participants and I hope to be contacting them and making up the schedule soon.

Be sure to check out CodeBlueBlog next week, for Grand Rounds #13.

An Evening in the Examining Room

Dr. Charles hosts this week's edition of Grand Rounds. What can I say? He makes me want to read my post over again.

I count 26 entries, which is a record. Also, seven entries come from blogs I've never heard of before. But they're good, so go check it out! And the Carnival of the Caregivers marches on. Here are the upcoming hosts for Grand Rounds:

12/14/04 Parallel Universes
12/21/04 Code Blue Blog
12/28/04 CodeBlog: Tales of a Nurse
1/4/05 Rangel, MD
1/11/05 Chronicles of a Medical Madhouse

Parallel Universes will be our first international host; Dr. Emeritus hails from the Philippines.

CodeBlueBlog, in addition to distinguishing himself as the master medical sleuth of the blogosphere, will be our first host who's involved with Tangled Bank, the Carnival of the Scientists.

Geena from CodeBlog will be our first repeat host, for several reasons. Her first gig was spectacular yet received no Instalanche (the Professor was on vacation). Also, she was willing to host right smack in the middle of the holidays. These nurses, they're saints (and if Instapundit is on vacation again, well, I'm just going to hit Refresh on my browser a few thousand times).

If you want to host Grand Rounds, drop me a line. I've tried to favor bloggers who write mostly about medicine, who've been around a while, and who post at least weekly. There are more such medical blogs that I've been meaning to solicit, but not many more.

I've received hosting offers from political blogs that happen to be written by health care professionals, from spankin' new blogs, and from blogs that are infrequently updated. I'm more reluctant to give them the spotlight of hosting Grand Rounds, but at the same time, I'd like to see what some of these writers come up with. And I'm not quite ready to cycle through the original hosts again. Any thoughts on this matter? Let me know.

Sponge Count Squareness

Atul Gawande has a new book coming about that most egregious operating room mishap: when a sponge or clamp is left behind. I wrote about his last book, Complications, back in February (twice). Now Douglas Starr of the Boston Globe Magazine has interview with the author of When One Is Missing:

"Anytime you hear that someone has left a 12-inch retractor in a patient, you think, `What kind of idiot did that?'"

But what if the surgeon wasn't an idiot - in the same way that not every pilot in a plane crash is an incompetent? That's the question that has medical experts beginning to take an engineer's view of hospitals. Rather than see them as warrens of individual doctors and nurses, the new view posits them as complicated human and mechanical systems with small, undetected flaws that can make mistakes inevitable. To borrow the airline industry's language, it isn't pilot error that causes most mistakes, but subtle system problems instead. Gawande's simulation conforms to a growing interest in finding new ways to reduce medical errors - not by punishing doctors after the fact, but by building more safeguards into the system.

Anesthesia was the first field to institutionalize this viewpoint, and it led to a dramatic decrease in dosing mistakes. Now that kind of systems approach is coming to surgery (and other fields) with all its obviousness. As Gawande remarks in the article:

"For God's sake," he says, "you can't walk out of a bookstore without an alarm going off. How can a patient leave an OR with an instrument inside him?"

Some common-sense solutions, and neat statistics, are found within the paper. Read the whole thing.

Touching Me, Touching You

In New York right now there's news about one family's attempt at receiving a kidney donation. After 10 months renal failure following a rare cancer, the sister of Neil Diamond (not the singer) placed an add on Craig's List on his behalf.

Here is one early report of the effort, and I've since found two new pleas for kidneys. The story has been picked up by mainstream New York media.

(Aside note: Not to make light of their situation, but if Diamond's eventual donor is named Caroline, I think you'd have to call it poetic justice).

This Craigslist post is a new wrinkle in the method employed by Todd Krampitz this past August. Krampitz caused outrage when he bought billboard space and took out ads, all asking for a liver. Some feared we were heading toward a system where the wealthy could publicize their need for an organ, but the poor would suffer in anonymity.

Yet the Diamond family has achieved at least the publicity that Todd Krampitz did, even though posting to Craig's List is free. I suspect, however, the "me-too" posters are less fortunate.

There's lots of potential stories here:

1) the New York Daily News editor replacing "ailing" with the misleading "dying" in the front-page story (Diamond's condition is managable).

2) the fact that Krampitz, as far as we know, has a malignant tumor that will likely claim his new liver in time. Did the donors know? Do people lining up from Diamond know he's not dying (see #1)

3) Dave Winer tried something similar on his blog last year, for friend Dave Jacobs. The attempt failed to catch on and Jacobs is still waiting for a donor. Is online solicitation really the way of the future, or simply a case of using the right publicity at the right time?

4) Will any of these public cries for help raise awareness about the shortage of organs? Or, better yet, lead to any improvements in organ recovery?

I was fortunate to recieve some informed commentary from a Gift of Hope coordinator. He has written before on the details of organ recovery (pdf, page 6).

He wrote a lot to blogborygmi, but Haloscan cut it off. Also, it was the comments to an unrelated post. So I'm reprinting what I can here, because his expertise deserves at least as much space as my armchair meanderings or the Daily News' sensationalism (emphases mine):

Private publicity campaings since they are cheap, and at least in the case of Mr. Krampitz effective are here to stay, but they shouldn't be dismissed as being without consequence.

The current UNOS policy on "directed donations" allow a donor family to name an individual to receive a specific organ. If the organ is not a medically suitable match it is then allocated according to UNOS allocation policy. (A family cannot btw discriminate based on age, sex, race, religion etc., nor can they demand that a class of patients such as those with HIV or alcoholic cirrhosis be excluded as a possible match).

There is no requirement that the donor or their family have any pre-existing relationship with the potential recipient.

The donation/transplanatation community is in an difficult position, because we need publicity to raise awareness of the need for families to consent to donation, and there are few effective options for touching the hearts and minds of the public beyond attaching a real individual's face and story to a faceless group of 87000 people. Private publicity campaigns certainly raise awareness.

To further complicate mattters, each cadaveric donor, on average donates 3 or 4 organs (up to 8 are possible) and many more benefit from tissues recovered from such a donor. Aside from the "directed donation" of a single organ, many more can benefit from the donor's gift. So while one organ may be allocated "outside the system", several more would be used for those determined to have the greatest need.

It is possible (though hopefully unlikely) that creating a policy denying the family the option of "directed donoation" to someone they have no relationship with could cause them to refuse donation altogether, which helps nobody.

If things are left as they stand, there is a good chance that public pleas for a directed donation will become so commonplace that they will fade into the noise of the information age and lose their impact. Another outcome is that such pleas may cause the American public to lose faith in the allocation system altogether.

We have reached a point in the shortage of donor organs where transplanting the entire waiting list of 87000 is a mathematical impossiblility. Our only hope is to continue to refine the system to prevent death on the waiting list by transplanting those with the most urgent medical need first. Poll after poll of the American public confirms that this is the way they want the allocation to be done. By circumventing the allocation system through directed donations on a large enough scale, this barely feasible goal will become impossible.

The policy on directed donations must change, sooner than later, before either scenario can come to fruition. But we can't seem to get across even the most basic of messages in many cases, and trying to get the public to understand that such a change is for the greater good would be difficult indeed.

Looking at the statistics, I'm inclined to think the transplant situation in the US can't get much worse, or at least, these "outside-the-system" efforts won't hurt it. Also, I'm heartened that the UNOS people seem interested in what polling Americans on what they prefer, and try to get the public to understand the donation.

I think it's pretty clear what allocation system the Diamond and Krampitz families prefer, if UNOS is polling them. And really, whose voices matter most in these situations: those of the patients and donors, or those of the masses, who UNOS can't seem to educate anyway?

But my few encounters with the transplant process pale in comparison to what the UNOS people endure every day. I just hope their frustrations aren't blinding them to radical but promising solutions.

Vocal Folds

I began writing a song last night in the ICU. It's called "Midnight Bronchoscopy." It's blues, based on the alarms of the mechanical ventilator. I'm particularly fond of the alarm progression that, when you let your mind go, almost sounds like the machine is saying, "I-am-not-breath-ing." If anyone with skills can get an mp3 sample of this alarm, I'll cut you in on royalties.

All I know so far is that the song begins, "Midnight bronchoscopy / what have you done to me?" I'm not sure if it's told from the patient's perspective, or that of the sputum-covered student. I think the song should end on an upbeat note, too, with some improved breathing, some samples for micro, and the promise of a portable chest film ruling out bronchopleural fistula.

The Hand of Spector

Jonathan Spector is many things to many people. Now, he's developed a relationship with the good folks from Passion of the Present.

When you combine his ground experience and Passion's, well, passion for raising awareness, I hope good things could finally happen for Sudan.

And if that doesn't work, they're re-recording "Do They Know It's Christmas?" This version will feature Keane, Snow Patrol, The Darkness, Dido, and Radiohead's Thom Yorke. Bono returns with his piercing lyric, "Tonight thank God it's them instead of you." Blur's Damon Alban was on hand but did not sing.

Hat tips: Ingrid.