Grey's anatomy, First episode. and Grand Rounds

I couldn't resist another Grey's Anatomy post. This sunday I saw the first episode (rerun) and it answered some questions. First, Miranda is a resident. Just a simple resident, which was a let down because with her attitude I had her pegged for Chief Resident. Now, she's too bitchy to be just a resident.

Second, they are supposed to have a seven year residency which I found strange since most Surgery residencies are only five years. But at least they won't have the same problem 'Scrubs' has with running out of residency years too early in the show.

I could see why the show caught on so fast. The first episode was a little better with Surgery handling Seizures and the usual Attending begging brand new interns to figure out what's wrong with his patients. Reminds me of my intern year when my Attending practically knelt before me and kissed my feet so that I would bail him out and mis-diagnose everything! (they're INTERNS).

the series opens with Meredith Grey sleeping with Dempsey. They act as if this is so casual they don't even know each other's name. Except this really doesn't fit with the Ms. Grey we've come to know. It's terribly out of character.

OK, no more Grey's Anatomy for this year. Maybe forever, the show really doesn't interest me so much any more. I feel bad switching to reviewing 'House' since others are already doing it. But hey, it's my blog.

Grand Rounds is here.

Update: Tangled Bank here

Cold

We were married three years ago on a beautiful summer night in a kibbutz near Tel Aviv. I remember how beautiful my wife looked and how much in love we were (still are). We were inseparable then.

We recently visited a friend with whom I've lost touch. The last time we were at his home was one month before our wedding. The planning was beginning to take its toll but we still remained true to each other, inseparable.

He greeted us in his living room. We were shown into the house by his wife. We hugged and shook hands upon seeing each other for the first time since. When we sat down he broke into wild laughter and his wife's face slowly broke out with an infectious grin."What", I asked, "is so funny?"

"Well", he said, "I remember that when you two were here three years ago, before your wedding, you were sitting next to each other all the time. She held your hand, kissing it very gently and you wouldn't even leave her to go to the bathroom".

I wondered how that was relevant to his laughter. So I said "How is that relevant to your laughter?"

"Well, look at you now. Three years later and you're sitting on different couches all together. No more hand touching, kissing. Now you really know what it's like to be married."

I thought it was a funny observation and it reminded me of a recent thought I had after reading a study published on the infectious quality of the common cold. The cold is by far the most common complaint seen in a primary clinic. It is transferred by hand to hand contact and costs the U.S. a tremendous amount in healthcare costs.

The authors, attempted to study the infectious quality of this virus. They wondered what percentage of partners of individuals infected with the common cold would show symptoms attributed to the virus. Their results: 38% rate of transmitted infection.

Of course this is an average, which brings me to my next point. I would have loved to see subgroups incorporated into the study. Maybe stratisfying the groups into newlyweds, couples married >1 year but <3; and couples married for more than three years. I have my hypothesis on how the subgroup analysis would pan out. I think it would look something like this:

Newlyweds: Rate of transmitted infection 80%.
>1 year but <3 years: Rate of transmitted infection is 40%
Couples married more than three years: Rate of co-infection too insignificant to be detected using current scientific methods.

Try not to think about what my hypothesis says about my life.

Books for Sale: Look, I’m like Barnes and Nobles

Those of you who have read this blog for some time now have witnessed my pathetic wining at the debt I’ve accumulated studying to be a physician. Likewise, my sad attempts at making a few dollars off this venture have brought you to the brink of nausea. Those who remember my humble beginnings with a blue template remember the Google ads that did nothing more than dirty my up my blog. Since the ads were guided by keywords they continually pitched “Residency Finders”. Too bad not enough foreign med students trying to find residencies read this blog. That whole attempt at profit grossed me exactly no dollars and no cents. Let’s call it “Unsuccessful”.

Now, I am trying once more but this time with something that makes slightly more sense. In case you haven’t noticed, I’ve installed an Amazon search box on this page. Its right below that long link list on your left (Go ahead, scroll down). Above the search box I’ve also listed a few of my favorite books. I thought I’d take this opportunity to try and pitch you some of these. If you like reading this blog I have no doubt you will love these books.

“Complications”
This book is a compendium of essays written by Atul Guwande”. Guwande is a surgeon and a master writer. In this book he writes about his experiences during residency. Each experience is a gateway into a discussion that explores the power and the limits of medicine. His writing is superb and he will give you a first hand view of what goes through a physicians mind when the going gets rough. That’s when one encounters “Complications”.

I highly recommend this book.

“The House of God”
To the medical personnel reading this blog I think this book really needs no introduction. If you like reading this blog, which began with a set up very much akin to the House of God, you will LOVE this book. It’s an extremely telling satire comedy about the state of medicine in the 1970’s. It’s funny, sad, emotional and a great read. It’s a book you won’t be able to put down without finishing.

I often make references to it and I’m sure that those who haven’t read it are left puzzled as to what my intentions are. This is your chance. This book is the bible of medicine and often gets quoted in actual practice, usually as a punch line, but nonetheless is a must read!

To the medical students or residents who have not taken the time to read this novel, SHAME ON YOU!

Tarascon Internal Medicine and Critical Care Handbook
The absolute best pocket guide for any intern or resident. It has everything you will need to know on an emergent basis. The rest can be studied on UpToDate.

Fear and Loathing in Las Vegas
This book is just a big’ol drug trip! After a long call, this book will do it for you.

Well, that’s my pathetic attempt at selling books. Again I’m reminded of why, after getting fired from my third sales position, I realized my true calling is medicine. I plan on changing them intermittently, whenever I get inspired to recall another great novel I finally bothered to pick up.

If none of these books picks your interest, well, just use the search box to find whatever you would like to buy. Of course, you can always go to Amazon and cut me out of the action. But, really, the price is no different there and that just means Amazon gets all the money. Why would you ever do that?

In case this doesn’t work I may just have to put one of those pathetic “Donate” boxes from Paypal on this blog. But that would be a real low and no one really wants to see me go there.

Happy Birthday Madman

It’s my birthday today. It’s always during Memorial Day weekend. So, I hope everyone out there has a piece of cake for me, or a beer. Forget it, make it a good barbeque.

Happy Weekend everyone.

Great Reading

today there are three carnivals that I'd like to inform you about. Lots of great reading for the weekend.

First, my favorite Skeptics Circle is up promising an enormous collection of debunkers! (your's truly, among them for the first time)

Second, The COTV is quite "alarming" (I'm sure everyone's been using this same line).

Finally, The comedy festival is up.

One of my Loves

Last week's New England Journal of Medicine contains an essay written by Katharine Treadaway (Free full text here) that I thought I would share with you. She is an assistant professor at Harvard medical school where she teaches the patient-doctor course.

The essay is a reflection on her goals as the teacher of this course. Most striking, are the points she makes concerning the typical evolution of medical student to doctors:

I watch the second-year students file into the Ether Dome for their first day of my "Patient–Doctor 2" course. For me, this course marks their true entry into medical school. Here, they will refine their history-taking skills, building on their knowledge of pathophysiology and disease; they will learn how to perform a physical examination; and they will touch a living stranger's body as clinicians for the first time. For them, right now, these are just skills to be learned. They do not see how they will be transformed by them.

I remember my embarrasment during my first physical, I did everything wrong. I listened with the stethoscope to the heart sounds, then palpated the abdomen, went back to the stethoscope for lung sounds, then palpated, back to stethoscope etc. I suppose the crackles I heard in her lungs were really just quiet chuckling.

But was I transformed? I am more cynical than ever, more suspicious of others than before and more skeptical about what I hear. This is positive in a sense but it also makes for a negative view of reality. On the positive end, my understanding of the human condition (What people actually go through and endure) is so much greater now.

They do not understand the importance of what they learned last year, because they do not know how powerful they will become, how patients will hang on their words, how devastating a careless word can be. They do not know how they can "do everything right" and still be ineffective because their behavior has alienated a patient who therefore never returns or does not take necessary medication.

I think this point is just so important. It really never occurred to me until I heard my own mother recall what her own doctor had told her. Something didn't fit and so I contacted the physician myself. I learned that hearing is selective, especially my mother's.

Patients have so much respect for everything you say. Sometimes this doesn't come across in an encounter. One wrong word is all they remember. One chance is all you get, choose your words wisely.

Studies suggest that medical students become less compassionate by the end of medical school, that during the process of professional socialization, their original "commitment to the well being of others either withers or turns into something barely recognizable." In between, they have shifted their focus from the patient to their own learning process.

Is this universally true? Of course not. She’s right in that it happens to most medical students and residents. It’s a consequence of feeling overwhelmed with the body of knowledge one must master. It definitely happened to me as an intern. I’d like to think that as a second year it's resolving and that I now see patients as human beings, friends even.

To try to make it real for them before it actually is real, before they think that the entire purpose of taking a history and performing a physical examination is to develop a diagnostic plan and then a treatment plan, instead of understanding that this is only the beginning of caring for a patient.

Oh boy, I’m sure my medical colleagues can agree on this one comment: “Tell us about it!”

This is one of the extraordinary things about medicine, I say: it is an intensely intellectual endeavor, demanding that you learn and understand an enormous body of information and that you constantly update that information as new knowledge becomes available, but it is also an endeavor of your heart. At the same time that you are learning about disease and diagnosis and treatment, you are learning about illness, the patient, and yourself.

You will learn things about others that you could never imagine, good and bad. You will learn about the human spirit things which you will never be able to convey with words. Most importantly, you will learn places in your heart you never knew existed.

You will discover the bright and dark sides of your soul.

CSI Medlogs: What the hell happened to CodeBlueBlog

Can anyone fill me in on the sudden discontinuation of one of my favorite blogs?

Grand Rounds

A host of witty remarks, today, at the Chaplin

Prove it Prove it and I Still Don’t Believe it.

This time I promised to make a submission to the skeptics circle. I’ve been debating who to victimize? Why, there are more than your fare share of scoundrels, thieves, and con men on the World Wide Web to fill Alcatraz seven times over.

Should I aim my wrath at the herbalists that swindle people’s money without a conscience? How about the homeopaths? How about the world of medicine? Why, I would never consider myself a con man. I’m a physician, trained at providing the best of care, using methods clinically proven to be effective, or am I?

We, as physicians, often discuss how medications should first be proven with appropriately conducted trials. To be more precise, what we mean is a trial conducted by a prospective double blind method. In english, that means the drug is tested over time with neither the physician nor the patient knowing whether they are taking the studied dose or the placebo/medication used for comparison. Thus, the design limits bias. There are a number of other trial designs, but that is another topic for another time. The double blind method is considered to be the most accurate.

But what would you have of a double blind trial that was designed well, limited bias, and showed a significant beneficial clinical correlation favoring a certain new medication. Should doubts continue to linger in a physician's mind or should he/she accept the conclusions as self-evident, absolute truth.

A physician or patient should seek one more critical piece of information, Where did the funding for the research come from?

The pharmaceutical industry now spends more on research in the United States than the National Institute of Health (NIH). Research that is unfavorable to the sponsor- meaning, trials that prove that the drug is less clinically effective, cost effective or safe than other medications used to treat the same condition, can pose very significant financial loss. This pressure may result in biases in trial design, outcome, and reporting of research sponsored by the pharmaceutical industry.

A recent systemic review in BMJ (Free copy available here) found that in research conducted by the pharmaceutical industry systemic bias favors the products which are made by the company funding the research. They found that their results applied across a wide range of disease states, drugs, and drug classes over at least two decades and regardless of the type of research assessed. The authors hypothesized four possible explanations.

First, companies may selectively fund trials on drugs that they consider to be superior to the competition. This is unlikely, since researchers could never predict results of trials in advance.

A second possible explanation could be that positive results could be the consequence of poor quality research conducted by the industry. However, the authors concluded that the research sponsored by drug companies is at least as sound as methods in research funded by other sources.

Other explanations include selecting an appropriate comparator. Often, doses of the medications being compared are not equivalent and a paper by Safer reported that in trials of psychiatric drugs the comparator’s drug is often given in doses outside the usual range or there is a rapid increase in the dose of the comparative drug, thus increasing the likelihood of side effects.

A final explanation suggests that publication bias may explain this finding. Research funded by the industry is less likely to be published than research sponsored by another source. Critically, the studies did not point out whether non-publication applied only to research with non-significant outcomes. The publication of these results would be harmful to the advancement of a new medication.

Most of the Giants (Older, wiser physicians) I know refuse to prescribe any new medication until it’s been on the market for at least 5 years. I believe that sounds like the advice of men who’ve learned their lesson. This brings me to the last and hardest to attain ingredient in making a great physician. Experience is everything!

Grey's Anatomy, Who's Zoomin who: A Resident's Review

As I sat twitching while the writers managed, once again, to make a blunder out of what happens in real medicine I had a very illuminating thought. What if I stop considering Grey's Anatomy a medically oriented show and rather begin considering it as a world within itself, seperated from the world I live in.

I prefer to think of it as a spin-off from Desperate Housewives. I mean, what is the real difference? Everyone is sleeping with everyone.Its a sopa opera within itself. It's own imaginary world.

Shall we explore this world:

In Seattle Grace Hospital Surgery is the only residency. This is why Surgery must handle all medical issues. In Seattle Grace Hospital there is no medical hierarchy, there is no accountabiity, interns do Everything without supervision. Attendings sleep with interns, the staff sleeps with everyone and surgery interns are so friendly that they feel perfectly comfortable discussing masturbation, sex, and even strip naked, at every oppurtunity, in public. None of this has any consequence on their proffesional reputation. In the world of Grey's anatomy, when hearing hoofbeats, think Zebras. I love this world. Oh why can't the Mad House be in Seattle?

The season finale seemed more about the internal conflicts than about actual medicine. It was intended to make sure we come back when the super-six return for a second season.

1. Mr. Fragrin and the Cirrhosis.

In Cirrhosis of the liver scar tissue replaces healthy liver tissue. Most commonly this happens as a result of alcoholism but other, more rare diseases, can cause it as well. Due to the decrease in productions of proteins by the liver Ascites often results, a condition where fluid accumulates in the peritoneal cavity, the abdomen. Yang and Izzy perform an abdominocentesis and the patient dies during the procedure. In order to prove that the death was not of their doing they perform an unauthorized autopsy.

Paging Surg-path intern you're needed in the morgue! (For the death of your own career).

These 'expert' pathologists discover that he had a condition also known to cause cirrhosis (much more rarely though) called Hemochromatosis. It is a genetic disease that causes excessive absorption of iron from food. This iron accumulates in the liver, pancreas, skin and heart and can cause Cirrhosis, Jaundice, Heart Failure and Diabetes (Often called 'Bronze Diabetes').

It's much more rare than alcoholism but we must think Zebras. For fun, I suggest attempting to perform your own unauthorized autopsy. I take no responsibilty for what happens.

2. Gonadal Hermaphrodism: A case of a man, Burke's best friend, who presented with hematuria (microscopic amounts of blood in the urine) that led to a cystoscopy. During the procedure a mass was found that was later diagnosed as an ovary.

The condition is a congenital defect that is present at birth. The genitalia are usually ambiguous and these children need surgery to correct the appearance. A finding such as this in a thirty year old male is unlikely in that he would have surely known about his condition.

The story gets more convoluted for drama, his wife is pregnant. His condition makes it impossible for the baby to be his and so Burke discovers the wife's infidelity, which he now must disclose. Talk about a bummer? how would you like to find out you have ovaries and a wife who cheats. Poor Burke doesn't know he's got a doozy coming his way next season!

Paging Surge-Psych!! Surge-Endocrinology! Surge-gyn!
Paging some sanity in an impossible world.

The story of Yang's pregnancy doesn't really continue. We are left to wait for next season.

As for Dempsey and Pompeo (Meredith), the last scene is a cliff hanger as Dempsey's wife spontaneously appears and says to Meredith:

"Hi, I'm Mrs. Shepard, and you must be the bimbo who's screwing my husband!"

Ouch!

I bet they're seperating, otherwise, why would Dempsey be sleeping in a trailor?

BTW Ms. Pompeo, my wife hates your eyebrows. Sorry, she made me put that in.
Until next season, this is the MMM signing off on my round-table of a mediocre medically oriented soap opera.

Dangerous, Do not Touch

Recent evidence shows that physicians are less likely to report errors made in the course of patient treatment. The reason most often cited for this lack of reporting was fear of legal action. Thus, this has become a significant obstacle in improving patient care and working towards safer and more efficient methods. Recently, many programs began implementing anonymous reporting systems as a way to circumvent this fear, in the hope that reporting of adverse events would increase.

The program director of the Mad House Medicine Residency program announced that he would install a reporting system on our residency website. The system would be completely anonymous and would allow the interns and residents to report situations in which patient safety was endangered in various ways. It was, after all, a relief. A system of instituting interventions which ultimately will lead to less morbidity and mortality.

But then how was I expected to restrain myself from reporting what I know to be the greatest danger in our hospital? Believe me, I tried. But unfortunately, one day after the system was instituted, much to my dismay, I found myself writing an email that clearly explained what I thought to be the most threatening factor to the future health of my patients:

“Medical Students, Interns, Nurses, and Me”.

Grey's Anatomy Season Finale Tonight

The last two weeks have included the best of Grey's Anatomy and then the dismal bottom (or so I hope). Tonight is the season finale, review tomorrow. I hope for a good show.

God what if we couldn't inject morphine for the pain? how in the world would we dull the agony of residency?

It's Morphine's 200th birthday. Go to the party.

Go Laugh

I know I've been kind of light on the medical comedy lately. It's not that I can't think of any it's simply that I've decided to outsource. So go have a good laugh at the Carnival of Comedy. Somehow, my entry was intercepted over the world wide web (I'll give the host the benefit of the doubt for not including my entry). Well, there's always next week.

The Carnival Introduction Tradition

Staying true to my Tradition of wrapping up any Carnival hosted here it's time to do a roundup of the most interesting introduction links written by my fellow bloggers.

I have to be honest in that I really didn't like how the Carnival turned out. I've been thinking about different themes for about two weeks and after trying out three different themes (Which came out horrible) I scrambled to put this one together in the last minute. On the whole, I think it came out interesting but I wish I would have thought of something more creative. I'm kicking around the idea of hosting the Carnival of Comedy but it'll be a long time from now (I am tired!).

Hosting a Carnival is no small task. Thirty entries take time to read and, honestly, some are really not "up my alley". Which means I either misunderstood the piece, didn't have the expertise to judge whether it was true at all (which is probably what happened with the Einstein God piece that's getting objection for being included), or, really wasn't very interested. Mostly though, I did enjoy the majority of the entries.

So on to the fun task. First up:

Orac linked with this entry:

"Hey, wait a minute! Debunking quacks and dubious alt-med is my territory! (OK, it's also the territory of Peter, Anne, Paul, Skeptico, and others, and I know I've gotten derailed a bit dealing with "intelligent design" pseudoscientists during the last couple of weeks. Don't worry, though, the alt-med stuff is coming again next week.) And, worse, the Mad House Madman is funny about it. Now I remember why I stole his idea for an interesting and unusal format to do Grand Rounds when I hosted my first blog carnival way back in February. Damn. If I had known the Madman's intent, I would have submitted this article instead of the article about the risks and benefits of phase I oncology trials that I did submit".

So there Orac, you just did submit that link. Anyways, I love most of your entries so I have no problem hosting another post of yours.

Although debunking alties isn't exactly my territory I am hoping to make it into the next Skeptics Circle. Heck, maybe I'll just submit the Tangled Bank for it. I hope to come up with something original to debunk, but I'll start slow. For now, I've debunked the fact that your the only debunker in town (except for Peter, Paul, Anne, and Skeptico).

St. Nate:

"And, once again, the Madman has taken a very creative approach to the project and arranged them like a row of alternative medicines. Yeah, he's crazy, but it's a fun kind of crazy".

Depends who you ask. Some of my patients don't think it's so "fun". But I hope you do.

BTW, I have absolutely no idea how Nate, Orac and Charles were the first entries. I mean they gave their submissions in so late, except for Nate. Really, how in the world did they end up at the top?

And I loved this one (Great Job) 10,000 birds:

"If television has taught us anything (and hasn't it taught us so much?) it's that medical professionals lead tragic, tortured lives. Misanthropic Becker, bitter House, and the agonized souls in the E.R. all explore the depths of human misery, their only crime presumably being that they care too much. Bearing the weight of the world on your shoulders and a stethoscope around your neck clearly takes its toll. Bones McCoy was gripped by a Messiah complex, Dr. Bombay of Bewitched obviously suffered from syphilis-induced dementia and Quincy was ostracized by the medical examiner community because of his closeted relationship with his finicky roommate. Further examples of doctors, nurses, and dental hygienists ruined by their profession are legion, at least on TV.

The Mad House Madman of Chronicles of a Medical Madhouse is obviously another casualty. At this stage in his career, this second year resident seems to have already cracked under the strain of medical practice and has been reduced to peddling dubious wares via the twenty-eighth installment of the Tangled Bank. By all means, you should examine this fascinating case study".

I just love it.

That wraps it up. If I had to pick a site I discovered from the Carnival that I just love reading it would have to be Mindhacks. I'll add it to the sidebar, somewhere.

Tangled Bank #28: “Alternative” to a Healthy Mind

Welcome to the Tangled Bank, a carnival that’s everything scientific. The Tangled Bank has evolved over the year to include medicine and topics closely related to science. The Medical Mad House is proud to host this wonderful carnival in what we hope will be another success.

We wanted so badly to be original that we decided to highlight, for the first time in Tangled Bank history, some of the more questionable practices of medicine. We therefore reached out ot the homeopaths and the herbalists for submissions. Quickly, we learned how to swindle people's hard earned money ourselves and developed our own Mad House line of products. If you would like to purchase any please email me at I’m_a_sucker@Madhouse.com

I encourage you to read all the entries as most of them were well written and very interesting. The highlighted link is the only part of the introduction that's related to the post. Don't understand what I mean? Read on.

But remember, I am a second year resident, which automatically denotes a certain amount of residual psychiatric pathology from internship. So if you don't love the "theme", blame it on the haldol.

Shall we begin?

St. Nate's All Natural Olive oil and Garlic Mix
This first line agent for life threatening disease has never failed in clinical trials (We’ve never conducted any). Our medical expert, the health minister of South Africa, recommends the supplement to cure AIDS in his country. Look at the great results he's getting.
Side Effects: Stupidity, Lunacy, Delusions, and Dying of AIDS.

Dr. Charles Green Man Stone Carvings
Sure to reconnect you with Mother Nature, you will feel soothed and naturally cure hypertension and diabetes. Simply crack one of these over your head every morning.
Side Effects: Hemorrhage from cranium, epidural bleed, subdural hemorrhage, contusions, and induced mental retardation.

Orac's Phase I Easy to Swallow Powder
Ever wanted to know how Oncology Phase I trial are chosen and conducted. This essential remedy contains mountain daisy and marsh tea and is proven to cure resistant cancers. My grandmother's sister's husband's former roommate from college knows this guy who was instantaneously cured by this stuff. Really!
Side Effects: Advance in Stage of Cancer. Loss of internal organs unnecessarily

Andy's Natural Killer Cell Evolutionizer
This anti-pathogen cream is made of an Epstein Barr Virus solution combined with poison Ivy in large doses to boost you body's Natural Killer Cell population. Didn't know you had Natural Born Killers? Sexy isn't it.
Side Effects: Lysing, complement fixation, spending excessive efforts engulfing or just golfing.

The Milkriver Xeric Snail Complete Kit
A medicine par excellence to cure the possible decline in this magical species and will increase your enthusiasm for life and give you that energy you've always wanted. You will magically lose weight when combined with appropriate diet and exercise.

Einstein God's Darwinian Supplement
Feel unable to respond a creationist appropriately? Simply omit Spencer from the argument and this supplement allow you to think more freely and rationally.

Bnug Ferret Cocktail
Specially engineered to combat nausea or induce it (we're not sure).
Side Effects: Retching, Vomiting, Nausea, Wishing for death as you hover above your toilet so that it will all end.

Kelly's Fluoride Flavored Powder
When given in small doses can be toxic to tooth-decaying bacteria. Recently it was discovered as a toxic compound, did you know this? Neither did Kelly. We’ve decided to change marketing strategy and sell it as insecticide.
Side Effects: Insects with clean teeth.

Circadiana Circannual Rhythm Chant
Ever feel tired after strenuous exercise or a large meal? Chances are your circannual clock is not accurately functioning. The Chant (Melody and words sold separately) is meant to be sung in public and is known to increase the amount of riboflavinoid Manisticast in muscle.
Side Effects: Appearing unintelligent, Psychiatric hospital admissions, possibly some jail time.

Technogypsy Soda Pop
Wonder how much science goes into making a simple soda bottle? Simply buy this drink and place it on to increase your taste bud sensitivity level and waste your hard earned money.

The Harvester Butterfly Compound
An introduction to this magical species of carnivorous butterflies. The shell of this former caterpillar is ground and mixed with “ultra-plasma”. Also buy Harvester stool, which is known to have a high percentage of gastroflabric flavinoid, a first line agent in fracture treatment (you must first get the fracture cast first)

Bootstrap's Ivory-Billed Woodpecker Wood Extract
An account questioning why the US government doesn't help the Woodpecker where they do know it exists? A pure extract from Cuba made from bird droppings. Guaranteed to not be guaranteed.

Political Calculations Easy Math Memory Tape
This book by Political Calculations on the easy to memorize mathematical system of calculating GDP will allow you to forecast the exact point at which this administration will drive the Gross Domestic Product into the dirt.
Side Effects: Bankruptcy and Property Seizures. Death by Uncle Sam.

Canadian Cynic Creationist Complex (Quad C Mix)
The magic quad C mix is made of marigold and Comfrey and was “directly observed” to be quite ironic.

Evolgen Chimeric compound (ECC)
What is a Chimeric gene you ask? The optimal treatment for deep cuts and bruises. This extract works wonderful, after stitching.
Side Effects of ECC are mild and include death, coma and persistent vegetative state.

PZ Myers Sea Monster Cream
What do you think of when you think of Kansas? The Niobrara is a geological formation where we found these special gems made to help with your typical this and that and give me your money.

Brentrasmussen Human Origins Cleansing Enema Treatment
By learning the origins of the hominids (that, hopefully, is you), we’ve discovered a liquid that’s equivalent to a deep rectal massage. I will save you the gross details.
Side Effects: Gross Details

Feministe Female Orgasm Original
A soy based formula to help your possibly useless female orgasm and designed to stimulate and indulge the mind’s more erotic centers. Work when used in conjunction with good sex.
Side Effects: Let's face it, even I would buy this.

Rhosgobel's Antibiotic Resistance Resistor
Know how bacteria acquire resistance? No? We can definitely sell you some of this useless crap then. Made of seaweed and salmon serum it’s designed to protect bacteria from the damaging effects of antibiotics, and useless other things.

Blogology 101 (Great name BTW) Pundit Silencer
Just load this wonderful pistol and aim it at your television next time some science pundit appears on MSNBC and says a whole bunch of crap that's not true. Now, pull trigger!

Aydin Stupid Mummy Recipe
Investigation into Mummy curses have led to an interesting finding. We just don’t have a pill for it, yet!

Sound and Fury Dark Matter Combo
What fills the galaxy? An extract to improve dark matter vision, it will open your eyes to the wonderful world of astrology. The only downside of this wonderful extract is spending valuable time thinking about astrology.

Ware Farms Genetic Sexual Device
Since Sexual orientation is coded for in genes we've invented this easy to carry Quick Sexual Orientation Analyzer. Easy to afford in 3 simple payments of $89.99.

10, 000 Birds Sexual Dimorphism Decoder
Ever felt like your hubby was better looking even though he's also human (I hope)? Now you need not wonder why. The process is called sexual dimorphism and if you buy this decoder absolutely nothing will happen.

Organic Matter Wollemia nobilis Resurrector
Stumbled across an extinct species recently? Once Believed to Be Extinct, Wollemia Nobilis may just be your key to the next great discovery. But it’s unlikely.

Vaughan’s Depression Pick-Me-Up Workout Tape
Some scientists have determined that depression is a "physical disease". Duke Tightbutts, famous celebrity trainer, will help you squeeze and flex those blues away. Take control of your life, your mind, body and your bank account.
Warning: wearing tights may make you look silly enough to push you into further depression.

B and B GIFTS Package
Ever heard of Geosynchronous Imaging Fourier Transform Spectrometer? It’s a NASA mission that led to the discovery of our holy crap I’m drained out of ideas and this theme is long past overused. It’s a great article, read it.

Joshua Starling Prepackaged
A Starling grapples with a predator. Since starling are evil we can’t use them in any of our "medications", I use that term loosely.

Cameron offers a variety of computer projects others can participate in. He calls it computer research.

Dave's Drum Machine
Demonstrating how tempo changes mood and an interesting experiment that showed how drummers convey different emotions buy simply changing the tempo and volume of a drum.

So feel free to celebrate life to the sound of a different drum.

That wraps it up. I would like to thank all thirty contributors for taking the time to write such great stuff simply for pleasure. I had a wonderful time reading your entries. Thanks to PZ Myers for letting me host the Carnival. E-mail host@tangledbank.net if you would like to host or for submissions. The next Tangled Bank will be hosted on June 1st at Organic Matter.

Finally, when I was in eighth grade a banner hung above the blackboard. It was a quote by William Harvey and it read "All that is known is infinitely less than all that remains unknown", so get to work.

At the Front

Future Intern wanted a front row seat for tomorrow’s Tangled Bank. How could I say no to that face.

Tangled Bank, Last Call

Last call for the Tangled Bank. All submissions should be in by tomorrow 6 pm EST.

Suddenly there was a tremendous inflow of submissions. Way to go guys, better late than never. I have them all. It should be a good one.

See you Wednesday.

Gray's Anatomy "Save Me". A Resident's Review

I am contemplating changing series. Maybe, I'll begin to review "House" or some other medical oriented show, something on cable.

I really don't even know where to begin last night's overview. It was just so bad. Just so terribly bad. I know I repeated myself, it's really from the overwhelming disgust that something so abundantly misleading could ever end up on network television.

How were any of these patients placed on the surgery service? Did they ever hear of "Internal Medicine" at Seattle Grace Hospital? Apparently not.

Opening Scene: Pathetic.

Dr. Shepard (Patrick Dempsey) wakes up at Ellen Pompeo's house with her fellow interns. He goes to the kitchen and eats breakfast with them. Everything is soooo cool and mellow. Yep, just your typical Attending sleeping with intern in over at other intern's house. Yo dudes, whussssuuppp!

Simply put, NO! If they only understood how ridiculous that entire scene seems to medical personnel. It undermines any last inkling of authority this Attending would have.

No further comment on this plotline, it's a real loser for me and highly unrealistic.

Lets get this over with:

1. Orthodox Jew with Presumable Endocarditis: I say "presumable" because no one ever specifically states she had endocarditis. They say she had a dental procedure, then a fever, and now she needs a new valve. I'm assuming it's endocarditis. It's a recurring theme with this show where we have to guess the diagnosis. Like the unknown "advanced carcinoma" (we'll get to that soon) so I'm guessing the budget is too tight to bring in a medical consultant who can spell the diagnosis and teach them how to "pro-nou-nce" it.

The writers/directors screwed this story up so royally. First, endocarditis is an Internal Medicine case. Second, I am also an orthodox Jew and have never even heard of such a RIDICULOUS argument as to say that a porcine valve would be unkosher. Seriously!

Third, if you decided to make her orthodox, even have an outright argument with her parents during the show about the merits of reform Judaism then she would need a MALE rabbi, as one of the BIGGEST differences between Orthodox and reform Jews is the fact that the former does not accept females as rabbis.

Next horrible story line:

2. Seizures/Psychic man with the AVM: AVM stands for Arterial-Venous Malformation, it is the main cause of most subarrachnoid hemorrhages, a specific type of stroke. I will be brief with this one:

Seizures go to Internal Medicine. Surgeons don't do seizures. Surgeon's also don't do psychiatric clearance. Psychics don't really exist. Is this a medical show? I'm starting to have doubts.

Ms. Glass. Invasive "Carcinoma":

3. WHAT TYPE OF "CARCINOMA"???

Really, I'm getting more upset.

Mainly to highlight Chang's own conflict with her pregnancy this patient had the choice between her own life and termination of her pregnancy. Would have been a really interesting case, maybe deserved a little more attention. Could have used a lot less of the ridiculous couple.

however, The show's apparent need to be as non-specific as possible is harmful since it perpetuates the common misnomer of "Cancer". There are different types of cancer, each with it's own form of treatment, it's own prognosis.

BTW, Were they planning on calling Obstetrics? Really? You think you should call OB? Naaa....Why in the world would you ever call OB? C'mon, you're a surgeon.

Thank goodness this is the last one:

Mr. Walker and the ascending paralysis.

Tthis case was ridiculous. A Neurologist never sees this man, Guillen-Barre (The most obvious diagnosis) is never entertained, the MRI is negative and Dempsey drags this man into the OR and opens his spine, just to prevent intubation.

Wait, let's examine how surgeries are done: Pt goes to OR, pt gets placed in position, patient is INTUBATED!

Let me help you with this "pro-noun-cia-tion", can you say "mal-prac-tice"?

No wonder people misunderstand the way modern medicine functions.

Last night show was deplorable.

Grey's Anatomy "Save Me". A Preview

Of course tomorrow I will write a full review so don't chime in with your comments just yet (Save them so we rag together). I just wanted to lay out all the things I loved about this week's show in a well arranged, well thought out list:

1. Well...The show eventually ended

Meanwhile, why don't you go learn a little history at the History Carnival. Nate's Hosting.
Or...you can piss away all your time with posts that will not make you one bit smarter at the Comedy Festival at IMAO.

So which one will you choose.

Stop PISSING!

I've Been Upgraded

Just noticed that my status in the TTLB Ecosystem just upgraded overnight to Marauding Marsupial.

Marauding: "To rove and raid in search of plunder"

Marsupial: "Any of various nonplacental mammals of the order Marsupialia, including kangaroos, opossums, bandicoots, and wombats, found principally in Australia and the Americas"

I would like to thank everyone who links this page on their blogroll. I'm proud of my little achievement. Now I'm a roving Kangaroo. Maybe I'll change the name of the blog to "Roving Kangaroo". Naaaaa!

With the Tangled Bank coming and PZ checking out the site once in a while I'm happy to know I'm escalating on the evolutionary ladder.

Update: I've been downgraded again. Who deleted his link? (As they say on south park: You Bastard!)

The Skeptics Circle

I try not to make too many of these one liner entries but this is a carnival I've really grown to love. The writing is often great and the topics are so interesting. You can pick and choose, of course, but I'm sure it won't let you down.

I've been wanting to hand in a post for the longest time but couldn't come up with anything to write about. I guess I find I'm not that skeptical. Even when I do find someone who truly annoys me with some off base comment I often react very poorly:

"What the hell are you talking about?"

Or something like that.

I don't have the patience to sit and debunk their theory point by point. I often leave that up to the experts, my Skeptics Circle.

My next goal is to debunk something. St. Nate is hostin the next circle and in addition to being one of my favorite sites he's the one who began this whole thing in the first place. so I will make my debut there, I've decided.

This weekend I will be working on the Tangled Bank. Get your entries in because nothing drives a man more nuts than last minute integration. And I'm already crazy!

Dear NBC;

Recently, I’ve taken the liberty of reviewing medical television shows. I was not appointed this position by a higher power, no; I simply assumed the project as I realize it is missing from the blogosphere. During this time I have grown enough confidence to believe that my opinion counts and that often it is dead on accurate. I believe that my readers would tell me otherwise. I am turning to you in a desperate attempt to save the few fond and warm memories of a show I once loved.

When ER first aired it was a tremendous sensation. We were introduced to a staff of physicians who seemed to have a higher purpose. You showed us the intricacies of emergency medicine, trauma surgery and even departmental politics. The weekly compendium of complications and resuscitations were exciting, and at the time, different from anything we've seen before.

I still remember relating to Noah as a medical student, and how irate it made me when he, and all the other med students, always knew the answer. But I loved him no less. Yes, I even remember Lucy and the tragic end.

I can safely say that you alone have inspired a whole generation of wanttobe doctors. Many of my fellow residents owe their dreams solely to your show. Which makes what I’m about to write all the more difficult.

It is with sad tears that I say this to you. Not like an unwelcome stranger but more like a Forty year old son still living at home:

You have overstayed your welcome.

One too many codes, a few too many psychiatric rages, motor vehicle accident victims, medical students dying, burned out nurse stories. Too many child abuse cases and way too many physicians from past episodes unexpectedly popping up and mysteriously returning to full time posts.

Let’s face it; the original cast is long gone except for Noah Weiley. It’s like watching Guns and Roses after all the band members left to rehab, or died in their own vomit. Maybe a sports analogy would be more appropriate. I think the closest would have to be watching Micheal Jordan in a Wizards uniform. Yes, it was Micheal but you just felt sorry for him. It was unbefitting.

That’s kind of how I feel when I watch your show now, I’m disgusted. You’ve managed to take all the love I had for you, you spit on it, threw it in the mud and stomped on it incessantly.

I was sure that after the episode with the helicopter crash through the ER you would have thrown in the towel. Alas, I was wrong. I was horrified as you continued to return for more abuse. I now have no more pity on your soul. To me you will always be a constant reminder of how Seinfeld did it right. Couldn’t you learn what he was teaching? He wasn't that far away, only one half hour separated you both. You must have been aware of the concept, go out on top.

Now as Noah is finally about to leave you must come to this same conclusion. What is ER without Dr. Carter? We’ve watched him grow from a medical student. We’ve endured his drug addiction and now, even he is leaving you.

This is a sign. I beg you. Stop!

More Medical Blogs Reviewing Medical Shows

I happen to run across this review of House from Polite Dissent.

COTV

at Cynical Nation

Happy Independence Day

We Remember

Over the last eight months I have invited you into my world.

I began to blog as a hobby. Something that would allow me to unwind, share my thoughts, maybe, even meet a few people who would grow to know me as a person. Until now, I’ve shared a lot of my professional, as well as, my personal life with you. There is one area of my life I’ve never shared on this blog and it goes to the heart of who I am as a person, how I view my world, and where I call home.

I was born in Israel and moved here when I was ten years old. As opposed to my brothers, who at the time were much younger than I, the transition to life in the United States was difficult for me and I’ve always longed to return to my place of birth. I still do. Often, I will visit there and be reminded of my former life and how much I miss it. With my fellow Israelis I feel every tragedy that occurs there deep in my soul. I am disgusted, hurt, and horrified. The Israel I know is a wonderful place, with amazing vibrant people who love life, want peace and nothing more than safety for their children.

On the fifth of Iyar, 1948 (according to the solar calender) Israel won its independence. It is a day of happiness, festivals and pride. Israelis are extremely nationalistic. Each must serve three years (two for females) in the army as soon as they turn eighteen. The political situation in the area is such that they are constantly glued to news reports and political events and decisions..

This Thursday marks the fifty seventh independence day of a country once thought to be doomed to annihilation. however, so ingrained is our dedication to those who protect us that each year, one day before Israel celebrates it's freedom, we hold a day of remembrance for the heroes who have given their life to protect our freedom and this land.

This is a very sad day. Ceremonies commemorating those who have fallen are full of tears and relatives of those now gone tell the stories of heroes. The television is full of sad stories and the mood in the country is quite somber. During the middle of the day a siren breaks out all over the country and everyone stops for a minute of silence (Even people driving their cars on the highway pull over). Everything stops!

Eleven wars and conflicts in fifty seven years and there seems no hopeful end in sight. In each, Israel has only acted in its own self defense.

Today, I stand with my fellow Israelis to commemorate the soldiers who gave their life, the thousands wounded and the others who continue to struggle and die to combat terrorism.

Tomorrow is our independence day.

Grand Rounds

today they're straight to the point. So don't mess around just get there and read the articles and...well, that's it!

BTW, next week the Tangled bank is coming to the Medical Mad House and I still have only two entries. I'd hate to see my medbloggers under-represented. You know you'd get first billing. so get'em in.

Madhousemadman@gmail.com
host@tangledbank.net

It should be great.

Grey’s Anatomy: The Self Destruct Button. A Resident’s Review

Oh my, where shall I begin?

It is not entirely out of the question that someone on the Grey’s Anatomy writing staff has been reading my blog. I'm sure they’ve read through my review of the last two episodes (here and here).

In fact, they’ve taken such a dislike to my criticism, however constructive and supportive I may be, that they have devised a simple but effective strategy to deal with it.

“We shall overwhelm the resident with multiple plotlines so that he shall be rendered incapacitated, unable to think, and furthermore, unable to offer any criticism”.

Oh Let Me Count The Ways: Everyone finds out about Dr. Grey and Dempsey/Dr. Shepard, Clair from overseas with an over neurotic mother and an unnecessary gastric bypass, little child (yes, we take care of peds too now, what you haven’t heard?) with the fascinating case of Rasmussen’s Encephalopathy, Masochist bullet man, Crazy swallow key boyfriend, dear alcoholic anesthesiologist, and the topper, Yang (YGMNS) is PREGNANT!.

Did you really believe this would work?

In what I have to say would be the best episode yet, the Producers/Directors/Writers have decided to incorporate seven, yes this number is correct, plotlines into one episode. Some were more developed than others, some more interesting, but all in all I was much more intrigued that usual.

Take it from the top Sam:

The Affair: The opening scene sets the tone as a naked (but well-covered) Meredith Gray awakens in bed next to her favorite brain surgeon. The roommates are intrigued by the romp’opalozza that took place during the night that they sneak a peek at the lovely lover leaving.

Oh what a tangled web we weave.

The affair quickly spreads throughout the hospital and looks like it will only get more interesting as the season goes on. It will get her in more trouble. You can bet your life on it!

Dr. Grey, still not doing surgery interns just right, is involved in probably the most interesting case of the night, the young girl who travels overseas to undergo an unnecessary gastric bypass operation. Still, as much as I love to look at Ellen Pompeo, and as much as I hate the way she plays a surgery intern, she did manage to have the best line of the night:

“Why do I keep hitting myself with a hammer? Because it feels so good when I stop”

Clair: This teen wanted so badly to live up to her mother’s expectations and staying thin that she went overseas to have a gastric bypass unnecessarily.

I found this plotline really interesting. A quick search on the net turned up no previous cases. I am sure any licensed physician, even in Mexico, would have lost his license had he performed such a surgery on this patient.

She goes on to develop complications and when it’s all over now suffers of short bowel syndrome. She will never be fat again, unfortunately, for people suffering of this condition that is the least of their problems.

Short Bowel Syndrome occurs in people who have had more than half of their intestines removed. The etiology is evident in the name in that the main problem is the fact that their intestines are too short and therefore unable to absorb enough, or the right kinds, of nutrients to sustain life. They often need injections, IV infusions, and more of the same to properly develop. The most common reason for short bowel was resection due to severe Crohn’s Disease (IBD). Over the years, surgery to treat Crohn’s became discouraged and is confined only to extremely severe cases. Therefore, Short Bowel Syndrome is now rare.

Overall, great Psychiatry case. Oh wait, no psychiatrist saw her, hmmmmmm…

Jaime Haze: WE DON'T NEED NO STINKIN NEUROLOGIST

This is a little child with Rasmussen’s Encephalitis.

Fear not, even I had to look this one up.

You can find more information on it here. Of course it’s rare, extremely rare. But hey let’s face it, diabetes is not all that exciting and this is prime time television.

Rasmussen's Encephalitis (RE) is a progressive inflammation of the part of the brain called the cerebral cortex, which is made up of a right and a left hemisphere. The disease starts at one site in one hemisphere and spreads to adjoining areas on the same side. Curiously, it does not spread to the other hemisphere. The inflammation leads to loss of nerve cells and scar formation and usually results in severe disability. Although RE is most often diagnosed in children under the age of 10 years, it can also start in adolescence and adulthood. It is a rare disorder and probably affects one person in every 500,000 to 1,000,000.
Here is what’s even rarer. They had the correct diagnosis, in the right patient, and here’s the big bang, they even performed the correct procedure. Will the writers please stand up and give yourself a big pat on the back…okay…stop! The story was then complicated by an alcohol impaired Anesthesiologist.

Substance abuse among physicians is well documented and has become a significant problem. In some reports rates of alcohol abuse among physicians is the same as the general population, whereas substance abuse rates are slightly higher than the general population. One of the main problems is ease of access. Anesthesiologists are especially at risk because of their ability to obtain controlled substances through their work. This has become such a significant problem in the specialty that some advocates are pushing for random drug testing.

All other plotlines: Masochist bullet man got what he deserved. Key swallow boyfriend needs more psychiatric help.

Psychiatry, what’s that?

And keep family members and all other close friends OUT of procedure rooms. You ask why? Don’t.

Miranda is a chief resident or a resident. I finally figured this out. I am confident saying this, I’m unsure why.

They’ve committed to making Dempsey the “Brain Specialist”. Not quite confining him to “Neurosurgeon” so that he can scrub in on practically anything and I can offer no criticism for this paradox. Very underhanded and devious. I love it!

Yang is Pregnant. Nice hook into next week’s show.

More “bitch” please Dr. Grey.

Overall, loved this episode. I must say you’re improving steadily. I will continue to comment on your performance of course, but I will be picky. I will choose only some plotlines to comment at length and others for one liners. That will be my counter-strategy. Whadaya gonna do now?

We are Family. Happy Mother's Day ,and an Unfortunate Unhappy One

Over these last 8 months I've had the chance to interact with many of you over this blog. Many of the names on my blogroll are not simply people I read, they're people I've emailed and kept in touch with.

So, First, the bad news and then the good:

Shrinkette just lost her mother in law on mother's day. She wrote a post about it here. her email is shrinkette01-at-earthlink.net . She sounds pretty shaken up, please drop her a line.

Second: I would like to wish a Happy Mother's Day to everyone out there. All of you mothers are unbelievably special. and to those of you who have a mother and do not appreciate it enough. Take my word on it, when you're up at 3 am changing diapers and feeding your own baby, you'll finally get it!

Dear Wife and new MOM: I LOVE YOU. Happy mother's day babe! (Jordan)

Dear MOM (who never reads this blog): You ARE the BEST

The Inner Life of Blog

Ambivablog has a great entry today about the life of bloggers. I'm sure many of you can relate. Today, I have nothing, so there, I admitted it. Read some of my older stuff or

come back tomorrow.

Maybe I'll have something then.

Via, Althouse

But Would You Do It Again?

Red State Moron posts an entry from the Mercury News today:

"The everyday grotesqueness of medicine often doesn't sink in until they are given hands-on experience in the field -- usually after they have already spent years -- and countless dollars -- pursuing a medical career.

So Santa Clara University is helping its students determine whether they're cut out for it early, long before they even enter medical school. Pre-med students who land a much-coveted spot in a special university program shadow doctors, nurses, social workers, chaplains and business administrators at San Jose's O'Connor Hospital for the better part of an academic year.

They see births. And deaths. They learn how to remove a catheter and burp a baby. They watch the calming bedside manner of chaplains during a patient's final hours, and discuss how hospitals can keep financially afloat when caring for many uninsured and under-insured patients".

He asks:

“But do we need to help "students determine whether they're cut out for it early"? Does this accomplish the goal of recruiting the best candidates to medicine? Assuming we can agree on what constitutes the best.”

Most of the doctors I spend time with would say they didn’t really understand fully what they signed up for now that they’re physicians. Not that we don’t enjoy what we do. However, I would say that it’s much different than the glorious life I had expected. It’s tough, there’s a lot of stress, and yes, sometimes you even have to deal with all the disgusting stuff, like meconium landing on your shoes.

It’s the greatest job in the world and every day it’s more challenging than the other. Sometimes though, I do question it. Did I really understand the difficulties I would endure or was I blinded by societal expectations. My parents always told me how wonderful doctors have it, but they never mentioned the gory details.

But you know, spending time with physicians isn’t always detracting. I remember my mentors from medical school. They loved what they did, yes, even the parts that deal with human secretions, they loved those to. They inspired me to be the best physician even in times when they were tired and upset, and being taken advantage of.

In a way, when I’ll look back on my residency, many of my memories will be those few hours when being a doctor just didn’t feel so great. The times I felt inadequate to do the job but when I still had to. Those are the memories that stay with us. Pumping the chest of your favorite patient when you realize something went horribly wrong. Waking in the middle of the night to write a Tylenol order. Joking with the nurses about why they found it necessary to wake you for a Tylenol order.

I hope the students get to see the times when we have to succeed and yet, often, we fail. Those whom we helped will remember us as heroes. Those whom we failed will teach us another lesson in how to succeed. I do hope they see these moments of vulnerability because that is what a physician is; he is a compendium of all the triumphs and miseries, of all the victories and losses. That is life as a doctor in all its gruesome detail.

So, would I recommend that students spend time with real physicians before applying to medical school?

It just may be the best thing they ever did.

Whatever they decide!

What Vignette?

In order to qualify for a residency position a medical student has to complete multiple tests successfully. The most important of these is the USMLE. These tests are divided into three segments, called steps. Step one tests basic scientific knowledge in topics such as biochemistry and microbiology. Steps two and three are more interesting in that they test an applicant’s ability to form a diagnosis derived from a simplified clinical vignette.

I often think back to these vignettes. They inspire a sense of achievement and history. I’ve come a long way since the boards and now face vignettes that are slightly more challenging. They even talk back.

For example I remember this one from my second step:

"53 year old alcoholic male comes to the emergency room complaining of a sharp epigastric pain radiating to his back, accompanied by nausea and vomiting. His breath smells of alcohol, what is the most likely diagnosis"?

Any medical student worth his salt shaker would easily recognize this obvious case of pancreatitis.

Three years have passed. Now more experienced, my clinical vignettes have become slightly more challenging. Daily, my patients introduce me to more mysteries in the form of complaints. I must say, the mysteries have gotten more interesting and, sometimes, more practical.

I will challenge you with yesterdays' patient in the form of a clinical vignette, I’ll even provide a multiple choice, just like the boards:

"62 year old male with past medical history of congestive heart failure, hypertension, hypercholesterolemia, diabetes, asthma, and a past stroke. The patient recently was admitted to the hospital with severe pulmonary edema, barely able to breath. He underwent cardiac cath that showed an indication for bypass surgery but then signed out against medical advice. He absolutely refuses to take medications. Occasionally, he likes to use cocaine and heroin. Today his chief complaint is “I don't feel so well”. What is the most likely diagnosis"?

a- No Shit!
b- You Don’t Say
c- Take Some Responsibility for yourself you out of control, self destructive, ##$^% idiot
d- I Don’t Care

The Tangled Bank

This week's Tangled Bank is up and it looks great. In two weeks the Mad House will have the pleasure of hosting the Tangled Bank. We've been wondering about where to put everyone. Scut Hall needs a few renovations after the Grand Rounds riot. (Give people some great medical lectures and how do they repay you? by ripping out the carpeting, abusing the staff and tearing down the curtains, We'll never host Grand Rounds again).

Good that the Tangled Bank crowd is known to be more capabable of self restraint. So, if you'd like to be included send your submissions to madhousemadman@gmail.com or to host@tangledbank.net or to PZ by May 17th, 6 pm eastern.

Grey’s Anatomy: If Tomorrow Never Comes. A Resident’s Review

Welcome to my review of this week’s Grey’s Anatomy. The super-interns are back single-handedly saving Seattle.

Various interns are continuing their streak of developing “personal” relationships with their favorite Attending. This will surely get them in trouble, but hey, how much fun would it be if it didn’t? How inappropriate is inappropriate and who is to say it is inappropriate? In a hospital where interns talk down to Attendings and the medical hierarchy seems to have been reversed why point out ethics or other inconsequential arguments.

But, before I review a show I mostly like. Would the writers for the show please clarify the following points as it is beginning to interfere with my enjoyment of your show:

1. Please change the theme song, it sucks!
2. Who is Miranda? What is her exact status? Is she Chief Resident? Is she just a regular resident? How come she can talk down to Attendings?
3. One person does not a code make! Codes are called overhead and attended by at least 3 residents.
4. Finally, and most importantly. Surgery Residents and interns are supposed to be BITCHY! Take my word for it, they are. Actually, “Bitchy” is giving them a compliment! (I am looking at you Dr. Gray)

Now for our episode:

Subplot 1: Ms. Conners and the mysterious unidentified tumor.

Denial was the theme as this tumor was known to have been growing for the last 2 years while Ms. Conners was afraid to consult a physician. It continued to grow until it encircled large blood vessels and became extremely difficult to remove, eventually ending in her demise.

My friend Orac has blogged about the phenomenon of denial before and, personally testifying, denial where a cancerous growth is the concern often ends badly. I’ve heard her story before and it’s tragic every time.

In the end, she dies on the operating table due to a lack of blood supply (Unlikely in a real life situation since they knew there would be bleeding complications) after the surgeons nicked a major blood vessel. Dempsey runs a one man code while everyone stands around. Again, one man does not a code make!

And please, can we have a biopsy diagnosis. Since "mysterious, very rapidly growing, huge, freaky looking tumor" can’t go on a death certificate.


Plot 2: Mr. Lemangy, Parkinson’s Disease and DBS (Deep Brain Stimulation)

Exactly why were surgery resident taking care of a Parkinson’s disease complication I will never know. Why Neurology was never mentioned (or consulted) I will never know. Why spotlight a relatively unproven treatment of Parkinson’s to be a life saving procedure, well, this was done because it’s primetime television.

I suspect that many Neurologists are returning calls from various clients today asking about DBS. Although early trials are optimistic, with clinical benefit apparent in the majority of patients, the results of a large double blinded study have yet to be known. Currently, there is no such trial.

Meredith Gray enters and announces that the patient is willing to undergo the procedure if it is done immediately. Apparently, Dr. Shepard (played by Patrick Dempsey) can perform such complicated procedures at the drop of a hat. In real life, one would need an MRI as well as assorted other imaging to confirm the correct placement of the electrodes first. But, super-surgeon can do this on command as he heroically scrubs out of the tumor surgery and into the brain procedure.

All ends well and Dr. Gray happily walks Mr. Lemangy down the hall, dyskenisia free. Just the type of heartwarming moment that would make any REAL surgery resident VOMIT!

Dear Ellen Pompeo:
This viewer requests that you portray a surgery resident in the correct light. I would like to see more attitude, less smiling, maybe a tantrum or two about how nobody in the hospital does anything except you. You’re a surgery intern so please act like one.

Plot 3: Mr. Harper:

Well, this plot really didn’t develop. No comment except one: If you are going to insert a plotline into the episode then let it develop!

Mr. Harper, I suspect you had a few scenes. I am sure you were lost in the final cut and are now staring up from the bottom end of some trash can inside the editing room.

Poor Mr. Harper, he survives the cardiac tamponade but was deceased from the final version of the episode.

In summary: Descent episode, you’ve had better. Still not quite early ER days but you’re slowly improving.

Grand Rounds

This week at the Md/PhD student. Guaranteed to be smart.

Gotcha

It’s been difficult to get Future Intern (a.k.a. Jordan) to smile long enough to capture it in a photograph. It didn’t help that my digital camera is so late with the photo that the smile is long gone by the time my reflexive finger squeezes the trigger. I therefore made an arrangement with Future Intern. The conversation went something like this:

Madman: C’mon Future Intern give your daddy a smile
FI: Leave me alone Madman. I got two cultures and a rectal to do. I got no time, don’t you know that?
Madman: Just one smile, pleeeeeeeeeaaaaaaaassssseeeeeee?
FI: Get outa here you pathetic groveling shell of a Resident. Don’t you have any respect for yourself?
Madman: Just one smile. I’ll make you a deal. If you give me one smile, just long enough to get it on camera I’ll do all the cultures for the rest of the month. Any fever on our service, you shouldn't worry, cultures are taken care of.

I do believe this agreement suited her because she flashed the biggest smile Future Intern has flashed to date. And then it was back to pure, unfiltered, aggravated soberness. I was officially stuck with all bacterial specimens obtained for the duration of our rotation. And ecstatic.

Of course, our entire service mysteriously began a course of Tylenol every four hours. Just enough to mask any unfortunate temp that would signify some life threatening disease ahead of its true purpose, and would only add to this Resident’s workload.

Interns know so little about how improper medical management can work for you.

Fear and Loathing, a Recent Golden Tribute

Overnight I managed to finish Fear and Loathing in Las Vegas. I began the novel after reading a tribute to Hunter Thompson by the Cheerful Oncologist (now at his new home). The true madness in the entry made it a classic in my eyes and I pondered if the book could truly measure up to the eulogy.

After the two hundred pages left me hungry for more I knew the truth. Always, I am only left with a sense of loss. I wish I knew of him sooner, or that he would have stayed with us a little longer so that we may have enjoyed his sarcastic genius for a few more fleeting seconds. Maybe another article, another word. I guess, all of those who have somehow touched the lives of others who took their own life feel this way, no matter how inconsequential the connection.

I wanted to write my own tribute to Thompson but I realized that a the true greatness of any physician is only measured by what he knows he does not know. I’ve come to realize I could never write a more befitting tribute than the one written by Dr. Hildreth and therefore I have copied it here for you to enjoy.

It is an entry of high standing in the Medical Mad House:

"When the going gets weird, the weird turn pro."

FEAR AND LOATHING IN THE E. R.
(written in the manner of one Raoul Duke)

Why am I here? Who is this woman in a giant muu-muu, standing before me squeezing what appears to be a copperhead snake in her hands? She spoke to me in some strange language - obviously disrespectful of the country that took her in after a long canoe trip across the oceans. I thought of screaming "Back! Get Back!" but suddenly sat bolt upright and remembered:

I am a doctor...on call in the emergency room of the world's greatest hospital. My shoes were smeared with thick crusts of vomit and blood, as were my pants, except I wasn't wearing any. I must find them, I thought. The lights above my head burned into my skull like the first kiss of the electric chair. I reached for my pistol to shoot at them, but it, too, was missing. The situation was rapidly deteriorating. I began to sweat like a champagne fountain at a coal miner's wedding.

She continued to bark at me as I stood up and surveyed the room. I had been working since six o'clock the previous evening, and felt like I had been stomped by buffaloes. I desperately wanted to claw my eyes out, but instead hunched over the desk, searching for a pack of cigarettes. What was it - 12 hours of pure massacre, or had I been trapped in this reptile pit for weeks? No one seemed to hear me as I asked for matches and a can of kerosene...

"Yes, yes," I said to the nurse. "You're doing fine, doing a fine job for all of us here." She glared at me as if she had just seen Martin Bormann in an Argentinian health club. What did she want from me? She followed me across the floor as I attempted to break into the crash cart...a nice ampule of epinephrine ought to help, I thought - perks a man up to the point where he would not hesitate to offer his aunt a quick game of Russian roulette. I looked over my shoulder at the nurse. Maybe I should inject her first - give her just enough to get her to dance on the counter top, holding a gunny sack full of live rats. I laughed hysterically at this idea until a security officer tried to club me with a sap. He missed and accidentally whacked a pizza delivery man right in the pepperonies.

I quickly grabbed a clipboard and walked into the nearest exam room. "What is your problem, sir?" It was difficult to see him through the cheap Saigon sunglasses my attorney had given me."

My chest hurts and I can't breathe so good" he said. My God! His left arm suddenly fell off and he grabbed it and flung it at me! Another damn zombie in the emergency room - how they sneak past the metal detectors is beyond me. I rushed the gurney and toppled it over, sending the fiend crashing into an EKG machine. Musn't panic, I thought - just walk nonchalantly out of the room and down the hall to the lounge. Poor bastards... they'll find out soon enough what the living dead can do to a man's aorta with their teeth. Better let Security handle this, or better yet an armored company of Camp Pendleton's finest.

As I reached the lounge I realized that the sun was shining, meaning my hell-night was about over. All that was left to do was clean up the forty or so charts that I had tossed behind the soda machine, locate the rest of my clothes, sign in to the intern relieving me and slip out through the window in the men's room. Before leaving I decided to eat - after all, being a servant of the needy gives one an appetite like a crazed Samoan wrestler. My forged I.D. card was good for at least one more trip through the outlet store for the local waste dump, also known as the hospital cafeteria.

My surgical colleague sat next to me as I sliced up grapefruit with a stiletto. "Man, you sure had a rough night, didn't you? Last I saw of you, you were standing on a trash can during that code, screaming 'Somebody get me a chainsaw!' How long have you been on E. R. call?"

I turned my head to reply, but gasped - scorpions were crawling out of his eyes! He grinned at me like a Jolly Roger as I sprang from the table. I tossed my glass of ice water at him as he tried to grab my arm. I could hear him bleating like a goat caught in a vise as I ran through the glass doors and out to my car. I jumped into my 1971 red Cadillac convertible and sped off, playing "Mr. Tambourine Man" at full volume. I looked at my watch.

My next shift in the emergency room would start in just 23 hours and 14 minutes.