The biggest radiographs I've ever personally handled have been 14 x 51 inch (0.36 x 1.3 m) films of an entire human spine.
However, these are pretty small potatoes compared to some of the work by photographer Nick Veasey, who has X-rayed backhoes and entire buses full of people. Check out this shot of a Boeing 777 and hangar, which may be the largest radiograph ever taken.
Besides these enormous objects, his online portfolio also includes a lot of other cool stuff, such as bats, spiders and the perennial male favorite: looking inside ladies underwear.
A succinct summary of my radiology day job: "applied anatomist".
Perhaps because of this, I have a special affinity for art well-depicting the endlessly fascinating human body. The sculpture of Ron Mueck is a notable example of this. The impact of his works comes from not only their breath-taking realism, but also from the creative way he uses scale to give fresh and unexpected views of our particular primate group.
Can't wait to get a real iPhone 3G? This week's edition of Grand Rounds will give you a reasonable fascimile to play with for the next 18 days, preloaded with the best in medical blogging. This iPhone App has been programmed by My Three Shrinks of the Shrink Rap Blog.
Every parent quickly learns this lesson about young kids: anything they can grab is going straight to their mouth.
My son taught this to us over and over when he was small. While we managed to keep most truly dangerous objects out of his grasp, we did have a few scares. One night a large but nonvenomous house spider (leg-to-leg span = 3 inches) ran across the living room floor and stopped right in front of our son. To our horror, he reached out and grabbed it.
Reacting quickly, the paternal unit did a stuntman dive across 10 feet of carpet and pinned his hand to the floor -- Dad's next conscious thought being "How the hell am I going to get something out of his hand that I'm afraid to touch?"
As this was happening, the maternal unit came really, really close to declaring an instant end to breast-feeding. Her exact words were something like "Lips that touch spider will not touch my..."
Somehow we solved this dilemma, and breast-feeding continued as before. However, this incident made us even more vigilant about the hand-to-mouth issue. Since my spouse is a pediatrician, we both deal with this problem professionally as well.
When a kid ingests a foreign object, the drill goes something like this:
a quick X-ray of their tummy is taken to document the presence/location of the item
parents undergo the character-building exercise of straining every stool specimen for the next few days
if everything does not come out all right (so to speak), another X-ray is done
repeat 2 & 3 for a while until the object is out
if no luck, move on to Plan B (endoscopy or surgery)
I would love to know what sick bastard at Kellogs came up with this genius idea. I just spent the first three years of my sons life trying to get him not to eat blocks, and now you're telling him they taste like fucking strawberries. Thanks a lot assholes. Seriously, how in the hell did this ever get past their legal department. You can't tell me that this isn't a lawsuit just waiting to happen. I can only assume that their next product is fruit flavored thumbtacks.
George Carlin, skeptic, atheist, and Jedi master of comedy and social commentary, died yesterday, June 22, at the age of 71.
He was known for many things, including the Seven Dirty Words you can never say on television. When his monologue on these words was aired in 1973, it set off a kerfuffle that led all the way to the U. S. Supreme Court, whose narrow ruling (5-4) formally established indecency regulation in American broadcasting.
Since then, American children who have grown up hearing these words from their parents and each other have been spared that special moral degradation that comes from also hearing them on the air. As Carlin told the Associated Press earlier this year:
So my name is a footnote in American legal history, which I'm perversely kind of proud of.
Rest in peace, friend. May your words ring on in the Internet forever.
With a name like The Amaz!ng Meeting, one expects a certain amount of hyperbole. However, in the words of Dizzy Dean, "It ain't bragging if you done it."
There have already been some truly amazing presentations, as I've described in my other posts on TAM6. One keeps wondering how any day can possibly top the last. I'm happy to report that Saturday provided a very satisfactory Big Finish™ to TAM6.
(Okay, okay, there were some fine papers on the schedule for Sunday morning, but I wasn't able to attend them.)
Saturday highlights follow:
Dr. Michael Shermer, executive director of the Skeptics Society, kicked things off with a fine talk on Why People Do Weird Things. He cited recent fMRI research suggesting that skeptical thought may actually require more effort and time than uncritical thought.
Sharon Begley, senior editor at Newsweek, is widely known for her ability to break down complex scientific theories and write about them in simple prose. She spoke on "Creationism and Other Weird Beliefs: The Role of the Press". If we were expecting the press to bail us out in the struggle against irrationality and scientific illiteracy, her suggestion is: "Don't get your hopes up."
Jeff Wagg, general manager for the JREF (James Randi Educational Foundation), gave some late-breaking news about TAM7. The contract has been signed, and TAM7 will take place in Las Vegas at the brand new South Point Casino from July 9 - 12. He also raised the possibility of a future edition of TAM in the UK (woot woot).
Dr. Phil Plait, astronomer, writer, skeptic and author of the Bad Astronomy Blog, was the first afternoon speaker. He was introduced by PZ Myers, who continued their daily game of conference badinage. Phil's rejoinder:
In a way that only a roomful of atheists can appreciate, PZ's writing is god-like.
Phil then treated us to a quick and breezy tour of our solar system. His skeptical conclusion:
The Universe is Cool Enough Without Making Up Crap About It!!
Adam Savage, movie special effects artist and co-host of Mythbusters, quickly proceeded to make everyone's list of speakers they never, ever want to follow on stage. He started by regaling us with his ongoing quest to build the perfect replica of the Maltese Falcon. I'll just say that compared to Adam, I'm a lot less anal than I thought I was.
He wrapped up his presentation with a short video clip of "explosion porn" from the show. At the next break he gave away 1000 ping pong balls (and autographed many of them) that were used in one Mythbusters episode to raise a boat off the bottom of Monterrey Bay.
Concepts that the Discovery Channel has not yet allowed them to develop for Mythbusters:
Matthew Chapman, author, journalist, director and great-great grandson of Charles Darwin told us what he loves about America. He has written widely on the creation-evolution controversy in the U.S. Among other things, he visited Dayton, TN, home of the original Scopes Monkey Trial, to see if the town had evolved appreciably since the 1925 trial. Alas, it hadn't.
Mr. Chapman is founder and president of Science Debate 2008, which calls for a public debate of science issues by the two U.S. presidential candidates. To date, 28 Nobel laureates, 102 university presidents and quite a few other large names in science have signed this initiative.
Dr. Richard Wiseman, magician, psychologist and author of Quirkology, gave the final talk of the session. It was immediately apparent why he drew this slot, because it would be hard for even the other stellar speakers at TAM6 to top him.
Dr. Wiseman is not your usual psychologist, as can be seen from a glance at some of his prior research topics:
why do incompetent politicians get elected?
does déjà vu actually exist?
what is the perfect pick-up line?
does déjà vu actually exist?
Do you consider yourself an observant person? Find out in the following Wiseman video:
Richard Wiseman definitely knows how to put the "grand" in grand finale -- in this case, by setting a new world record for simultaneous spoon-bending. His minions proceeded to pass out 800 metal spoons to this hall full of skeptics. But wait, there's more!
The next step: teaching 800 skeptics how to pull off (so to speak) this simple illusion. The key concept: "the more you stroke it, the softer it gets." Wiseman was quick to point out that this is one of the few contexts in which that happens to be good news.
Instead of teaching us spoon-bending himself, he delegated the task to someone else. In this case, that someone else happened to be one of the world's great magicians: Teller. After a quick post-graduate course in the theory, art and perils of spoon-bending by Teller, we were ready.
As the video camera rolled, we focused our skeptic energy fields on the spoons, and as one, bent and broke them all. Once the Quirkology SWAT team finishes editing all of their footage, keep an eye out for their final cut, coming soon to a YouTube theater near you.
Q & A Panel
At this point, there was no easy way to top Wiseman short of tactical nukes. Despite this, a blue-ribbon panel of skeptics stormed the stage for a brief Q & A session. My choice for most memorable quote is Adam Savage's:
Before you become a skeptic you might think the world is in color. But once you become a skeptic, it goes to HD!"
Dinner with Randi
About 60 of us then headed over to the Rio for dinner with Randi and other TAM6 faculty. After a fine evening of food and conversation, this group mitosed and half of the new organism headed for the Penn & Teller show at the Rio. In a word, awesome, in the original sense of awe. And, as an airport billboard promised, "Fewer audience injuries than last year!". (Extra tip: don't miss the 30 minute pre-show, and pay particular attention to the bassist...)
It's been a fun few days at TAM6, but I'm glad to be on my way home.
I have to say that McCarran International Airport (at least the D terminal) has some of the coolest (and most appropriate) airport art I've ever seen. These three desert creatures, partially buried in the floor, are especially swell.
I've had a great four days in Las Vegas at TAM6. However, when I'm not at the conference, I keep getting daily jolts of the alternative reality that is Las Vegas.
As I finished a solitary supper last night, my waitress said "Have a lucky evening!" I was momentarily nonplussed. The last person wishing me to "get lucky" was my college roommate as I headed out for a blind date. I felt like Lisa Simpson in the Bart vs. Australia episode where she sees a movie facade reading: "Yahoo Serious is Young Einstein". Her reaction: "I know those words, but that makes no sense!" It took me way too long to remember why other people come to Las Vegas, and finally mumble something like, "Uhhh.... thanks! You too."
My first walk through the casino floor gave me flashbacks to med school physiology class, where we learned about the complex lining of the intestines. This convoluted lining results in an extremely high surface area for maximal absorption of nutrients from the stuff passing through. Ever since this class, the bowel has remained my mental metaphor for every resort I've ever visited. The relentless absorptive area here is easily Disneyland class.
Gambling has never been much of an attraction to me, especially since Psych 101. My daily passage through the casino floor to the convention center takes me by hundreds of humans voluntarily spending the day in Skinner boxes. This is a very creepy place.
It is also a very hot place, getting up to 107° F today. Fortunately, it cools off at night. I had a nice breeze while walking back to my hotel after a show -- with the wind chill, it only felt like the low 90's.
My evening walk also took me by the Bellagio Hotel. It was nice to finally see the fountains that launched a 1000 Mentos.
It's time for another report from TAM6, coming to you from sunny downtown Las Vegas, where it got up to 107° F (41.7 ° C) today.
Highlights from today:
Ben Goldacre, M.D. is a British physician and journalist, and author of The Guardian's weekly Bad Science column. He spoke today about homeopathy in the U.K. He pointed out that in 1846, John Forbes, the Queen's own physician, was a strong opponent of homeopathy. He contrasted that to today, where the Queen's personal physician is a homeopath. Only partially tongue-in-cheek, Dr. Goldacre wondered if this movement toward wacky medicine correlated with the loss of the British Empire.
Richard Saunders gave a short summary of skeptical matters in Australia. The best part of his session was an audience-participation experiment of dousing. This elegant experiment was designed to help teach critical thinking to school children. With 5 plastic buckets, a bottle of water, a simple dousing rod, and about 15 minutes, he showed how elementary school kids can grasp and even derive for themselves the principles of randomization, and single and double blinding of an experiment. The next time one of my residents seems a bit hazy on these concepts, I'll bring out the dousing gear.
Penn and Teller hosted a short but zesty Q & A session about their Bullshit! TV series, politics and skepticism. As a longtime fan of their stage act, it was a great treat for me to hear Teller actually speak, which he does quite eloquently, by the way. My favorite Teller quote today:
Q. What skeptical accomplishment are you most proud of? A. Bringing bare breasts, genitals and profanity to the service of skepticism.
My favorite Penn Jillette quote today:
Q. On your Bullshit! show, are you trying to be fair and unbiased? A. No. We are trying to be fair and extremely biased.
Alexander Jason told us about some of his exploits as a crime scene analyst, and pointed out how helpful a critical mind was in his line of work. He also described his work with James Randi in the 1980's to help debunk fake faith healer Peter Popoff. The video clip below summarizes some of the events of this scandal.
George Hrab, singer, songwriter, and author extraordinaire entertained us with a number of his creations. My favorite Hrab line, when he had some early sound problems with his guitar: "It's a PC guitar." To a Mac user, 'nuff said.
Dr. PZ Myers, biologist and author of the excellent Pharyngula blog, did not actually disembowel a Christian on stage, as was earlier predicted by some. Instead he gave a nice discussion of the evolution of bat wings. He wrapped up his presentation with a slide of "gratuitous squid porn". It is noteworthy that his presentation is the only one so far in which video clips have worked flawlessly. As you might expect, he uses a Mac.
These "droppings" covered a wide variety of topics, all built around the central theme of the close relationship between the scientific literacy of a population and the intellectual and creative health of their nation. Tyson gave a vivid account of the role of rising religious fundamentalism in the fall of the Islamic intellectual empire around 1100 CE -- a disaster from which the Islamic scientific community has never recovered. Parallels drawn by Dr. Tyson between this disaster and the current U.S. decline in scientific literacy were quite chilling. One hopes that the next administration can begin to repair some of the great damage done in the last 8 years to U.S. scientific research by the current administration.
A brief list of some of the questions considered in this 90-minute talk:
would an iPhone user have been burned at the stake 10 years ago (maybe so)
is there life on other planets (almost certainly)
does swami levitation work (yes, but only with sufficient flatus)
should we put pictures of scientists on our money (yes, and equations too!)
can lunar tidal forces affect your brain (yes, but they are a trillion times less than those exerted by your pillow)
is breathing, eating and drinking through the same orifice evidence of intelligent design (duh, no -- this is a stupid design that actually kills people)
Note to self: Never, ever, ever speak after this man. I'm pretty sure that everyone on the program following Dr. Tyson was thinking the same thing. Neil deGrasse Tyson combines a keen intellect and a strong background in science and history with the passionate lecture style of an evangelical preacher. He makes a powerful advocate for science and its essential role in society. One can only hope that we begin to elect politicians worthy of such an advocate.
The title of this post is appropriate for two reasons:
1. this post is my 100th post on this blog 2. this was a phrase used today at TAM6 by Dr. Art Benjamin, the Mathemagician.
The Art of Memory
My favorite afternoon workshop was The Art of Memory by Banachek. Banachek is billed as the world's leading Mentalist, and he kicked off his session by memorizing an entire deck of cards in about 47 seconds. Over the next 2 hours, he showed us several ways to do this. This has got to win the prize for the most practical first day talk ever at a Las Vegas convention!
By the end of this two hour session, he had given us mnemonic tools for memorizing a grocery list, a speech and a 74 digit number. Knowing these techniques back in my pre-med and med school days would have been worth the price of admission, all by themselves.
Besides his prodigious feats of memory, Banachek performs some pretty swell illusions, as shown in the video clip below.
If Art Benjamin were John Henry, the steam drill would have had its ass handed to it in a handbasket. Art demonstrated this right off the bat, by outperforming 5 people with calculators in several numerical feats.
It's hard to wow a room full of practicing skeptics, but Art accomplished this pretty quickly, spouting out the squares of 4 digit numbers about as fast as the audience could call them out. Before the calculator dudes on stage could even enter the digits for most of the problems, he was writing the answer down on a flip chart.
It's usually a let-down when a magician tells us the secret behind a trick. Benjamin, however, is a great exception to this rule. Even after he explained to us the details of how he did all of these mental calculations, it remained jaw-dropping to watch him blasting through these techniques at warp 4.
In the following video clip from the TED Talks, you'll see why we also gave him a standing ovation:
Besides being a great stage performer, Art Benjamin is a professor of mathematics at Harvey Mudd College, with a special interest in combinatorics and Fibonacci numbers. In the Q & A session, someone asked him for the URL of his website. He joked that despite these credentials and being able to recite the first 100 digits of pi, he was unable to remember his own web address. How does he find his site online? He googles himself.
I'm spending four days at the Flamingo Hotel in Las Vegas, Nevada, attending the 6th annual edition of The Amaz!ng Meeting, aka TAM6. The following blurb is direct from the TAM website:
The Amaz!ng Meeting is a celebration of critical thinking and skepticism sponsored by the James Randi Educational Foundation. Thinking people travel the world to share learning, laughs and life with fellow skeptics and distinguished guest speakers.
The Amazing Randi tells an anecdote about Art Benjamin
With a name like that, one would expect the talks to be a lot more, well, amazing than the fare at the usual radiology meeting. The program includes some stellar talent, including James Randi, Dr. Neil DeGrasse Tyson (astrophysicist and PBS Nova host), Adam Savage (Mythbusters co-host), Matthew Chapman (author and great-great grandson of Charles Darwin), Dr. PZ Myers (biology professor and Pharyngula blogger) and Penn and Teller.
Critical thinking is one of the many things I try to teach my students and residents, and I'm always up for new ways of teaching this material. From the partial TAM6 faculty list above, one can see an unusually large fraction of the Jedi Council of critical thinkers. If one can learn by osmosis alone, I should get a lot out of this meeting.
June in Las Vegas is pretty much what you would imagine - 103° F (39.4 ° C) today, with 107 ° F (41.7 ° C) predicted for tomorrow. However, the air-conditioning at the Flamingo is so relentless that I shivered my way through the afternoon sessions. That pile vest I felt silly packing at home will stay on me for the rest of the meeting.
I'll post some meeting highlights as time permits.
What do you call a patient who fakes their history, symptoms and physical exam to gain medical care? For many of us, this sounds like a classic case of Munchausen syndrome.
So what would you call it when a hospital administration hires such people to covertly evaluate the quality of care in their facility? Users and purveyors of this service use a variety of terms, including "mystery shoppers", "secret shoppers", "ghost shoppers", "undercover patients" and "sham patients".
This concept of Munchausen management is currently being pushed, ironically enough, by the ethics council of the American Medical Association. During their current 5 day meeting (which began on June 14) the AMA ethics council is pressing the rest of the AMA to endorse the use of undercover patients to evaluate the quality of care at medical facilities and physician offices.
The AMA's Virtual Mentor site has a point-counterpoint style discussion of this topic, with commentaries on both sides of the issue. Of the opinions posted there, I think that University of Illinois professor Richard C. Frederick, M.D. gets it right:
This practice highlights the crisis of medical professionalism—failure to view the physician as a professional. Finally there is the huge question about the consequences of using deceit in a field where truthfulness is a core virtue.
A Priori Assumption of Guilt
When police set up a sting operation in a pawn shop, a downtown hooker hangout, or a congressional office, they are not out to improve quality control. They are not doing it to prove that someone is innocent. They do it because they are pretty darned sure that something is wrong and they want out to nail someone for it. When there is sufficient evidence of malfeasance, I'll grant that a sting is a fine technique.
However, foisting the same tactic on physicians for "routine quality control" is a completely different kettle of fish. The message it sends is not: "We want to help you improve your care." To a health care practitioner, it clearly says: "We don't trust you." To patients, it is equally clear: "We don't trust your doctors."
Surrogate Endpoints
I am all for improving patient care. I want all of the patients in our medical center to feel welcome and well-taken care of. However, let me emphasize the word "patient" here. I want to get as much feedback as possible from actual patients on how we are doing and how we can do it better. Contrast this with data collected from a sham patient -- no matter how well these folks are trained, their data is going to be, at best, a surrogate of what an actual patient feels, needs and experiences. Since these medical mystery shoppers don't have actual medical needs of their own, they will pretty much be checking off items on someone else's arbitrary feature checklist. As Dr. Frederick puts it:
One wonders how effective the secret shopper can be in assessing physicians' most important roles. If these people are not sick, frightened, tired, and vulnerable like real patients, how helpful is their appraisal to the physician whose patients are frightened and vulnerable?
Doré's caricature of Baron Münchhausen
Is Anyone Actually Harmed by Sham Patients?
How ethical is it to put a sham patient through medical tests and procedures for which there is no medical necessity? If the only people concerned were the sham patients themselves, this might not be an issue -- after all, they volunteered for it, and are often paid to do this sort of thing.
However, sham patients are not the only ones put at risk by this practice. Consider the patient with real chest pain who has to wait in the ER a little longer while a sham patient with no disease at all is seen first. But wait, there's more. Dr. Frederick again nails it:
Consider the scenario where a nurse or lab tech gets a needle stick while treating this "planted" patient and develops hepatitis or HIV.
It's only too easy to extend this concept to the radiology department. Any time I perform a shoulder arthrogram on a patient, I and my radiology technologist are exposed not only to needle sticks, but also to a certain extra dose of ionizing radiation. I am quite willing to take a few extra rays if it will help an actual patient. However, the thought of doing so on a sham patient for no medically indicated reason makes me a bit livid.
The Problem of False Positives
Some apologists for medical mystery shopping rationalize the practice by pointing out the rare cases where unexpected findings turn up in these sham patients. A big problem with this is that the predictive value of a positive test is tightly coupled to the underlying disease prevalence. In a sham patient, that prevalence is usually going to approach zero. This means that a false positive result is far more likely than a true positive result.
What if a false positive result leads to a more invasive procedures, such as a biopsy or surgery? The results of this, alas, can occasionally be dire, and I'll offer one extreme example from a good friend. Two of his medical school classmates, upon reaching a certain age, gifted each other with a full-body CT exam. One of them underwent a needle biopsy after the CT showed a questionable lung lesion. This biopsy was complicated by a tension pneumothorax and death. This is about as dire as it gets.
Reaping What One Has Sown
If this management fad becomes commonplace in medicine, I can only hope that its proponents are quickly hoist on their own petard. For example, why should a hospital be the only one who can set medical spies on their staff? There's really nothing to stop a competing practice or hospital from doing the same thing. A disgruntled patient or former staff member could do the same thing, and spray the results all over the media and the web.
On a personal note, I would find it extremely hard to ever trust a hospital or departmental administration who inflicted a program like this on me. I'll let Dr. Frederick have the last word on this:
Finally, we teach our residents and medical students that when we are not truthful with our patients, we violate their trust. We also put into question the next physician's truthfulness. We have all heard a patient say, "Those doctors at that institution lied to me, so I trust none of them." In reality maybe only one physician lied, but all are tarred with the same brush. Trust is fragile, and, once violated, it is hard to restore. But trust goes both ways. Are we physicians not human too? Once we are fooled by these "good actors," will there be an element of doubt about the legitimacy of the next patient with a similar complaint? I work in an emergency room and have been lied to frequently, but not by my administration or the executive director of my group. Cynicism, already a problem in medicine, will only be made worse by the use of official deceit. As physicians in a profession where high ethical standards are essential, deceit, however well meaning, is not a tool we should use.
Friday the 13th was a fairly routine day in our radiology store today. Except for 4 of our patients who underwent shoulder arthrograms today, I don't think anyone here regarded it as a particularly unlucky day.
Just for the heck of it, I idly googled "13 radiology" just to see what popped up. Here are some of my hits:
The European Society of Musculoskeletal Radiology had its 10th Annual Meeting on Friday, June 13, 2003 in Aarhus, Denmark. A quick follow-up google search of "ESMR", "disaster" and "2003" didn't turn up any obvious catastrophes, so I'm assuming they survived somehow.
Happy Baisakhi to Punjabi friends It is, I think, a rare coincidence that a major festival falls on what is traditionally thought to be an unlucky day.
Hopefully, Vijay will post an update next April so that we can see how the Punjab fared following this inauspicious juxtaposition of dates.
Chapter 13 of Emergency Radiology, edited by Reisdorff, Schwartz & Williamson turns out to be "Radiology of the Cervical Spine", surely one of the more terrifying body parts to image.
Most frightening of all, the chapter for "Radiology Services" in the U.S. Medicare Claims Processing Manual turns out to be Chapter 13. Coincidence or Satanic confluence? You be the judge...
This has nothing to do with radiology, but I feel compelled to share it here anyway. This has got to be one of the most excruciating 6 minute video clips I have ever seen. I enjoy mountain hikes, but I'm not too wild about sheer drop-offs.
On second thought, this post does have some specious anatomic relevance. Let's just say that this clip would make a great workout video for one's cremaster muscles.
This video is best viewed full screen (click the little icon at the bottom of the video screen that looks like a square with brackets).
Originally built in 1901, this walkway now serves as an approach to El Makinodromo and El Chorro, famous climbs in Andalusia, Spain.
It's been yet another full, rich week filled with way too many activities.
My son graduated from middle school, my niece graduated from college, my residents and fellows are graduating in about 2 weeks, and all of our residents passed the Awfully Big Radiology exam last week in Louisville.
In honor of all these graduates, I thought I'd share another batch of medical malaprops. Again, these are courtesy of a good friend who is also my personal mole in the world of medical transcription.
The patient was hypomagnasemic, hypomagnasemic; he had a low magnesium.
Diagnoses include potassiumemanemia.
No evidence of stereoagnosis or graphesthesia in both stereognosis, no evidence of stereoagnosis, graphesthesias, and, or rather graphesthesia or graphesthesia, I should say, in the upper and lower extremities.
The patient was not able to visually see her family member; however, she had on her husband’s glasses, which could explain why she was not able to see.
The uterus was entered in the midline, extended laterally with a Band-Aid.
Hypopharynx and laryngeal exam is entirely normal today and she has absolutely beautiful mucosa.
The patient’s activity prior to the event was over-extending: trying to clean snow in the cold weather.
The patient is wondering whether he might have a personality disorder like a borderline personality disorder.
Her last colonoscopy was in the year 703.
She was voiding satisfactorily upon discharge and was passing grass.
Review of systems was unavoidable due to mental status changes.
The patient may have a subtle torus fracture of the distal radius. The family was contacted. They were placed in a metal splint.
The lesion is essentially necrotic and melodious (malodorous).
X-rays of both knees show moderately severe osteoarthritis with joint space narrowing medially -- mild -- with -- with moderate joint space mediately -- moderate medial joint space me -- - ahh -- narrowing bilaterally.
Chief Complaint: Airway in the foreign body
HPI: The patient is a 62 y/o right-handed gentleman. FAMILY HISTORY: The patient has a 60 y/o twin.
Complications: None from procedures but ultimately, death.
Impression: Fat-containing ventral hernias. Findings discussed with Dr. Hernia.
We all eat to live. Most of us also eat for enjoyment. Many of us overeat for various reasons. A very few of us overeat as a competitive sport.
What's in it for the winners? For the eliter eaters, one can earn an annual 5-figure income. Plus, if you don't mind eating on the Anaconda Plan (Eat the Whole Pig. Right Now.), there's all that free food at the contests.
What does it take to choke down chow at a world-class pace? There seem to be many ninja tricks to help one really scamper while scarfing scads of scoff. Lubricating hotdog buns with water is one technique, and others polish off the Polish two at a time to increase their rate of input.
However, on an anatomic and physiological basis, there are only a few logical ways to explain the capacity of some supreme suppers:
increased stomach size
increased gastric emptying speed into the small intestine
disappearance of food into the fourth dimension
Of the possibilities listed above, scientists are pretty darned sure that no. 3 is definitely not the explanation. Beyond that, we don't know the whole story. However, a recent fluoroscopic study by Levine et al from the University of Pennsylvania sheds some light on ins and outs (well, mainly ins) of marathon munching.
Levine, M.S., Spencer, G., Alavi, A., Metz, D.C. (2007). Competitive Speed Eating: Truth and Consequences. American Journal of Roentgenology, 189(3), 681-686. DOI: 10.2214/AJR.07.2342
The purpose of our investigation was to assess the stomachs of a world-class speed-eating champion and of a control subject during a speed-eating test in our gastrointestinal fluoroscopy suite to determine how competitive speed eaters are able to eat so much so fast.
They did this by pitting a large burly control dude (6 ft 2 in / 210 lb aka 188 cm / 95 kg) with a hearty appetite against a slender subject (5 ft 10 in / 165 lb aka 178 cm / 75 kg) who just happened to be ranked among the top 10 competitive speed eaters in the world by the IFOCE.
Sonya Thomas and Tim Janus at the 2005 Midway Slots Crabcake Eating Competition
After a few preliminary tests, these two subjects were asked to eat as many hot dogs as they could. The big burly dude ate 7 before feeling uncomfortably full. The champion eater then proceeded to down 2 dogs at a time for the next 10 minutes. After he ate 36 hotdogs, the investigators terminated the experiment.
Despite the speed eater’s insistence that he felt no sensation of satiety, fullness, bloating, or abdominal discomfort, we became concerned that further dilation of his already enormous stomach could be associated with a small theoretic risk of gastric perforation. Therefore, a decision was made to terminate the speed-eating test over the objections of our participant.
While all of this was going on, the radiologists asked the eaters to also ingest a barium sulfate solution so they could watch the stomach under fluoroscopy. The control dude's stomach showed a large mass of partially chewed hotdog bits, but only minimal gastric dilatation. The eating champion looked a bit different:
His stomach now appeared as a massively distended, food-filled sac occupying most of the upper abdomen, with little or no gastric peristalsis and emptying of a small amount of barium into the duodenum.
It's hard to generalize these findings to all eaters everywhere when one only has 2 subjects in one's experiment. However, the investigators concluded:
Our observations suggest that successful speed eaters expand the stomach to form an enormous flaccid sac capable of accommodating huge amounts of food.
What happens to competitive speed eaters after years of gorging? We really don't know. No one has done long-term follow-up of eating champs, so educated guesses are all we currently have. The current scientific gut feeling is that digestive divas may have some problems awaiting them down the line.
We speculate that professional speed eaters eventually may develop morbid obesity, profound gastroparesis, intractable nausea and vomiting, and even the need for a gastrectomy. Despite its growing popularity, competitive speed eating is a potentially self-destructive form of behavior.
The closest I'll ever come to this degree of gastric overdistention occurred at a major radiology meeting about 20 years ago. My brother and I were invited to a wonderful French restaurant by some film manufacturers who wanted to buy our souls. We sold out to the triple whammy of food that was expensive, paid for by somebody else, and absolutely delicious. It was so delicious that we both ate way, way too much of it. By the time the satiety signal from our stomachs reached our brains, we were already a bit uncomfortable. By the time we got back to our hotel room, we felt too distended to breathe while lying down. Therefore, we sat up in bed, propped up by many pillows, and watched TV for a few hours until we had digested enough to get to sleep.
As luck would have it, the first thing that popped up on our TV happened to be Monty Python's The Meaning of Life. The movie was already in progress, somewhere in a scene where the Crimson Permanent Assurance briefly attempts to take over the film. "This looks entertaining", we thought. Just The Thing to occupy our minds during a few hours of gastric emptying.
Sometimes karmic payback is swift and sure. One of the next skits in the movie was the infamous encounter between Mr. Creosote and the "wafer-thin mint". You can imagine our mounting horror as that scene played out...
I was in Washington, D.C. last fall for work, and then got to spend a few days with my family just being a tourist. As we popped up out of the Smithsonian Metro stop the first day, we were surprised that the Mall was full of tents, celebrating the National Book Fair. We looked down the list of authors speaking that day, and noted to our delight that Terry Pratchett had just begun his talk in the science fiction tent. The SF tent was SRO, but we managed to find reasonable roosting spots there out of the sun.
In my opinion, Terry Pratchett is one of the greatest all-time writers in the English language. In my personal pantheon of penmanship, he ranks right up there with Mark Twain. I can't think of many other writers who blend humor, science, cosmology, political commentary, theology, and philosophy with such dexterity. The more one knows about any of these subjects, the more one enjoys both the clever puns and the deeper issues raised in his books.
As it turns out, Mr. Pratchett speaks just the way he writes, which made for a very enjoyable 30 minutes. After a witty and entertaining talk, he fielded questions and comments from fans. One young fan was almost incoherent with emotion as he testified how Small Gods changed his life.
More recently, I spent an hour of altered reality under the influence of both pain-killers and Pratchett, while undergoing a crown prep in my dentist's office. While my brain buzzed from laughing gas, Nigel Planer's brilliant reading on the audible.com edition of Guards, Guards! made for a particularly vivid visit to the Discworld.
I'll wrap up this paean to Pratchett by mentioning what the author himself has termed "an embuggerance". In August 2007, he was diagnosed with posterior cortical atrophy, an early-onset form of Alzheimer's disease. In March of this year, he donated a million dollars to the Alzheimer's Research Trust. Some of his fans have established the Match it for Pratchett campaign, which hopes to match his generous gift.
One of the great things about the Firefox browser is its ability to add functionality via plug-ins. There are zillions of excellent plug-ins available for Firefox, and one of my favorites is Googlepedia, a mashup between Google and the Wikipedia.
Googlepedia modifies the behavior of the little Google search box in the upper right hand corner of the Firefox window. When you type in a search phrase such as "rickets", the result comes back in a split window. On the left hand side of the split is the usual Google result for rickets. The right hand side of the split window shows the Wikipedia result for rickets.
Since the answers I need are often on the first page of Wikipedia, Googlepedia saves me the trouble of clicking through there for quite a few of my searches.
I'm just finishing up my first month as a Kindle owner. I'm now past the acute phase of new gadget ownership where "Bright! Shiny!" is enough to keep a relationship going.
The Kindle and I have gotten our first few awkward dates out of the way. We now show up at parties together, go home together, share a bed frequently and are considered an item by our friends.
One defining moment in my relationship happened the second week I had the Kindle. When I arrived at work, I realized that I'd left it at home, and was a bit surprised at the mild but distinct sense of panic I felt. I wrestled briefly with the idea of running back home for it, but common sense prevailed. I found other things to do at work that day (like work), and occupied my breaks with something else to read. However, this one cautionary episode has caused me to add an extra item to my mental leave-the-house checklist:
Get car keys
Grab iPhone
Where the heck is my Kindle?
It's interesting that even a month later, I have still seen no other Kindles in the wild. This is despite living in one of the great tech centers of the known galaxy, and having an inordinate number of geeks among my friends. However, I finally ran across another owner earlier this week, and he seems to like his unit about as much as I like mine. The device still attracts a lot of attention, and my restaurant reading has been frequently interrupted by strangers asking about it. So far, these impromptu demo sessions have been fun, and I'll probably miss them once the device becomes more commonplace.
I just got back from a week on the road, using my Kindle as a traveling companion, and it worked out very well. The only thing I'd do differently would be to bring along a reading light for it. Even with the seat light turned on in my plane, I would have liked a bit more light. Reading in my hotel bed at night would have been lots easier with a reading light. I've been very happy at home with the Mighty Bright XtraFlex2 light, which clips to the cover of my Kindle and give plenty of light.
I usually buy several books while traveling. For once, I haven't had to worry about fitting them all into my luggage, or agonizing over which one to bring with me on the plane.
I have also used the Kindle to deal with a case of newspaper envy on a plane. While waiting for my flight to finish boarding in Chicago this week, I noticed the dude across the aisle from me reading a copy of the New York Times. Out of the corner of my eye, I could glimpse just enough interesting-looking articles to make me wish I had a copy as well. It would, of course, have been a sign of weakness to ask him to borrow his paper. Therefore, I salvaged my geek pride by firing up the Kindle and grabbing copies of both the New York Timesand the Seattle Times just before the cabin door closed. Take that, newspaper dude!
Since my earlier posting on the Kindle, I've also run across several cool Kindle hacks. My favorite site for this so far is Igor Skochinky's series on reverse engineering the Kindle operating system. Therein I learned several useful tricks, such as:
Alt-Shift-MMinesweeper
Alt-Tshow time
Alt-1show current location in google maps
Alt-2find gas station nearby
Alt-3find restaurants nearby
Alt-Shift-G make screenshot
Speaking of screenshots directly off the Kindle, below are a few that I just made, while viewing a Word document from a case report of sarcoidosis of the humeral head. The radiographs suck somewhat at 4 gray scales, but the nuclear medicine and MR images are not too terribly shabby. Due to an implementation bug, screenshots can only be stored on an SD card, and not the main Kindle storage. However, it's easy to access these images -- a .GIF file is saved at the SD card root for each screenshot.
I'll offer one final metaphor for the Kindle: a bottomless purse. Variations of this theme, such as a bottomless purse of gold, a bottomless food pouch, and an always-full pitcher of water are among the many common motifs found in fairy tales, such as Table-Be-Set.
The Kindle coveys that same "bottomless" quality to me. Amazon's one-click method of pulling books and newspapers across their wireless 3G network makes it easy for me to keep the device stocked with all sorts of goodies. With the addition of an inexpensive 4 GB SD card, it's going to be a while (several thousand books from now) before I fill that thing up.
Just down the street from Churchill Downs in Louisville, radiology residents from all over North America are currently running their own version of the Kentucky Derby at the annual Awfully Big Radiology exam.
Radiologists proctoring this exam wake at the crack of dawn and head for breakfast. While they are foraging, an assault division of maids storms their rooms and cleans them up in time for the exam.
One examiner returned from breakfast yesterday to find his room filled with a special SWAT team of maids, who told him he had to evacuate his room immediately. Once he saw the reason for their agitation -- an infestation of bedbugs -- he grabbed his stuff and ran. Rumor has it that the room will be sealed for 3 months before humans will be allowed to sleep there again.
There's a lot that most radiologists don't know about Cimex lectularius, the common bedbug. As news spread of this infestation, many iPhones and Blackberries were pulled out and many web pages were quickly consulted.
Bedbugs are generally active only at dawn, with a peak attack period about an hour before dawn, though given the opportunity, they may attempt to feed at other times. Attracted by warmth and the presence of carbon dioxide, the bug pierces the skin of its host with two hollow tubes. With one tube it injects its saliva, which contains anticoagulants and anesthetics, while with the other it withdraws the blood of its host. After feeding for about five minutes, the bug returns to its hiding place. The bites cannot usually be felt until some minutes or hours later, as a dermatological reaction to the injected agents.
Furthermore,
Due to the widespread use of potent insecticides such as DDT, bedbugs were nearly eradicated. However, many of these strong insecticides have been banned from use in the United States are being replaced with weaker insecticides such as pyrethroids. The problem with the weaker insecticides is that many bedbugs have grown resistant to them. A study at the University of Kentucky randomly collected bedbugs from across the entire United States. These “wild” bedbugs were up to several thousands of times more resistant to pyrethroids than the laboratory bedbugs.
If your local radiologist seems to be scratching a bit more than usual, ask her if she just got back from Louisville.
As for me, I'm thinking about taking my suitcase straight from the airport to our radiotherapy department. Any mutant ninja bedbugs that have survived the journey back home next to my dirty underwear will hopefully have a little more trouble dealing with 100 Gy of hard radiation...
Grand Rounds is a weekly collection of the best writing in the medical blogosphere. I was delighted to host Volume 5, no. 20 here on February 3rd, 2009.
What does a radiologist do? Who are these rarely glimpsed and mysterious figures that float through the background of medical care?
Why would someone want to spend all of that time in medical school learning to be a Real Doctor™, and then throw it all away by becoming a radiologist?
Welcome to Not Totally Rad.
As the masthead suggests, most, but not all, of the topics discussed here will have something to do with radiology, medical imaging and imagers. Hopefully light will be shed on these matters, even if it's invisible to the naked eye.
The Samurai Radiologist has spent more than 20 years as a diagnostic radiologist, most of them professing at various university medical centers.
The "samurai" part is a nod to the late, great John Belushi, whose samurai skits on Saturday Night Live featured a samurai with a day job in some other field, such as dry-cleaning or a delicatessen. The plot usually gave him some hilarious job-related excuse to use his sword.
Since much of medical imaging (e.g. CT and MR) involves digital "cuts" through the body in various planes, I always hoped to someday see him portray a "samurai radiologist". I guess I'll just have to play that role myself.
The biggest radiographs I've ever personally handled have been 14 x 51 inch (0.36 x 1.3 m) films of an entire human spine.
) reveals them all within its pages.
changed his life.
owner. I'm now past the 
