Tuesday, September 30, 2008

Presidential Candidates and Science

Nature magazine is one of the preeminent science journals in the known galaxy. With U.S. elections looming this November, Nature was naturally (what else) interested in what the two major presidential candidates think about science.

They pursued this question the old-fashioned way -- they asked the candidates:
Barack Obama accepted Nature's invitation to answer 18 science-related questions in writing; John McCain's campaign declined. Obama's answers to many of the questions are printed here... Wherever possible, Nature has noted what McCain has said at other times on these topics.
Sounds like a clear win for Obama in the lip service war, at least.

Why would a lowly radiologist care about this? I mean, we're not considered Real Doctors™. To make it worse, physicians are not even Real Scientists™. However, despite this double whammy, I persist in doing and caring about science. Candidates' attitudes about science will be a major factor in deciding my vote for any office, and I'd love to see a huge voter turnout of other scientists and medical researchers on November 4th.

What if somehow, against all odds, I suddenly found myself in January 2009 as Science Advisor to the next U.S. President? What should I tell him in support of science? It would be hard to improve on Phil Plait's advice:
Stop standing on its throat.

The current administration has spun, folded, and mutilated science and scientific research since practically day one, letting ideology trump reality. If the next president does nothing but let science do its thing unfettered, then the situation will be dramatically improved.
(via Bad Astronomy)

Grand Rounds - Vol 5, No. 2

This week's edition of Grand Rounds just went online, hosted this week by Jeffrey at his Monash Medical Student blog.  

His theme, "medicine and war" seems to be curiously apropos for my contribution: 
And Then He Sewed the Guy's Head Back On...
Jeffrey also scores extra props for the appropriately lurid photo he located on Flickr to accompany the link to my blog.

Monday, September 29, 2008

Surviving Cardiac Arrest: Location, Location, Location

Some places are just safer to live than others.

A study by Nichol et al in the latest issue of the Journal of the American Medical Association estimates one's chances of surviving a cardiac arrest in 10 different sites in North America: Regional Variation in Out-of-Hospital Cardiac Arrest Incidence and Outcome.

ResearchBlogging.orgNichol G, Thomas E, Callaway CW, Hedges J, Powell JL, Aufderheide TP, Rea T, Lowe R, Brown T, Dreyer J, Davis D, Idris A, Stiell I. (2008). JAMA, 300 (12), 1423-1431

Their study population included 20,520 patients with out-of-hospital cardiac arrest (OHCA), and concluded that there are significant regional differences in survival.

This study estimated 3 different survival rates: all cardiac arrests, all arrests in which resuscitation was attempted, and all arrests with shockable rhythms. I've summarized these 3 rates for 9 of the 10 centers in the bar chart below.

The top of the red bar is the survival rate for all cardiac arrests.

Many of the 20,520 arrests were not resuscitated, for various reasons (do-not-attempt-resuscitation directives, terminal illness, etc.). The top of the green bar represents survival for those who did receive resuscitation.  As one can see, it's a lot better to be resuscitated than not resuscitated.

Not all cardiac arrests are equal. Patients with arrest due to ventricular fibrillation and other shockable rhythms have a much better chance of survival than arrests from other causes. The top of the blue bar represents their survival rate.

The Pacific Northwest has a reputation of being a great place to live. The plot above suggests it is also a great place to survive a cardiac arrest.

Nichol et al conclude:
These findings have implications for prehospital emergency care. The 5-fold variation in survival after EMS-treated cardiac arrest and 5-fold variation in survival after ventricular fibrillation demonstrate that cardiac arrest is a treatable condition. However, only 31.4% of treated cardiac arrests (84.8% of bystander-witnessed) received bystander CPR. Therefore, ongoing efforts are necessary to encourage the public to be ready, willing, and able to provide CPR when necessary.

Further improvements in outcome could be achieved by reducing the time to arrival of EMS providers capable of advanced cardiac life support by improving early detection of cardiac arrest, dispatch protocols, deployment of existing vehicles, number of vehicles available to respond, quality of CPR, and real-time or postevent quality assurance.
The same issue of JAMA also includes an editorial by Sanders and Kern, from which I have filched the title of this post. Their editorial puts Nichol's study nicely in perspective. As they point out, although OHCA has a dismal prognosis in many communities, even small improvements in survival translate into thousands of lives saved.

From the graph above, it's apparent that someone in Seattle deserves enormous props for achieving the survival rates shown. However, as Sanders and Kern note:
...protocol and technique can be more important than location for survival of OHCA. Focused attention and improvements to identified local issues within the chain of survival can significantly influence survival.
In other words, similar rates of survival should be achievable by any community that cares enough to do so. Sanders and Kern conclude:
It is time to work to overcome barriers in each community, devote appropriate resources, and optimize survival of all patients so that location by city becomes a minor factor in survival of cardiac arrest.

Sunday, September 28, 2008

E-mailing Your Doctor

Doctor, should I have the surgery?
Even mere radiologists get asked this question -- usually while they are performing face-to-face procedures on their patients (or face-to-butt, in the case of a barium enema). I usually give the stock reply that I'm a diagnostician, and treatment concerns are way out of my area of expertise.

When patients started e-mailing questions like this to me in the '90's, they were enough of a novelty that I answered them all. Currently, when each day brings me 50 - 100 nonspam e-mails, that's out of the question, and I cope by ignoring most of them. My reasons include:
  1. not enough time
  2. out of my area of expertise
  3. I've never met the patient
  4. rarely any way to verify they are who they say they are or have what they say they have
  5. potential legal exposure
  6. yadda yadda...
I do make a few exceptions. I answer e-mail from the rare patients who are actually in my care. I'm happy to help guide friends and family through the medical wilderness. In special cases, I also respond to others. With the resources of a humongous university medical center, I can sometimes answer a question they still have after months of digging on their own.

Since Real Doctors™ spend more face time with patients, they probably also get a boatload more patient e-mail than I do. I suspect that they handle these messages similar to the way I do it, and that any residual guilt I feel over unanswered messages is that much worse for them.

Real Doctors™ may find some solace in a recent Freakonomics post by Stephen Dubner: "So That’s Why Doctors Don’t Use E-Mail":
But surely it’s in everyone’s best interest for patients to stay informed, right? For patients to do their own research, to ask lots of questions — especially of their own doctors — and so forth, right? Right?
He answers his own rhetorical questions with this quote from a new working paper from the National Bureau of Economic Research, titled: Demanding Customers: Consumerist Patients and Quality of Care. From the abstract:
Consumerism arises when patients acquire and use medical information from sources apart from their physicians, such as the Internet and direct-to-patient advertising.

Consumerism has been hailed as a means of improving quality. This need not be the result. Consumerist patients place additional demands on their doctors’ time, thus imposing a negative externality on other patients. … Data from a large national survey of physicians shows that high levels of consumerism are associated with lower perceived quality.
In other words, if the squeaky wheel gets the grease, the other wheels resent it.

And we can't have that.

Friday, September 26, 2008

Forensic Cake Pathology

A friend just tipped me off to the Cake Wrecks blog, whose byline says it all:  
When professional cakes go horribly, hilariously wrong.
The latest posting has a medical theme:  a cake baked in the ironic shape of an insulin pen.  

It would be swell if the right shape could cancel out things like calories.  Alas, a pile of insulin-shaped sugar is still just a pile of sugar.

Jen's cake post mortems are a hoot to read. For more interesting cake pathology, check out other faves from this site, including Naked Mohawk-Baby Carrot Jockeys, Sexual Harassment Cake, The First Censored Cake Wreck, and the Creepy Baby Cake. Follow the construction of the latter cake in the video below:

(hat tip to Anita Anderson)

Listen to Yourself

Alas, this probably also applies to bloggers and med school professors.  Eep.  

Another home run from the excellent XKCD site.

Monday, September 22, 2008

A Tone for Our Sins

One of my fellows is the only person in the whole section with an actual ring on his phone. Plain vanilla rings are now so rare that every time he gets a call, we all ask, "What's that sound?".

(via xkcd.com)

Saturday, September 20, 2008

And Then He Sewed the Guy's Head Back On...

This is a story about my med school roommate. Not for him the cool, dark caverns of radiology -- he went into ear, nose and throat (ENT). While I learned about CT and ultrasound, he studied tympanoplasties and facial reconstruction. While I battled barium enema blow-outs, he struggled with snot, or as he called it: DIMPS and IMPS (dessicated inspissated mucopurulent secretions and inspissated mucopurulent secretions).

After a stint in the Air Force, I headed for the hushed groves of academic radiology. My roomie got out of the Navy about the same time, and headed for a solo practice in the foothills of the California Gold Country. He shared call with the only other ENT in town, and his practice started out fairly slowly and routinely.

This all suddenly changed during dinner one night, with a page from the emergency room. The ER doc was direct and to the point:
ER: Come here, quick!

ENT: Why? What's up?

ER: Don't ask questions! Just get your ass down here!
The suspense grew as as my friend drove across town to the ER.

Awaiting him there was a local crazy dude, who had tried very hard to saw his own head off with a chainsaw. With the luck that is often bestowed on drunks and crazy dudes, this guy had managed to miss his spinal cord and major blood vessels, while severing just about everything else holding his head on.

Most residencies don't cover this specific clinical situation. However, my friend made a, shall we say, heads-up job of it anyway. After his initial shock, he took charge of the ER, stabilized the bobble-headed crazy dude and proceeded to sew his head back on. Where it apparently stayed.

As you can imagine, this single incident made my friend's surgical reputation for life. As the word spread among other patients and other doctors, his practice grew pretty fast.

We could all tell war stories about defining moments in our own practices, when one good or bad call made a noticeable difference in our professional reputation. However, it's humbling to me just how often my stock rises or falls on some other non-clinical basis. Little things like the following have sometimes made more difference to my practice than years of CME:
  1. playing with a surgeon in a musical jam session
  2. my son dating an oncologist's daughter
  3. getting stranded by weather in an O'Hare bar with a colleague I rarely see at home
This social karma can pay off in the form of referrals, which are important to any specialist. These are particularly critical for radiologists. No matter how spectacular a barium enema we give a patient, it doesn't affect our bottom line (so to speak) nearly as much as impressing a fellow physician. As I mentioned above, this is contingent on a lot more things than clinical competence.

Social karma also makes it easier to weather turbulent times at work. Consider this simple stimulus/response situation. Suppose you miss a subtle torus fracture of the radius in a 10 year old boy, like the one shown below.

Someone you know pretty well will probably cut you some slack:
Man, that was a subtle fracture -- I didn't see it either. Kids' films scare the hell out of me.
However, to someone you don't know, you may now be:
That asshole radiologist who couldn't find his butt with both hands.
Given the choice, one would obviously prefer Door Number 1. Unfortunately, practicing Door Number 1 Radiology™ gets harder all the time.

In the old days of hospital-centered radiology, just about every physician in the hospital would drop by our department sometime during the day. This gave us lots of chances to work on those social skills that don't come naturally to people who work in the dark. However, these opportunities to schmooze with our clinical colleagues have dropped off considerably with the widespread adoption of teleradiology.

Nowadays, it's common for radiologists to work in freestanding imaging centers (we call them boxes), miles away from the hospital, reading X-rays across the internet. My department current reads images from about 16 sites around town, and we spend a lot of time calling reports to people we will never get to meet. We are left to squeeze any human warmth and interaction with these busy people into the interstices between bits of diagnostic information. This makes these little bits of humanity all the more important.

Of course, I could be wrong. A lot of radiology tasks are easily commoditized, and can be beamed to well-trained radiologists in the antipodes who are willing to charge a lot less than I do. I've already heard prospective radiology residents wondering if their future jobs will be siphoned off to some offshore radiology factory. Will the world all go WalRad, or will personal relationships forged with one's referral base keep at least some of that work at home? Beats the heck out of me.

While this all works itself out, I'll continue looking for heads to sew back on. In the meantime, I'll keep on reading cases, enjoying the physicians who still physically visit our department, and teaching our larval radiologists how to give great phone.


By popular demand (n=1), I have added an additional view of the wrist, with arrows pointing out the subtle buckles in the cortex that indicate the radial torus fracture. The discontinuity is best seen on the lateral view. Kids' bones are more flexible than those of adults, and often don't present with the classical linear lucency seen in fractured geezers (anyone over 21).

Friday, September 19, 2008

Watching Football on the Wayback Machine

The closest I come to watching football these days is reading the knee MR's of local players. However, I was fascinated by this Mark Bowden article in the Atlantic Monthly: Distant Replay.

As part of his research for a book, The Best Game Ever, Bowden watches game footage of the 1958 NFL championship game between the Baltimore Colts and the New York Giants with Andy Reid, head coach of the Philadelphia Eagles.

Dead tree & Kindle versions of the book

A great review of the evolution of professional football over the past 50 years, as seen through the eyes of a Jedi master:
“Okay,” he’d say, when he had examined a play from snap to tackle, “here’s what happened.” Then out would pour a detailed explication: what the offense was trying to do, how the defense was trying to stop it, the techniques (good and bad) of the various key players, the historical roots of the formations and the play’s design, and ultimately why it worked or failed, and who was responsible, either way. The wealth of information Reid gleaned from a single play reminded me of the way Patrick O’Brian’s 19th-century naval hero, Jack Aubrey, eyeballing an enemy ship during a sea chase, could read from the play of its sails and the disposition of its crew the experience, intentions, strengths, and weaknesses of his opponent.
(via Daring Fireball)

Tuesday, September 16, 2008

World's First Fungus Opera

The world's first fungus opera: coprophilous (they live on cow poop) fungi discharging their spores, accompanied by the Anvil Chorus from Il Trovatore.

Don't try this at home -- unless you have a 250,000 frame/second video camera. The spores are blasted away from the parental unit at 180,000 g's of acceleration, reaching speeds of up to 55 mph. Fortunately, my human patients are much slower off the mark, making their imaging a lot easier.

For more details on these fascinating organisms, see Money et al. in the journal PLOS One.

(via The Loom)

Giant Animal Smasher May Discover Darwin Particle

As I reported here recently, scientists at CERN are now using the Large Hadron Collider in Geneva to probe atomic structure. Their quarry includes the elusive Higgs boson.

Physicians and other members of the soft sciences will be delighted to learn of progress on the Giant Animal Smasher, now under construction near Dallas, TX. As one CERN scientist stated:
Biologists are just jealous of all the attention the LHC has been getting. Since they aren't real scientists, they had to come up with this atrocity.
Much of the early work in animal smashing is anecdotal, and has largely been carried out informally by pickup and semi-trailer trucks on the roadways of the world. However, this important work has been greatly limited by local highway speed limits.

The GAS, however, can theoretically collide animals as large as squirrels at relative speeds of 12,000 meters per second. This device may thereby demonstrate evidence of the Darwin particle, unlocking the secrets of evolution and life.

Not to be discounted is
...the visceral enjoyment of seeing two squirrels collide at thousands of miles an hour.
Of course, if it's visceral enjoyment we're after, there's nothing like flinging actual viscera around. Luckily, we may not have to wait too long for this...
Next thing you know the psychologists will build a brain smasher to compete.
Among psychologists, I'm guessing that the schadenfreudians will be the first on board with this new tool.

(hat tip to David Goldman)

Sunday, September 14, 2008

Interview with a Vampire (Suit)

Last month, I blogged about the need for a randomized clinical trial of parachutes. Looks like the experiment has already begun in Norway...

I'm just thankful that that vampire suiting hasn't hit, so to speak, our area trauma centers yet.

(via Geekologie)

Thursday, September 11, 2008

The X-Ray Whisperer

I got laryngitis last week, and spent most of my work days whispering my findings to the residents and fellows. My voice came back online yesterday just enough so that I could give two hours of lectures at a CME course. Whew!

After spending the past week talking funny, I found the following performance by Adam Savage to be especially hilarious...

Wednesday, September 10, 2008

Is It The End Of The World Yet?

Some hysteria has occurred over the idea that the Large Hadron Collider in Geneva will create a mini black hole today that will eat the earth.

For those spending way too much time worrying about this possibility, a helpful website has been created to help you answer the following question:
Has the Large Hadron Collider destroyed the world yet?
Click here to learn the answer.

Not convinced? The Bad Astronomer offers further reassurance here.

Thursday, September 4, 2008

Top Ten Viagra Ad Straplines

I just found the following list on the PharmaGossip site. Like the old fortune cookie game, where you add "in bed" to every fortune, you can also add "Viagra" to classic ad straplines for other items. Here's some of the results...
10. Viagra, Whaazzzz up!

9. Viagra, The quicker pecker picker upper.

8. Viagra, like a rock!

7. Viagra, When it absolutely, positively has to be there overnight.

6. Viagra, Be all that you can be.

5. Viagra, Reach out and touch someone.

4. Viagra, Strong enough for a man, but made for a woman.

3. Viagra, Home of the whopper!

2. Viagra, We bring good things to Life!

1. This is your penis. This is your penis on drugs.

(via AdPharm Blog)

Two Minute Presentation Workshop

The UBC Terry Project has a swell idea: bring 8 of UBC's most fascinating and engaging students together for a day, where they can give the talk of their lives to 350 of their peers.

If this sounds familiar, it's because the conference is intentionally modeled on the wonderful TED conferences. Unlike TED, you don't have to be a Nobel laureate, write a best-seller or cure cancer -- you just have to be a UBC student willing to go for it.

Even for us non-UBCers, the following short (1:49) promo video from the Terry Project provides a great presentation workshop all by itself on Things to Avoid When Speaking Publicly.

(via Pharyngula)

Monday, September 1, 2008

Grand Rounds - Vol 4, No. 50

This week's edition of Grand Rounds just went online, hosted this week by Laurie at her blog: A Chronic Dose.

My addition to this carnival bridges two of my favorite worlds: medicine and music.  

As an ivory tower radiologist, I give and receive a lot of presentations. Over the years, I've really learned to really, really hate presentations that suck.  

My post on Jazz and the Art of Medical Presentations shares some of the things I've learned from the jazz world on how to avoid presentation suckage in my own talks.