Grand Rounds Vol 5. No 28 is up

The latest issue of Grand Rounds is hosted this week by Paul Levy, at Running a Hospital.

This week's episode is devoted to "When things go awry". My contribution -- "Getting the Finger From a Patient" -- is about 4th from the top.

Hook 'em Horns

My undergraduate education was at Texas A & M, which has long had a friendly rivalry with the University of Texas.

It was always our contention that the Hook'em Horns gesture was merely the sign of a careless carpenter ordering 4 beers.

I don't know if the person above is actually from Austin, but it's possible...

Getting the Finger from a Patient

A patient gave me the finger not long ago.

Not once, but twice.

How did that make me feel?

The first time, intrigued.

The second time, embarassed but relieved.

Here's why:

It started when her dematologist ordered an MR scan to "R/O glomus tumor" of the middle finger. In case you're not completely up on your small, rare, soft tissue tumor lore, here are a few facts: glomus tumors are usually small (often 1 - 2 millimeters in diameter), benign , rare (we only see a few a year), typically occur in the tissues under the nail bed, and can be exquisitely painful.

Looking for something this small is a real challenge -- even with current MR technology. Most MR machines are optimized to look at large chunks of human tissue -- sometimes as large as the abdomen on a 350 pound dude. In this patient's case, we were pushing the other extreme, and trying to focus all of the resolution of this giant machine down on a single finger. Tumors this small sometimes end up in the small gap between MR slices -- making them invisible. Even when things work perfectly, we may be lucky to see a lesion on only one image out of hundreds that we scan from that patient.

Despite these challenges, I enjoy looking for these intriguing little lesions.

To improve our odds of seeing this millimetric lesion, we gave her an intravenous injection of a gadolinium solution, which is designed to concentrate in tumor tissue, and make it stand out better against normal tissue.

Alas. We screwed up. My MR technologists omitted the critical sagittal image sequence that best shows the nail bed. To make matters worse, I didn't get around to looking at her study until she had already gone home.

Merde.

It's painful to have to admit to a patient that you, a professor at Enormous Medical Center, have screwed up, and need her to come back in for another scan.

Painful, but we did it. She took off from work yet again, endured a new IV injection of gadolinium, and gave us her finger for another session in our scanner. However, we finally got the crucial sagittal images. This time, I was standing by the scanner and looked at her images before we ended the study.

The happy ending: we saw the tumor this time -- it was indeed so small that it only showed up on a single sagittal image. Small, but unmistakeable.

Afterwards, I showed her the key image, and offered one more abject apology for the extra imaging hassles.

Her reaction? She forgave us our mistakes, and was delighted to finally know what had been causing her pain for so long. We both left that encounter a lot happier than we entered it.

In the past few months, I've become pleasantly used to hearing a president willing to claim responsibility for his mistakes. Are my patients any different? Admitting mistakes to patients is not yet a universal practice , but it sure felt good this time, to me and my patient.

Finally, there is the concept of grace -- an ecclesiastical term for unearned forgiveness. Being a physician or a parent gives one endless opportunities to screw up someone else's life. Happily, kids seem to dispense a boundless supply of grace when this happens. Fortunately, some patients give it too.

Generations

We just got home from one of the sweetest events I've been to in a long time -- a surprise 70th birthday party for an old friend.

This friend is part of the large extended family of folk musicians and dancers that we have fallen in with since we moved to town years ago. For this occasion, our family became even more extended, with folks driving in from hundreds of miles away.

Our local folk community reminds me a bit of Eureka, the TV series about a mythical town in the Pacific Northwest where everyone is a scientific super-brainiac. In our community, however, the norm is that practically everyone you know plays several musical instruments, sings and performs music, dance or some other art.


For this kind of crowd, it long ago became a conditioned reflex to bring an instrument along to any gathering. This means that the usual tasty food and conversation are also well-mixed with great live music and dancing. Several of our gang composed original tunes and dances in honor of our pal and performed them on the spot. It was a hard choice for me between watching them perform and watching the look on his face.

However, the sweetest parts of a very sweet event were when my friend's children sang to him. This began when he walked in the door to find the place filled with friends, a 15-person live band, and his daughter singing Bei Mir Bist Du Shoen. Soon after, his son stood up and sang a touching but funny song he wrote about his long and continuing friendship with his dad. Not too many dry eyes in the house at this point.

We're back home now. Since we got back, I've been wrapping up a statistical analysis, tweaking some lectures and doing a bit of blogging.

As I write this, the sounds of my own son singing and playing his guitar are filtering up from the basement below -- a sound as beautiful as any I've heard today. It gives me high hopes for my own incipient geezerhood...

Readability

A radiologist makes her living by spotting tiny details in a sea of noise, and does this hundreds of times every day. However, sifting subtle diagnostic findings out of the visual clutter that forms the rest of a human body can be tiring work.

Even if you're not a radiologist, you probably have the same experience trying to read many of today's web pages. Most of my favorite online newspaper and magazine articles are filled with zillions of navigation bars, ads, images, links, headings and other visual cruft.

However, this just got a lot easier, due to two cool little tools called Readability and Quietube, that run in most web browsers.

Readability

Readability works this way:

1. you tell the Readability website a few reading preferences (i.e. format, text size and margin size).

2. Readability creates a custom "bookmarklet" -- a link that you drag to your web browser's bookmark toolbar.

These two things are done only once. Later, when you find a web page worth reading, you do one more thing:

3. click the Readability bookmark on your toolbar.

That's it!

The Readability bookmarklet is actually a short Javascript program that filters out most of the non-content from an online article. I use it all the time to reduce the visually busy New York Times website to a calmer, simpler page of text.

I also use Readability as a pre-processor before converting an article from text to speech. I do this so that I can listen to these articles during my work commute. Once Readability has removed web links and other crud I'd rather not have read to me ("aitch-tee-tee-pee-colon-slash-slash....."), clicking an icon on TextCast converts this laundered text into a speech file on my iPhone's playlist.

Readability works fine for most of the newspapers and magazines I read online. However, with online radiology journals, it fails to remove all of the special tables of content and references these articles include. My personal solution for this is a custom program I wrote in Ruby. I'll demo this program to some AJR pals at the upcoming ARRS meeting in Boston next month before releasing it into the wild.

Maybe one of my next projects should be to write a bookmarklet version of this in Javascript. We'll see...

(via Daring Fireball)

Quietube

Quietube is even easier to set up than Readability. Just drag the button on the Quietube site to your toolbar. Clicking it will then perform a wondrous cleansing of a cluttered YouTube page. Cooool.

(via Daring Fireball)

Society Doesn’t Need Newspapers

It's a bit sobering when a 146 year-old newspaper like the Seattle PI holds the presses for good and goes web-only. With this in mind, Clay Shirky's Newspapers and Thinking the Unthinkable is a very smart analysis of our planet's current move from paper to pixels. My favorite quote:

Society doesn’t need newspapers. What we need is journalism.

Steven Berlin Johnson's Old Growth Media and the Future of News makes a fine companion piece, and offers some upsides:

In fact, I think in the long run, we’re going to look back at many facets of old media and realize that we were living in a desert disguised as a rain forest.

Newspaper publishers are not the only ones taking trembling steps to digital publication. Most scientific journals, including the ones I write, review and edit for, are also somewhere along this path. This is an especially acute issue for learned societies that have long relied upon journal revenues as their cash cow. Finding an economic model that will pay for the stuff we need to read is going to take a lot of trial and error. On the plus side, it should be a great time for radical forces (such as myself) to try out all sorts of wacky experiments in radiology publishing. As Shirky concludes:

Many of these models will fail. No one experiment is going to replace what we are now losing with the demise of news on paper, but over time, the collection of new experiments that do work might give us the journalism we need.

(via Daring Fireball)

Extreme Sheepherding

Awesome use of sheep-as-pixels from Wales.

If I had had access to sheep-sized LED suits while growing up on a West Texas ranch, this is probably the sort of thing my friends and I would have done in the evenings.

Now that I dwell far away from the land of sheep and Mensa-smart border collies, I'd have to find some alternative animal model. Hmmm... I wonder how this would work with medical students and radiology residents...

How Do You Hide a Dollar From A Radiologist?

Financial security tips from Movin' Meat:

How do you hide a dollar from a radiologist?

Pin it to the patient.

How do you hide a dollar from a surgeon?

Put it in a textbook.

How do you hide a dollar from an internist?

Put it under a surgical dressing.

How do you hide a dollar from a plastic surgeon?

Ah, that's a trick question: there is no way to hide a dollar from a plastic surgeon!

But wait, there's more!

To find out several ways to hide a dollar from an ER doc, check out the comments on the original post. My favorite is the suggestion by scalpel...

Kindle 2: Some Features Better Than Reality

Usability pundit Jakob Nielsen’s take on the Kindle 2 and the Kindle iPhone app:

11 years ago, I wrote that electronic books were a bad idea. Has Kindle 2 changed my mind? Yes. The two factors that convinced me were (a) equal-to-print readability and (b) multi-device integration.

(via Daring Fireball)

CPR Will Never Be Quite the Same for Me Again

The latest issue of Dinosaur Comics has a handy mnemonic for getting your chest compression rate just right...



(via Dave Goldman)

Lots of Kindle News Lately

There has been a torrent of news lately on Amazon's Kindle, and I've had little time to write about it. For those who have been living in a cave, here's a quick summary and a few links.

Kindle 2

David Pogue has a favorable review of the Kindle 2. The title of his post sums it up pretty well: "Good Before, Better Now".

For comparison, he also recently reviewed the Sony PRS-700 e-book reader. He liked some of the design features, but gives the nod to the Kindle because of its wireless connection and Amazon's much larger collection of e-books.

I now have a Kindle 2, and will blog later about my experience with it, particularly with respect to how it does with displaying medical images (short version: improved, but still not optimal).

Kindle 2 text-to-speech controversy

One of the coolest features of the Kindle 2 -- built-in text-to-speech conversion -- has excited a bit of controversy among members of the Author's Guild. AG president Roy Blount wrote a recent opinion piece expressing the AG's point of view. I'm of two minds about this. On the one hand, I'm very sympathetic to an author wanting control of one's intellectual property. On the other hand, while the Kindle's computer voice is nice, it's no Jim Dale. Some books are at their best when read by someone as compelling as Mr. Dale; others are just fine read by a Kindle. There's a part of me that feels "Dude, if your performance can be replaced by a Kindle, you deserve to be."

In any event, it looks like Amazon will leave it up to authors and publishers as to whether the text-to-speech function is enabled on a given work on a case-by-case basis.

Kindle App for iPhone

The biggest news, though, is that Amazon just released a free reader application for the iPhone. This app lets one read any book in the Kindle library without having to buy a Kindle.

This is huge.

I've had a Kindle reader for over a year now, and read from it daily. However, the iPhone is always in my pocket, and follows me places that the Kindle never will. In general, the app works really, really well, with only minor syncing bugs.

I'll give a more in depth report on the iPhone app in later post, particularly on how it handles gray scale images (short version: great!).

Several pundits (1, 2) have pointed out that by releasing the iPhone app, Amazon is giving away the razor but hoping to make a zillion dollars selling razor blades. I agree. No one outside Amazon really knows how many Kindles have so far been sold (possibly up to 500,000). However, this number is dwarfed by the millions of iPhone now out there. In one swell foop and with minimal marginal cost, Amazon has multiplied its potential customer base for books manyfold. Brilliant.

I also enjoyed a recent review of the Kindle iPhone app by Glenn Fleishman of TidBITS.

Weird X-rays

A friend sent me a link to some weird X-rays on the Asylum site.

Weird, for sure. Looks like some of the stuff we see in our emergency room.

A bonus story at the same link tells of a Chilean man who carried his stash in form of a cast made entirely out of cocaine covering his own broken leg.

Wow. Gotta give him some points for imagination, if not for intelligence.

I've Been Programming

I haven't posted much lately, mostly because I've been tightly focused on a computer programming project. Let's just say that programming is easily as jealous a consort of one's time as blogging.

I've programmed personal computers ever since my first Radio Shack TRS-80 Model I back in 1976. I got my first Apple II a year later, and have stayed in the Apple fold ever since. Since 1976, I've programmed in Basic, Fortran, assembly language, several machine languages, Pascal, Python, S, R, C, Perl and a few others.

For the past few years, I've been closely eyeing Ruby, a relatively new language, but haven't had the right incentive to dive into it. However, there's nothing like building a cool, new project to learn a new language.

I've spent much of my academic time in the past two weeks writing a web-based text-to-speech application in Ruby. My goal: type in the volume, issue and page number of some article in a major radiology journal and get back an .mp3 version of that article, read by a fairly decent computerized voice.

It turned out to be a lot easier than I thought it would be, even with a few years of web-apps under my belt. Ruby is a fine language, with a fine library of built-in tools, making it easy to scrape a whole web page with just a few lines of Ruby code. For example, the following code is all that's necessary to grab a whole article from the American Journal of Roentgenology and assign it to the variable ajr_html:

urlRaw = "http://www.ajronline.org/cgi/content/full/"
   + ajrVolume +"/" + ajrIssue + "/" + ajrPage
ajr_url = open(urlRaw)
ajr_html = ajr_url.read

I have recently become a big fan of text-to-speech conversion. In December, I discovered a new Mac program called Textcast. Since then, I've used Textcast to make one or two hundred podcasts for my iPhone from NY Times articles and various blogs I follow. These have been a major defense against boredom during my work commutes -- sort of like having an NPR station where all the stories are interesting.

The only issue I have with Textcast is that it is optimized only for pages from Safari or NetNewsWire. If I want to use it to grab and convert an article from AJR or Radiology, I need to first do some serious hand-scrubbing of the text from their websites before I can feed it into Textcast. I got pretty tired of this after laundering a few articles by hand. My new Ruby script takes virtually all of the drudgery out of this process.

Now that I've refined my program into a reasonably stable version, I've asked several of my residents, fellows and fellow faculty to do some alpha testing. Once I get their feedback, I'll write it up for one of our radiology journals. Might as well get some academic mileage out of it.