Voiding Satisfactorily and Passing Grass

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.

Radiology of Competitive Speed Eating

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:

1. increased stomach size
   
2. increased gastric emptying speed into the small intestine
   
3. 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...

Match it for Pratchett

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.

Googlepedia

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.

The Amazon Kindle: A One Month Update

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:

1. Get car keys
   
2. Grab iPhone
   
3. 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 Times and 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-M Minesweeper

Alt-T show time

Alt-1 show current location in google maps

Alt-2 find gas station nearby

Alt-3 find 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.

It's a good time to be a reader...

Don't Let the Bedbugs Bite

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.

Here's the main scoop from Wikipedia:

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...

Lurking in Louisville

I'm currently on the road doing a multi-day gig at the Awfully Big Radiology event in Louisville, Kentucky. This has kept me almost too busy to check e-mail, much less blog.

There are sights aplenty here in Loouhvull. Alas, I've been way too busy to see any of them. Oddly enough, some of my senior residents in town for the Awfully Big Radiology exam have gotten to see more of the place than I have.

I'll try to post an anecdote or two from the road, as time permits.