29 January 2010

Friday Flashback

Rounding at 37,000 Feet

Anyone who has flown long-distance flights has heard the call: "If there is a doctor on board, please identify yourself to a flight attendant." But it's impossible to understand how that call induces the urge to flee to the lavatory and hide unless you are one of those unfortunate few who are on the hook, which is to say that you are qualified to respond, but you really really don't want to.

"But Gee," I can hear you think, "Aren't you an ER doctor? Isn't this sort of thing second nature to you? Don't you revel in the adrenaline and glory?" Well, yes. But. First of all, there is the performance anxiety thing. I'm used to working with a very small audience. In Economy class, there may be 300 people watching me try to do my thing, and I'm just not used to that many people being in the exam room -- and I know they are very interested in what's going on. Also, being an ER doc, I am terminally paranoid, and over the Atlantic Ocean there's just no easy way to differentiate the Very Bad Things[tm] from the more common complaints which occasionally represent Very Bad Things[tm]. So that also is anxiety-provoking. And then there's the potential that things might turn bad, and then it's a flog to run a code in the limited space available.

So, on Olympic Air, somewhere over the mid-atlantic, the dreaded call goes out. I cringe and try to sink deeper into my seat, hiding my face behind my magazine. Finally, seeing that nobody else responded, I gave a deep sigh and pushed the call light. It was a 60-70ish guy in First Class with abdominal pain which radiated through to his back. Great, I thought to myself, It's an Aortic Aneurysm. (see? I told you I was paranoid.) But his belly was soft with no pulsatile mass, good femoral pulses, and clinically, I thought the pain was much more suggestive of a kidney stone. I gave him some ibuprofen and said I'd check on him later.

I tried to sleep, but maybe an hour later, the attendant approached me again . . . there's another patient for you. Sheesh. This is an older fellow with a history of heart disease who has epigastric pain and nausea. How the hell am I supposed to tell heartburn from angina over the Atlantic? I asked the attendant if there was a defibrillator on board, thinking maybe I could at least look at the ST segments, but the Greek-speaking attendant seemed to not understand the question. I mimed shocking somone with paddles, and his eyes got very big, but then said, no, they didn't have anything like that. The patient said he has had typical chest pain with his heart attacks and this felt much more like his stomach. Then he threw up and felt a little better. I rooted through the medical kit and found something which looked like Greek meclizine and gave it to him. I checked on the first guy and he said he felt a lot better.

A couple of hours later, they roused me from a deep sleep (this was an overnight flight), to apologetically tell me that there was a third passenger in need of attention. Oh. My. God. This elderly lady was having trouble breathing and they had gotten an oxygen mask on her. Well, her lungs were clear and her pulse was normal and she seemed really panicky and her traveling companion said she had been under a lot of stress and hated to fly. So probably a panic attack. I told the flight attendant to keep her on oxygen for another half an hour (purely for placebo value) and told the patient in my most authoritatively reassuring tone that she would be feeling better by then. I then checked on the kidney stone (sleeping) and the nauseated fellow (much better, thank you). I went back to the galley and hung out with the crew, drinking coffee for half an hour, then went back to the panicky lady who had in fact experienced a miraculous recovery.

The flight crew was very nice and gave me a free bottle of champagne as a gift. And I swore I would never again admit that I was a doctor on an airplane flight.

The time in Greece was lovely. We started off on the island of Kos, Hippocrates' birthplace, and I got a cool T-shirt with the Hippocratic Oath on it, in Greek. As it happened, that was the only clean garment I had for the flight home (this time on Delta). This time we made it most of the way across the Atlantic before the call came for a doctor. I waited and waited and nobody else responded. Finally I decided that I couldn't very well walk around with the fricking Hippocratic Oath on my chest and not help out, so I gave in and rang the bell.

As I stood up, I saw an elderly man about ten rows in front of me, standing in the aisle in the tripod position, labored breathing, gray and sweating. That must be my patient, I thought. He doesn't look good. He couldn't tell me anything (too short of breath), but his traveling companion cheerfully informed me that he had had a heart attack only two weeks ago, and just got out of the hospital with congestive heart failure and had a pacemaker put in. Oh, is that all? His pulse was about 150, way too fast, and his blood pressure was also very high. When I asked, he nodded "yes" that he was having chest pain.

I figured that most likely he had gone into an irregular heart rhythm as a consequence of his heart failure and the low oxygen pressure in the cabin. I got out the defibrillator and moved him to an empty seat in business class because I figured that if he was going to code, I wanted room to work it. He looked that bad. I rooted through his med bag (a cornucopia of heart meds) and gave him aspirin, nitro, lasix, and metoprolol. And oxygen, of course. Then I went to talk to the pilot. We were two hours out from JFK, he said, but we could get down just a bit sooner by landing at Halifax, Nova Scotia. I tried really hard not to let the knowledge that I had a connecting flight affect my decision-making. Tough decision. Finally, I said that I thought he could make JFK but we should expedite it. I heard the engines spool up as the pilot accelerated the plane.

So I sat up in first class with him to keep an eye on him (The Wife eventually joined me when I didn't return to our seats in coach), and he progressively improved. His pulse came back towards normal with a second dose of metoprolol, and by the time we landed (almost 40 minutes early) his color was much better and his breathing was a lot easier. I wrote up a little report for the paramedics/ER, and after the fastest landing and shortest taxi I have ever had, the medics bustled him off the plane.

Again, the flight crew was really nice (and almost pathetically grateful, which was appropriate, since an unscheduled landing would be just about the end of the world to them). They took my business card and promised me a "nice little something." Lord knows what that'll be -- probably a fruit basket. It was rather a pain in the butt, but at least the guy really needed me, and it was gratifying to see him get so much better.

And I have resolved that from now on, I will fly with an iPod in my ears, cranked up so loud I cannot hear a single overhead announcement ever again.

Originally posted 2 June 2006

27 January 2010

Tablet PCs and Health Care

Looking at the iPad released by Apple today, it's a pretty natural impulse to see that sucker in the ER.  I can see viewing the EMR and the EDIS on it (if those platforms were safari-compatible, which they are not).  I'm not sure that I can see doing a lot of data entry on it with the virtual keyboard, but there is the dock option.    It's been pointed out that Apple has not generally done enterprise marketing/support very well, and most enterprise IT folks view Apple with something between aversion and contempt, so it may be an entirely moot point.

Chris over at Medical Software Advice reports that Apple reps have been spotted at Los Angeles’ Cedar-Sinai hospital, probing physicians about how a tablet (Apple’s iPad) could be used in a hospital setting.  While I like the idea, I'm pretty skeptical that we'll see the iPad much in large hospital environments.  We will see.

Chris also has an interesting survey on what features health care professionals would like/need in a tablet device.  If you are a health care provider, click the link and make your voice heard.  I'll be interested to see the results.


(Pulling out wallet) So, when I can I have this?  Sixty days?  Sheesh. It's gonna be a long two months.

22 January 2010

It's funny because it's true

Well, it's sort of true.  I can't see the Dems ever actually getting it together enough to overcome the opposition.  C'mon, they're DEMOCRATS, after all.  As the geniuses at Despair.com put it:

If they can't manage to govern with large majorities in both houses and the White House, they don't deserve to have those majorities.  As Ezra put it:
It's worth taking a step back from health-care reform for a second. What Democrats are doing isn't just abandoning a particular policy issue. They're proving themselves unable to govern.
Democrats spent most of 2009 with 60 votes in the Senate and about 256 in the House. They had a popular new president who was following a disastrous Republican administration and a financial crisis. The opposition party was polling somewhere between foot fungus and spoiled meat. You don't get opportunities like this very often. [...]

If Democrats abandon health-care reform in the aftermath of Brown's victory, the lesson will be that they can't govern. No majority within the realm of reason will give them the votes to move their agenda swiftly and confidently. Even the prospect of the most significant legislative achievement in 40 years, an achievement that will save hundreds of thousands of lives, will not keep them from collapsing into chaos when they face adversity.

At that point, what's the pitch for voting for Democrats? That they agree with you? A plumber and I both agree that my toilet should work. But if he can't make it work, I'm not going to pay him any money or invite him into my home. Governance isn't just about ideology. It's also about competence and will. That's where Democrats are flagging.

Sadly true.  And maddeningly frustrating.

Friday Flashback

Things Not to Say
Things you can say which will reliably discomfit your patients:

For patients who will need surgery: 

  • "There's no cure for what ails ya except cold hard steel."

For patients upon whom you are performing a procedure:
  • "Oops"
  • "What the hell is that?"
  • "Hold still, I'm going to try something."
  • [To Nurse] "How does this gadget work?"
  • "I've never done this before, but I'm pretty sure I can pull it off."
  • "Now this may hurt a little . . . actually it's going to hurt rather a lot."

For patients with a medical diagnosis:
  • "There's Good News and Bad News. The Bad news is you have [X]. The Good news is that it's you and not me."
  • "Everybody's got to die sometime."

Now, I've never said (most) anything on this list, but I have a wicked mind and have thought about it on many occasion. I'm sure you have thought about it, too. Feel free to add suggestions in the comments.

Originally Posted 1 March 2006

20 January 2010

Is that all there is?

I've assiduously avoided writing about the politics of health care reform for the past couple of months, for a number of reasons.  First of all, it has been such a fluid situation that my the time I could put any sensible commentary together it was already out of date.  Also, with excellent analysts like Ezra and Jon Cohn and others on the job, I didn't feel that I had a lot of substance to offer beyond linking to them.  And finally, since the whole thing was being played out on the big stage in DC, so very far away, it's not like like my voice was going to have any impact on the debate.  So I've watched carefully and I've kept mum.  Mostly.

I'll make a few observations on the status of things now, in the wake of the MA debacle, then resume radio silence till there's any substantive developments to comment on once more.

Is it time to write Health Reform's post mortem?

Sure seemed like it this morning.  Congressional Democrats, in one of their most disgusting displays of political cowardice, started a full-on freak-out, with liberal stalwarts joining jittery centrists in declaring the whole game over.  The Senate leadership preemptively declared defeat.  Conservadems in the senate like Bayh and Nelson who never wanted reform in the first place also took the opportunity to head for the door and declare the whole thing done.  Then Obama implied that the reform bill should be dropped and maybe something smaller could be passed instead.  This is the sort of galling weakness that makes it insanely frustrating to be a democrat.  These people are contemptible.  Talk about a worst-case scenario.

Fortunately, as time passed, cooler heads started to prevail.  The White House walked back the implication that they were giving up on the Senate Bill.  Barney Frank got over his moment of hysteria.  House leadership and labor leaders said they could live with a "fixed" senate bill, passed through reconciliation.  Senate leaders expressed openness to using reconciliation.  To everybody's surprise, it appears the sun will, in fact, still rise tomorrow. 

Whose fault is this mess anyway?
Boy there's plenty of blame to go around.  The old saying is that success has a thousand fathers but failure is an orphan; not in this case.  It's Martha Chokely's, fault, for blowing a gimme special election.  It's Ted Kennedy's, for dying at such an inopportune time (sad joke, not funny).  It's the MA Democratic party's fault, for screwing with election laws over and over.  It's Harry Reid's and Max Baucus', for wasting months of time in a fruitless quest for GOP cooperation.  It's Lieberman's and Nelson's, for being preening egotists and holding the bill hostage.  It's Obama's, for not using the bully pulpit to continue to make the moral case for universal coverage.  It's FOX's, for cynically and repeatedly lying about the proposed bill and demagoguing the issue relentlessly.  It's the feckless Democrats' fault in general, for failing to keep their caucus together and legislate effectively.  It's the GOP's, for their nihilistic approach of obstruction and refusal to compromise.

The list could go on for pages.  I guess it doesn't matter.  We are where we are, and if it works out in the end, all sins will be forgiven -- but not necessarily forgotten.

What comes next?

Best I can tell, the Senate has decided not to do anything till Brown is seated.  (Funny how the Senate didn't wait for Al Franken or Roland Burris, though, innit?)  Which means that the original strategy of the ping-pong of the Senate bill back to the House and then back to the Senate is dead.  There's some suggestion of getting Snowe (or even Brown? He does have to run again in MA in 2012) back on board with some policy compromise, but I suspect that is a fool's hope. 

Apparently, the plan is that the Senate bill, which has been passed, will be approved verbatim by the House, then signed into law by the President.  House liberals will not agree to this, however, unless the Senate bill is improved, and improved it can be, through the reconciliation process, which as we all now know takes only 51 votes.  The good news is that the major items of contention for "fixing" are appropriate for the reconciliation process, because in some way they affect the deficit -- the excise tax, the expansion of Medicaid, the Nelson Nebraska buy-off, etc.  The bad news is that this process could take a while, which could be fatal.  The opponents of reform smell blood, and the popularity of reform will probably continue to plummet in the face of increased attacks.

Will it work?

I think it will. Not because I'm deranged, or an incurable optimist.  But because the electoral calculus for the dems is very clear: pass this thing or it's 1994 again.  If this fails, the narrative will be that the Dems tried to do this awful thing and isn't it great that the people gave the GOP back enough power to stop them.  That's a formula for electoral disaster.  Pass it, and you can take a victory lap, talk about all the goodies in the bill, and gain some time to let the backlash die down before facing the voters.  Winning matters in politics.  I think in the end, simple self-preservation will compel the democrats to finish what they started.  But really, at this point, who the hell knows?

Why is this effort still worth supporting?
This is the case that the supporters of reform need to start making (again) and more forcefully.  To this point, we've been so embroiled in policy fights (public option) and internecine warfare (Baucus, Nelson) that Dems have inflicted their worst injuries on themselves.  They've not played offense at all.  Now there's little possibility of changing the bill -- the cement is poured -- so Dems can and must put aside the squabbling and remind Americans that despite the ugliness of the process, what we have is a relatively centrist, good bill.  We can stop apologizing for it and promote it:  It's a guarantee that nobody will ever need to worry about losing their health care coverage ever again.  It's a promise that exploding health care costs will (start to) be contained.  It's an end to some of the worst abuses of the insurance industry. It's the closing of the Medicare Part D donut hole.  It gives individual consumers more choice, and fairer choices.  It's more funding for primary care and prevention.  It extends the solvency of the Medicare program by nine years.   It's fully paid for and reduces the deficit.  It's a good start, a historic start, that future congresses can build on and improve.

It's time to take a deep breath, get back on the proverbial horse, and get out there and make our case to the American people that this health reform bill is still, after all, what America needs now.  And then let the chips fall where they may.

19 January 2010

Assisted decision-making

I recently was served notice that I have "made it" as a blogger -- power, influence, prestige, all the perks of fame. Which is to say that I was sent a review copy of a book I probably would have bought anyway. I mean, it doesn't get much better than that, does it? A free book!


Here's my bottom line: if I had paid good money of my own, money that could have been spent instead on ice cream or video games, I would consider it money well spent. You can't ask for better than that, right?

Oh yeah, I should probably tell you a little more, like the title of the book. I kinda feel like I owe the PR guy who sent me the copy that much at least. It was Atul Gawande's The Checklist Manifesto (available at Amazon.com for $10.00 with FREE Super Saver Shipping).

He has it named right: it's a manifesto, in the old sense -- it's a public declaration of a belief or creed. By which I mean Gawande has hit upon a good idea -- a very powerful idea with a lot of potential -- and he's not going to let it go. He worries at it like a dog at a bone, only with more evangelical fervor, and he's bound and determined to see it adopted as widely as possible.

It all began with his landmark article in the New Yorker, two years ago, called, more simply, The Checklist. Indeed the first couple of chapters of the book amount in large part to a reprint of the New Yorker article. I would have felt ripped off if it didn't go beyond that, but it does, fortunately. And the ultimate test of a good book -- it made me re-evaluate and change my thinking.

From my point of view, checklists in medicine seemed like a nifty idea -- for someone else. For surgeons and ICU doctors, they have good applicability, I thought. Those doctors are doing the same thing over and over again. Those doctors are vulnerable to the fatigue of routine and forgetting to do the simple obligate items, and a checklist can really help them. Central line? Good -- do a checklist. Ventilator patient? Good -- checklist. We're not like that in the ER. We don't do the same things over and over again -- we have too much variability from day to day and patient to patient. Our job is too different and unpredictable for checklists to play any role, right?

Maybe not.

Sure, in the ER there are lots of different patient types. There are the chest pains, the belly pains, the migraneurs, the minor traumas, the weak&dizzies, etc. But that applies to the OR as well, doesn't it? The checklists are not there to tell the surgeon how to resect the duodenum, and checklists for the ER would not tell me how to evaluate a patient with chest pain. Checklists are not for higher-level decision-making. They're for, as Gawande put it, "the stupid stuff." When Captain "Sully" Sullenberger decided to ditch his plane in the Hudson River, the checklists did not tell him how to pick the landing site or gently kiss the plane onto the river's surface. But the checklists did allow his co-pilot second officer to run restarts on both engines prior to ditching and reminded him to close the hatches without which the aircraft might have quickly sunk.

In "Checklist Manifesto," Gawande extends the concept from the ICU to the OR, as published in the NEJM [PDF] article about the surgical safety checklist which produced such seemingly improbable reductions in morbidity and mortality, and to more chaotic endeavors such as the erection of large buildings. What struck me were how simple and obvious many of the critical items were, and how well some translate to the ER.

For example: before the operation, very person in the room must introduce him or herself and state their role in the case (thankfully, this is done after the patient is asleep), and is given the opportunity to voice any thoughts or concerns they may have. What a simple and effective tool! I think of the ER, where we have 300 nurses, including part-timers and floaters, and how often it is that a nurse does not know me, or I do not know the names of the nurses, and how often that leads to a failure to communicate. Gawande admitted that this was one of the harder steps to actually adopt, and I sympathize. Last year, we tried "shift huddles" in the ER for the same purpose. It was a failure and quickly dropped by most providers, primarily because it felt silly and awkward. Now that I think about it some more, I think I will see if we can re-initiate these huddles. If they caught on, they could be very valuable.

When I initiated a discussion about checklists in the ER among our docs, there was widespread skepticism. Of course, I had top point out, we do already have and use a multitude of checklists, we just don't call them checklists. We call them protocols, or standing orders. Just like the USAir Airbus has checklists for "engine failure/restart" and "ditching," we have our checklists for "sepsis" or "Acute MI." Just as the checklists for aviation remind you of the critical actions, so the protocols make sure the simple but important items are not omitted. I recently had an MI patient who walked in who I nearly forgot to give an aspirin to! It's the most basic and hugely effective intervention for patients with heart attacks, but it's also usually done by the paramedics before the patient arrives. This got missed because this patient did not come in by ambulance. Fortunately, the checklist standing orders caught the omission. Similarly, when you have a shocky, hypotensive patient with sepsis, the tendency is to immediately put them on vasopressors to "fix" the blood pressure. By leaping straight for the pressors, you can forget to adequately hydrate them with a full 3L of saline, which will make the pressors more effective and in some cases may obviate them entirely.

These are simple, stupid interventions that are absolutely critical, as critical as remembering to close the hatches on ditching, and as easy to overlook. Just as the typical airline pilot has a sheaf of emergency procedures for every conceivable circumstance, so do we have reams of protocol order sets for most every common serious illness: DKA, CHF, MI, Sepsis, bronchiolitis, hip fractures, community-acquired pneumonia, etc.

I am wondering whether there are more concrete, global ways that checklists could be helpful in the ER, along the lines of the shift huddles. That will take some creative thinking.

Coming back to Gawande's book: it's more than worth the read. It's a great primer for anybody who is interested in organizational quality and patient safety. It also is very readable, with lots of patient stories and other anecdotes that ground the theory in real-world experience.

18 January 2010

I've Been to the Mountaintop

MLK's Last speech:

It gives me chills. He was murdered, I believe, the very next day.  A premonition?

Full text here.

17 January 2010

The Haunted Scrotum

An awesome case of pareidolia:

Mind Hacks:
The case of the haunted scrotum

A 45-year-old man was referred for investigation of an undescended right testis by computed tomography (CT). An ultrasound scan showed a normal testis and epididymis on the left side. The right testis was not visualized in the scrotal sac or in the right inguinal region. On CT scanning of the abdomen and pelvis, the right testis was not identified but the left side of the scrotum seemed to be occupied by a screaming ghostlike apparition (Figure 1). By chance, the distribution of normal anatomical structures within the left side of the scrotum had combined to produce this image. What of the undescended right testis? None was found. If you were a right testis, would you want to share the scrotum with that?

J R Harding
Consultant Radiologist, Royal Gwent Hospital

And I might add that "The Haunted Scrotum" would be a great name for a punk rock band.

16 January 2010

More Medicaid under-reimbursement

Hey, Docs: Walgreens Also Says Medicaid Doesn’t Pay Enough - Health Blog - WSJ
Walgreens is threatening to stop filling Medicaid prescriptions at 64 of its 121 pharmacies in Washington state because of state cuts in payments.

Walgreens, the biggest drug-store chain in the country, has been down this road before. It threatened to pull out of Medicaid programs last year before settlements were reached in Delaware and in an earlier dust-up in Washington state.

This time, the chain says it is losing money on 95% of the brand-name drugs it dispenses to Medicaid patients in Washington, so it will end Medicaid participation at the 64 stores on Feb. 15.

Programs for the poor are poor programs. Medicaid should just be federalized and merged with Medicare.  Then we can deal with their costs together an in a realistic fashion.

How to get compliance with quality initiatives

Pay for it:
Cold, Hard Cash as a Handwashing Incentive - Freakonomics Blog - NYTimes.com
we made hand hygiene rates part of the program; employees had to achieve and sustain >96 percent compliance with hand hygiene to get their full bonus. (This is a pooled bonus plan — either everyone gets it or no one gets it.) We did much better, but still not quite good enough until we hit on a second idea: we made the hand-hygiene performance part of the hospital executives’ performance bonus, even though they don’t care for patients. Magically, we have attained and sustained a rate of hand hygiene >98 percent, and won a national award for quality improvement from the Children’s Hospitals Corporation of America.

As they say in MBA school: you get the behaviors you incentivize.  Not at all coincidentally, when we renew the incentive metrics every year when renewing our contract to staff the ER, the metrics which determine our CEO's bonus wind up in our incentive structure as well.  Funny how that works.

15 January 2010

Friday Flashback

How Quickly We Leave This Life

Betsy was 85 years old, living independently, and in near-perfect health. Her daughter brought her in when she abruptly became short of breath. I saw her with her three adult daughters at the bedside. She was a bit gray, had labored breathing, with an irregular pulse at 135, and hypoxic. She certainly looked critically ill, but was cheerful and as talkative as the circumstances permitted. Her oldest daughter was a CCU Nurse Supervisor. I went over the differential with her – MI, Pulmonary Embolism, Atrial Fibrillation, Congestive Heart Failure, Pneumonia – and sent off a slew of labs. Her EKG was fast but unexciting, and her chest x-ray was essentially normal. Labs came back unusually quickly, and were unremarkable except for a mildly elevated Troponin, a heart enzyme indicative of a heart attack in progress. Just then the nurse told me that her EKG had changed and that Betsy had developed severe chest pain.

Sure enough, a repeat EKG showed an obvious, massive heart attack in progress, with marked ST elevation. This was actually a good thing, since a) now I knew what was going on, and b) it was treatable. I discussed the options with the family, and they indicated that they wanted the full treatment, so after quick call to the on-call cardiologist, who was dubious but professional, the cardiac cath lab was called in. I wrote the standard orders – morphine, beta-blocker, heparin, etc – and moved on to the next patient in the queue. The Emergency Department was just swamped, with waiting times over three hours. No sooner had I finished examining a young lady with pneumonia than I was paged overhead stat to Betsy’s room.

When I got there, she was dead. Unmistakably so. Her skin was waxen and yellow, and she was not breathing; the monitor reflected a heart rate of 30, but I knew that there would be no pulse if I checked her wrist. It is amazing how obvious it can be when the vital force has departed a body. Taking this in a fraction of a second, I reflexively said “Well, this isn’t good.” Her daughters looked at me with tears in their eyes and the eldest said “We know. We’re okay with it.” I turned off the cardiac monitor and removed the oxygen mask from her face. A few words of condolence and I left them alone. I called the cardiologist back, a bit ruefully, and cancelled the case. We called the chaplain, and I moved on back into the realm of the living.

It’s a bit curious. I’ve always said: “As an ER doctor, most of my patients come in alive and will leave alive no matter what I do; a few come in dead and leave dead. Rarely someone comes in dead and leaves alive, which is a victory, and occasionally someone comes in alive and leaves dead, which I take as a personal offense.” But in this case I wasn’t offended. It was the most natural, wholesome (if there can be such a thing) death I have ever been privileged to witness. It was quick and relatively painless, the whole family was there, and everybody was emotionally in tune with it. I hope I go as well. I’m still kind of shocked at how quick it was. As an ER doc, I see a lot of death, and it’s usually more of a process than an event, and there’s usually a longish time between when it begins and when it is irreversible. Not so with Betsy. There one minute, gone the next.


Originally posted 23 March 2006

14 January 2010


The ER is a highly effective bottom-filter for society.  When you work in the ER you are in daily contact with the worst that mankind has to offer: addicts, sociopaths, criminals, and the many many varieties of personality disorders with which a loving God has imbued humanity.  I say this not as condemnation: they are my people.  I know them and accept them for who they are.  I am here every day to serve them in their various needs, from the heroin addict who is dropped off blue and apneic to the homeless guy who just wants his unwashed feet looked at. 

One of the refreshing features of many members of the lumpenproletariat is their candor regarding their habits.  Sure, it's by no means universal, but it's entirely common for me to ask someone quite directly: "Do you use meth?" and have the patient respond in the affirmative and without the least trace of self-consciousness expand on the degree and nature of their drug use.  The hardest question for me to learn to ask without blushing was "do you ever have sex for money or drugs?" (And yes, I do ask that of both men and women, when it seems potentially relevant.)  But people on occasion forthrightly admit that they turn the odd trick to support their habit.  I have a good bullshit detector, because often enough you need to ferret out the real story, but sometimes I get lazy because so many of the patients I see are so open and honest about their vices.

The mores of some of these folks are amazing to me.  I see the fifteen year-old in the ER for her threatened miscarriage and I elicit the following information from her: she smokes; she drinks on occasion; she uses marijuana regularly, but avoids meth because she tried it and did not like it; she has has three sex partners this year.  And during the course of the interview, the child's mother is sitting next to the gurney without batting an eyelash at the horrific information so freely laid out.  Had that been me when I was fifteen, I would not have needed the services of a physician, but a mortician, because just one of those admissions would have caused my mom to simply kill me where I sat.  But to a certain segment of the lower-middle class, these lifestyle choices are mundane and unexceptional.

So it was with some pleasure that I saw a young lady recently with some gynecologic discomfort.  She was pretty, well-groomed, polite and charming.  She did not smoke.  She did not ever use drugs.  She reported that she was still a virgin. (And yes, I pressed her on the point; she was quite clear that she had never come close to having sex.)  She was extremely bashful about the pelvic exam, but tolerated it with good grace.  The nurse and I left the room and remarked to one another about now nice it was to see a "good girl" in the ER for once.     I liked her -- this was the sort of patient that you really want to help and it makes the shift a more pleasant experience when you are able to make a difference for them.

Since she was in some pain and needed an ultrasound, I ordered her some pain medicine: Toradol.  It's a non-narcotic pain med which is quite effective.  It is also notorious among drug-seekers for causing "allergies," the most common allergy being the adverse reaction of not getting one high.  The nurse was back in three minutes: "She says she can't take Toradol.  It doesn't work for her."

That's odd,  I thought, Where the hell has a girl like her had Toradol before?  And is she playing games with me?  I ordered her a conventional narcotic and went to do a more detailed chart biopsy.  The first thing that struck me was the fact that she was on clonazepam (an anti-anxiety med, which happens to be popular among the drug-seeking set).  I was busy and had missed this on the initial cursory chart review.  Her visit history was more concerning.  She had never been to our ER before the midpoint of last year, but had visited twelve times since then.

As time went on, more and more red flags started popping up: increasingly aggressive demands for more pain medicine; refusal of the ultrasound because she was in "too much pain"; escalating dramatic manifestations of the severity of her pain; and the complete lack of any findings to explain her symptoms.  She also started splitting: buttering me up quite shamelessly while verbally abusing the nursing staff.

It all culminated in a world-class meltdown when it came time for discharge.  Narcotics were of course at issue, but she by this point had developed a litany of grievances against myself, the "bitch nurse" and every other health care provider she had ever interacted with.  She screamed and railed and was ultimately escorted out by security.  The nurse and I shook our heads in disbelief at how stark the contrast was between the charming young woman we had met four hours ago and the shrieking demon we had just discharged.  "So much for your 'good girl,' Doctor Shadow," the nurse acerbically commented.

At this point my partner, a wise old doc who has been working in the ER since I was three years old turned to me and said, "See, Shadow, it all goes to prove the point I have been making over and over for years: when you are working in the ER, you can never be too cynicalIt's a logical impossibility."  I ruefully conceded the point. 

Guess I need to get my bullshit detector recalibrated.

13 January 2010

Disaster relief

Funny coincidence -- one of my partners just a few days ago notified me that he was going to be doing some work for the International Medical Surgical response Team.

Today, Haiti.

Wow.  Bad Stuff.

I've always been a fan and supporter of Doctors Without Borders.  Just sayin'.

11 January 2010

Again with the NSFW?

Apparently I still retain the capacity to be surprised by the weird and wonderful world we inhabit.  After the sex-athon of last week, I was made aware by another alert reader who shall remain nameless about an artist whose creations can be called nothing more than X-ray Porn.

The artist transformed a medical clinic in Belgium into a studio, coated his subjects with a slurry of barium and Nivea body cream, and let them do their thing for the cameras.

I'm not going to host the images, but you can see them here or here or Google the artist's name, Wim Delvoye.  Very very NSFW.

And I swear this is not going to be a habit.  But sometimes you just gotta link the wonderful crazy stuff.

08 January 2010

That's pretty big


Brian Beutler of TPM comments: Whoever paired the headline and the picture in this story deserves a special kind of Pulitzer

Friday Flashback

The Laws of Emergency Medicine
There are a number of indisputable tenets of Life in the ED. Some are inherently obvious, such as "Unspeakable evil will befall us should anyone utter the "Q" word." (That would be "Quiet" for the non-medical folks.) There are, however, a number of other fundamental principles which any experienced emergency provider can attest to. I have assembled some here for your education and edification.

  1. The Patient will always lie.
  2. (Corollary to #1) If the Patient is unable to lie, the family will do so for them.
  3. If you allow them to, the Patient will likely hurt you.
  4. Never, ever, under any circumstances, take off the shoes.
  5. Never start a shift with an empty stomach or a procedure with a full bladder.
  6. Multiply the stated amount of alcohol consumed by two (by three on weekends).
  7. The room where you perform a rectal exam will never have hemoccult developer.
  8. The word "stool sample" cure diarrhea.
  9. Never stand when you can sit.
  10. If it looks like a donut, eat it.
  11. Don't fuck with the pancreas.
  12. The likelihood the pregnancy test will be positive is directly proportionate to the intensity of the patient's protestation that she cannot possibly be pregnant.
  13. The probability of *any* patient having an acute medical problem varies inversely with the number of patients checking in together.
  14. The most dangerous diagnosis an ED patient can have is "Just Drunk."
  15. Every patient who comes to the ED has this common goal: to find a way to die on you and make you look bad.
And I hate looking bad.

Feel free to propose additional Laws in the comments.

Originally posted 14 Feb 2006

07 January 2010

In which I confess my ignorance

I know there are a lot of ER docs who read this, and some ER docs in training.  I'd be interested in your opinions on this:

There are two professional organizations in Emergency Medicine, ACEP and AAEM.  ACEP is bigger and older and better recognized.  AAEM is something of the insurgent group, and a big advocate for equity in physician management practices and for democratic group structures.

So, can anybody tell me what AAEM actually does that is of value?

I'm not saying they do nothing, just that I am completely ignorant of their actual current activities.  Fill me in in the comments.

BTW, I am not interested in a whole-bunch of anti-ACEP screeds, nor in an enumeration of why AAEM's principles are awesome.  I'm fine with ACEP, and I'm aware of and generally sympathetic to AAEM's ideology.  I want to know what they do that justifies their continued existence and/or the support of ER docs.

Thanks for enlightening me.

The honest patient historian

Exaggeration, drama, and histrionics are very much the rule of thumb in the ER.  Someone comes in and claims they were stabbed with an eight-inch butcher's knife, and the police later bring in the actual weapon, and it turns out to be a three-inch penknife.  Someone claims to have taken a whole bottle of tylenol, but their serum levels turn out to be nowhere near the toxic level (or even zero).  A patient reports to you that their last pneumonia was so bad their doctor didn't think they'd pull through, but you check the records and see they weren't even in the ICU.  (The sole exception to this rule, of course, is the stated alcohol intake, which is usually about half to a third the actual alcohol intake.) 

I'm not a nihilist here.  Some people are accurate historians, and some even minimize their issues.  As an ER doc, you never know, so take each case at face value and do whatever is reasonable and prudent to validate or refute the critical facts.  But it is fair to say that the more anxious/dramatic the historian, the more inclined I am to take their version of events with a grain of salt.  "Trust, but verify," is the saying.

So it was when I saw a kid recently for a complaint of a head injury.  They had been triaged as a "green," for low acuity, and had been waiting patiently on a hallway gurney for over an hour before I got to them.  The dad who told me the story was absolutely beside himself.  He was sobbing and full of remorse.  He'd walked away from the changing table for just a second, and the nine-month old had tumbled right off.  It could happen to anybody.  He hit his head on something, dad wasn't sure what, and had a huge dent in his head and (the father wept) it was "all my fault."

Looking at the child, sitting happily on the mother's lap industriously trying to cram as many cheerios as he could fit in his little hands into his mouth, I was skeptical.  More reassuring was the mother's complete lack of apparent concern.  She was laughing as she played with the baby and seemed to think that it was silly of them even to have come to the ER.  The rest of the history was also reassuring.  There was no loss of consciousness, immediate crying, normal activity since, no vomiting, and a perfectly well-appearing kid.  I kind of doubted he would even need a CT scan.

But I could see the "goose egg" or cephalohematoma sticking out of the right parietal area, so I figured a CT scan was in the cards.  I didn't know what to make of the reported dent, but sometimes the center of a hematoma can seem kinda spongy, so maybe that was what he meant.  I knew it simply couldn't be anything serious, though.  A true "dent" in the skull, also known as a depressed skull fracture, is a terrible thing highly associated with epidural bleeding and severe brain injury, and not consistent with this happy kid eating cheerios.  Kids tend to do even worse than adults with these injuries because their heads are so tight and prone to increased intracranial pressure.

With a sigh, having completed a normal neuro exam, I went to look at the "dent" in the head.  I palpated the rim of the hematoma and it all felt as it should.  As my fingers worked into the center, though, I realized to my horror that it really was dented in.  And not by a small amount.  I checked a couple of times to be sure, then calmly excused myself and called the CT scanner to let them know that this kid was now #1 on their priority list.

Here is his CT; I've helpfully pointed out the abnormality in case you couldn't see it.


Remarkably, his brain was fine.  No bleeding, no bruising, not even much in the way of edema, or swelling of the brain directly under the fracture:


We attributed this to the location; the fracture was quite high on the skull, which is an unusual place.  There are not so many blood vessels in the area to bleed.  And since he hit with very little force, there was little direct mechanical injury to the brain tissue from this low-energy impact.  It just doesn't take much to break a baby skull. 

So there you have it.  The kid did fine, and the moral of the story, if there is one, is that no matter how improbable the story you are told may seem, you always have to take the patient's tale at face value, because sometimes they really are right. 

Also, don't drop your baby on his head.  That's a good point to draw from this also.  But you probably already knew that.

06 January 2010

What's in a degree?

I was recently speaking with a longtime friend -- let's call him Barry -- who is a fellow ER doc and a highly accomplished person: an administrator, a policy wonk, and a software developer.  He holds a Master's degree in computer engineering.  He served a term as president of another state's chapter of ACEP.  He has for a long time been a featured speaker in seminars for hospital executives and health care innovators.  Recently, he sold his company and has been interviewing for new positions, mostly at the C-suite level: CEO, COO, CMO, CIO, that sort of thing.  Given his software background he is most juiced about Chief Information Officer opportunities, but his background and operational experience puts him in the running for any of the positions. Sometimes my wife hassles me and asks why I can't be more like him.  "You can bet your life Barry doesn't waste his time blogging," she says.

His doctoral degree, however, happens to be a D.O. -- Doctor of Osteopathic Medicine.

For those who are not tuned in to the medical community, there are two distinct paths to becoming a physician in the US.  The traditional (or conventional or allopathic or whatever you want to call it) way is to get into a traditional medical school and get your MD degree.  The alternate path is to go to an osteopathic school, which to the best of my knowledge is about the same, perhaps a bit less competitive, and covers more or less the same material.  There's more emphasis on body mechanics and some stuff on manipulation that I am completely ignorant of, but the general stuff is more or less the same. 

It is less prestigious, and I gather that there were bitter philosophic differences in the past, but nowadays to a health care consumer or employer there seems to be no distinction, I think.  I've worked with lots of D.O.s, and some of them were great and some stunk, just as with M.D.s.  I've hired D.O.s in the past, and will again.  You hire the person, not the degree.

So when Barry sat down with the recruiting team at a national hospital chain recently, he was astonished to have the first question be this:
"Why would we want to hire a D.O. for this position when there are lots of M.D. candidates who we could hire instead?"
In the general crosstalk that ensued, it was opined by another member of the interview panel that a highly qualified D.O. would be on more or less equal footing with a half-qualified M.D.

Staggering.  At this level, that someone would hold such a bias based on a certain degree, and would have the tactlessness to put it forth so blatantly.

Needless to say, Barry made his case for the D.O.s as civilly as he could manage, concluded that this was not the best organization for him, and proceeded on with his job search.  It is, quite literally, their loss, and a self-inflicted one, at that.

But it nevertheless is an astonishing thing that in this day and age, at such a senior level of management, there are executives with such regressive attitudes and the chutzpah to display them so openly.

There's no bone in there, but it can still break

Yeah, you know what I mean. 

Yeah, you can go ahead and cringe.  If you're squeamish, you may just want to go ahead and visit LOLcats now, 'cause this is downright uncomfortable to talk about.

The fracture of the penis. 

How does it happen?  As you might expect: the erect penis does not actually have a whole heck of a lot of weight-bearing capacity.  Despite what Tenacious D might have had you think, it is not possible to perform "cock push-ups."  So, when a man or his partner should happen to drop their weight onto the penis on its longitudinal axis, it cannot support the weight and it begins to flex.  The problem there is that when the penis is erect, it's sort of an inflated tube under pressure, with a tough, fibrous capsule to contain the pressure and give it shape.  This is called the tunica albuginea.  It's not very flexible, or the penis would just keep getting bigger and would never get hard.  When the penis is fully erect, the fibers are stretched more or less to their limit.  And when the erect penis is forcibly bent, the fibers on the outside portion of the bend may tear.

So we call it a "fracture" because that's what it looks like, but it's actually more precisely described as a tear in the fibrous envelope that is the tunica albuginea.

But boy does it ever look like a fracture.  It happens with an audible "snap" or pop.  Typically (I've seen this maybe four times in ten years) the penis is bent off at an angle away from the site of the tear; I've seen it bent a full ninety degrees.  There is also usually a large hematoma right beneath the skin at the site of injury.  It hurts like crazy, and if you were really unlucky, the urethra can be disrupted sometimes.  It's not a difficult diagnosis, as it's so unmistakable.  It's also a surgical emergency: it needs to be repaired right away for function to be preserved and to prevent permanent deformity.

The surgery is not for the faint of heart, either.  It involves (take a deep breath before reading the next phrase) degloving the skin of the penis in order to evacuate the hematoma and to access the site of injury to repair it.

So recently I saw an unhappy young man with such an injury.  It was sustained in the usual manner, but it was in fact the mildest one I have ever seen.  The hematoma was not large and the angulation of the injured member was slight.  I thought it was clearly a fracture, but the urologist who examined the patient was uncertain, and the patient, understandably, was quite unwilling to undergo surgery if the diagnosis was unclear.  We discussed diagnostic options.  Ultrasound apparently has a low sensitivity, but, the urologist had read, MRI was supposedly a useful tool.  I did not know that.  So I proceeded to order the first and only MRI of the penis of my entire career.  After an incredulous phone call from the radiologist to confirm the order, we obtained the following images.

The is a coronal image of the genitals near the level of the penile root.  The red circle indicates a hematoma.  The penis itself is shown in its transverse aspect, like the above anatomic diagram.  The corpora cavernosa are clearly visible, though somewhat distorted by the mass effect of the hematoma.

tunica transverse

This is the "money shot," if you'll excuse the phrase.  A transverse image, catching the penis in two sections as it curves down.  The resolution of this is lovely, and the anatomy is vivid.  The twin corpora are sharply delineated, and the fascia of the tunica is obvious, as is the small tear indicated by the arrow.  You can even see the communication of the blood between the corpus and the hematoma!  What a wonder technology is.

This is not something I expect is commonly seen.  After all, this is almost always a clinical diagnosis, and the only diagnostic study needed may be a retrograde urethrogram to ensure that the urethra is intact. But it's useful to know that there is an option if it is needed.

This case also has a happy ending.  The surgery went well -- with such a small injury it was an easy repair -- and as of this time the patient seems to have made a full recovery.

05 January 2010

Trophies and Toys (NSFW)

I'm not a hunter or collector, and have never been the sort of person to collect trophies.  But I understand the urge: you want to save the things you worked so hard to obtain, and you want to display them for the admiration of like-minded enthusiasts who visit your home base.  Some are nicely displayed in organized and conventional arrangements.  These pictures are just filler so those of you who clicked on this link at work have the opportunity to close the window before anybody looking over your shoulder can see the horrors that comes below.  Mom, you too.

Trophies come in all sizes and shapes, and some are downright unusual.  Some are displayed in crude or awkward places.  More filler:

An alert reader who for obvious reasons wishes to remain nameless sent me this link (so, so NSFW) regarding a Russian ER which kept its own trophy wall:

The original source is here, and it is even more insanely Not Safe For Work.

Supposedly the Cyrillic text translates to read "The Foreign Bodies of the Rectum."  Like most of you my first thought was "Wow this is the greatest thing ever," and my next thought was "Yeah, those all look about the right size and shape and WHOAH JESUS IS THAT A COFFEE MUG???"

What a wonderful world we live in that things like this exist.  I wish the hospitals I lived in could maintain that sort of trophy display.  But I guess that's about the most un-PC thing imaginable, isn't it?  I know I would have a few items I've "retrieved" that could be hung up on the wall.

By the way, I am sure that this page will get a lot of views by teenagers, aspiring fetishists and due to strange Google search algorithms, so for any readers who are viewing this as a "how-to" page, let me offer you a few words of advice:

1.  No Glass.  Really.  I mean it.

2.  Avoid non-commercial products.  They just don't belong up there, and there are plenty of sex toys available for purchase on the internet.

3.  Avoid products which are not intended for the rectum.  You want something with a large flare at the bottom, to prevent inadvertent complete insertion and subsequent loss.  Perhaps I need to be clearer.  A vibrator which is intended for vaginal use (like the black one at top right in the above picture) can easily slip in entirely.  So if you're too embarrassed to buy your own, and you borrow your wife's or your sister's or your mom's (eww) you may find yourself in my ER with a whole lotta 'splainin' to do.  No, you want something like this:

This obviously can never be completely inserted (indeed it would apparently defeat the whole purpose of this device!)  Yeah, I didn't know things like this existed either.  And some of them are expensive!  Aren't you glad you read this "medical" blog so you can learn these things?

4. Hygiene counts.  Clean 'em off, and no sharing!  (Eww again.)  Some people say that it's OK to share so long as you use a condom over the toy, but I beg to differ. 

5.  Size matters, but not in the way you might think.  Bigger is not always better.  Start small.  Being over-eager will lead to pain and injury.  You do not want to start out with one of these:

Yeah, that image is going to give me some nightmares, too.  Be modest and work your way up to larger things.  Or don't.  Start small and stay small maybe.  The more I look at this picture the more convinced I become that no matter how gradually you work up to it, it just can't be good for you.

6.  Use lube. The anus differs from the vagina in so many ways (so very many ways).  One key difference is that it is not self lubricating.  That sensitive skin and mucosa can chafe and tear easily, so use lube and be generous.  Never use lidocaine or other desensitizing lubricants, which can mask the pain of insertion of a device that is too large and thereby predispose yourself to injury.

And as always, contact your doctor if an erection persists for more than four hours.

Hey, if this doctoring thing doesn't work out, maybe I could try a new career as a sex advice columnist!

You can lead a horse to water

America does have very good medical care, all the grandstanding and political rhetoric notwithstanding.  It's imperfect and expensive, but it's still great care, and the despite the crisis of the uninsured, care is generally accessible for most, and for nearly all of those with life-threatening conditions.  Which is why it's so mind boggling when you see a patient in the ER who clearly has a terrible disease, has access to care, and simply fails to avail him or herself of it.

For example, I saw a patient with a craniofacial tumor.  At least, that's what I figured out it was.  She didn't come riht out and tell me that she had been previously diagnosed with a malignancy; her chief complaint was that she had been having double vision for "months" and that now she had totally lost the vision in her right eye.  It was obvious on first glance that there was something wrong with the orbit as the right eye was massively anteriorly and laterally displaced.  She looked as disfigured as some renditions of Quasimodo's face -- truly horrible.  Her pupil was nonreactive on that side and she had just about no light perception.  I was kind of mystified, and more perplexed at how long she had let it go before getting it checked out.    Here's her CT:


You can imagine the tension.pressure on the optic nerve!  Here's an annotated version for the non-radiologists:

proptosis note

You don't see the other eyeball because the head is rotated a bit.

It didn't make sense, and I noted that she had decent insurance.  I looked her up in the hospital computer, and found that she in fact had a lot of records in the oncology database -- including missed appointments for surgery and radiation oncology procedures and a final sad note that she had been "lost to follow-up."  She never got her tissue biopsy, and just stopped showing up after that, refused phone calls and ignored letters.  Wild.  She had, of course, failed to mention this to me in her medical history.  Sheesh.

I think it was a case of denial, severe depression/apathy, combined with social isolation that made this possible.  There wasn't much for me to do in the ER -- the eyeball was clearly a lost cause, and she was admitted with a slew of consults.  Sad case.  I never found out what it was that she had, which is also a pity.  I would have been interested.

04 January 2010


ER medicine is all about algorithms -- pre-established decision-making rules that determine the management of most any problem. You have your chest pain algorithm, the rule-out PE algorithm, the febrile child algorithm, and so on.  ERP provides a wonderful algorithm for the ER management of vaginal bleeding:

Vaginal Bleeding, Simplified for the ER Doctor
I wonder if we went to the same training program, since I learned the exact same algorithm.

Funny thing: you note that the decision tree does not necessarily include a pelvic exam.  Like Scalpel, I too have long questioned the value of the routine pelvic exams in the ER, and in many many cases it can be omitted.  Non-pregnant with unimpressive bleeding, stable HCT and vitals?  Don't care -- it's not an emergency.  Follow up with your PCP or GYN if it doesn't go away.  That description, by the way, accounts for something like 70% of ER presentations of non-pregnancy-related vaginal bleeding.  No pelvic required.  And if you are pregnant and bleeding, I'll get way more information from my bedside ultrasound than from the pelvic exam.

I think that at this point in my career I do about 25% of the pelvics that I did immediately after graduation form residency.  The funny thing is that I used to feel guilty about omitting it, as if I was breaking a commandment, but patients, when I tell them that I do not think they need a pelvic exam, are usually downright grateful.   Hmm.  Could it be that women don't enjoy pelvic exams?  What an odd thought.

Baby Steps

BBC News - US lifts HIV/Aids immigration ban
The US has lifted a 22-year immigration ban which has stopped anyone with HIV/Aids from entering the country.

President Obama said the ban was not compatible with US plans to be a leader in the fight against the disease.

The new rules come into force on Monday and the US plans to host a bi-annual global HIV/Aids summit for the first time in 2012.

The ban was imposed at the height of a global panic about the disease at the end of the 1980s.

It's a decade or so late, but well done.  May the rest of Jesse Helms' legacy be similarly negated as well.

This really shouldn't have been a partisan issue any more.  Why Bush could not have done this is a mystery.  But there you have it.

It's a wonder I survived my teen years

Had a terrible wreck here not long ago.  A car full of teenagers had a run-in with Newton's first law, with tragic results.  One fatality at the scene.  Two to the Level 1 trauma center.  Two to us.  What you are seeing here is a reconstruction of a CT scan of the spine in the sagittal plane.  Can you spot the abnormality?


Let me help you out:

lspine note

Surprisingly (or at least fortunately), the patient was neurologically intact.  There was some trivial numbness which was interpreted as possible impingement of the neural structures, so cord-dose steroids were given.  But the spinal cord actually ends around L2, and the fracture site here is at T12-L1, so very little of the cord's length is at risk, and the spinal canal at that level is pretty capacious, so injuries there are often surprisingly well-tolerated.

I think back to my own teenage years and how I drove then.  The report was that the speed in this accident was 85 in a 35, which was well within my capacity as a teen (though my 1980 Honda Civic could only hit 85 going downhill with a tailwind).  Still, I remember calculating my skid into my turns routinely.  It's a wonder that any of us survived.  And now I am very happy that the states are moving towards graduated drivers' licensing for teenagers.  I told my youngest son he could get his driver's license when he turns 21.

I'm Back

calvin new year

Well, Christmas is put away and the kids are back at school.  The family has gone back East, and I'm back at work.  Life resumes its normal routines, and as such, more-or-less regular blogging will resume shortly. 

It's a little amazing, looking back at my archives, how much I have put out there over the years.  I am entering my sixth calendar year of blogging (though only my fifth year of real time; I started in December 2005).  I have published over 1300 posts in that time frame, almost one post per day.  I think it might be fun to start mining the archives a little bit.  So my plan is to introduce a regular feature, "Flashback Fridays" in which I will dust off a moldy old post from the distant past and re-publish it.  Lemme see ... 52 weeks in the year ... 1300 posts to choose from ... hopefully I'll be able to find 52 old posts that I'm proud of.  Maybe.

As for this week: I've been fortunate enough to accumulate a few interesting radiographic images (and one *very* disturbing one) over the break, so it'll be "radiological oddity week" starting shortly.

Hope you all had as nice a holiday as I did, and Happy New Year to you all.