Ed’s corner of the web

With all of today’s talk about ricin found in Las Vegas, I have to tell a little story. I remember first learning about ricin way back in Prof. Krieger’s 7.20 class (Human Physiology) in college. The class distinguished itself from most other biology-major fare by being immediately and directly applicable to real life. The mention of ricin, however, was especially memorable to me because it was mentioned in the setting of the Bulgarian umbrella murder. It wasn’t a particularly positive use of biology, but I was pretty impressed. Espionage! Assassination! Secret spy gadgets! All made possible with science. If I remember correctly, one single molecule of ricin was capable of killing a human cell. That’ll make you pay attention.

I knew that there was a lunar eclipse that was supposed to happen, but I wasn’t sure I’d be able to see it from my Boston apartment. Still, when 10 pm rolled around, I walked outside, looked straight up, and was pleasantly surprised to see this:

I ran upstairs, grabbed my camera, and grabbed a few shots.  I had only seen one lunar eclipse previously, one summer night many years ago when I lived in Michigan.  I was excited to see one again.  I even dragged Carisa downstairs in her pajamas to see it, and she appreciated the sight nonetheless.  Astronomical events like this make me want to get a place out in the boonies and shoot cool pictures of the sky all night.  Maybe someday.

Every now and then I’m asked to cover a local solo pediatrics practice for a day or two. As a hospitalist, I have to dust off my primary care cap before I go in. I have to admit, I find it challenging. I deal with sick – sometimes very sick – kids on a daily basis as a hospitalist. While the kids aren’t (usually) as sick in primary care clinic, the pace is unrelenting. I barely have time to think before I have to run and see the next patient double-booked into a 15-minute slot. Fortunately, there is often not a ton of thinking involved, as a primary care pediatrics practice in winter involves a lot of runny noses and earaches. For those patients that require a little more thought than a simple cold, though, the stress level amps up. At least as a hospitalist I can pause between patients to look up an article or refresh my memory about a drug dose. In primary care clinic, I’m backed up 45 minutes and 6 patients if I so much as stop to pee. The challenge, then, becomes one of providing good, thoughtful, compassionate care in a time-limited setting.  Some days I do better than others.  I know I couldn’t do it for a career, but that makes me appreciate all the more those that do.  So to all you overworked, frazzled, brilliant primary care pediatricians out there, I tip my hat to all of you.

Man - I was doing so well, too.

A not insignificant portion of my pediatric practice is doing small procedures – blood draws, IV’s, lumbar punctures, etc.  Some of these – like lumbar puctures – go straight to me, while more routine procedures like blood draws usually go through nursing first.  Only when nursing has had their shot does the buck get passed to me.  Recently I had been on a bit of a roll with these little procedures.  It had been a long time since I hadn’t been able to get an IV, and my lumbar punctures had been single-shot affairs going way back.  Now I knew intellectually that this was just the vagaries of chance and probability, and that this streak would all come screeching to a halt soon.  But I was proud of myself nevertheless, and I allowed myself the luxury of enjoying the streak.  Just like the basket seems bigger to a shooter who’s on a roll, those little baby veins looked like huge pipes, and I almost felt I could do an LP blindfolded.

Then last week I flub two shots at what should have been a not particularly difficult IV.  Then on my last shift I get nothing but blood on three attempts at an LP.  Damn damn damn.  I feel like I’m an intern again.  Just like the basketball player, I know intellectually that I have to keep on shooting for the slump to pass, but I’d be lying if I said that those last procedures wouldn’t be on my mind when I’m doing my next ones.

I kicked off this wedding season with the nuptials of Tom Alexander and Laura Crotty this last weekend (which also prevented my blogging). I say wedding season because from now until August, I have a total of five weddings to attend, including my own. Crazy.

Tom and Laura are friends of mine from med school. Tom’s finishing up an ENT residency out in UCSD, and Laura recently ditched us here in Boston (sniff!) to be with Tom and finish her pulmonary fellowship on the west coast. Several other Dukies were invited to the wedding, not to mention a couple who were even in the wedding party, so I was looking forward to the weekend a lot.

The weekend did not disappoint. The festivities were all in La Jolla, which I had not had the pleasure of visiting before. Our little reunion group had a great time strolling the city, walking at the water’s edge, and trying out a few of the numerous restaurants. Tom and Laura had also been considerate enough to keep everything very localized; Carisa and I were able to get a room right in town and walk to both the wedding and the reception.

The wedding took place in Cuvier Park, right overlooking the ocean.

It being a public park, we attracted quite the peanut gallery.

I just like this photo.

See the rest of my meager photos here.

The ceremony location was beautiful, the bride and groom looked great, and everyone had a wonderful time at the reception. It was a great wedding. Congrats to Tom and Laura, best of luck for all your years ahead, and we look forward to seeing you again soon.

Throughout my residency, I never prescribed or recommended cold medicines to children under 12. The data showed them to be ineffective, and they were associated with cost and the potential for side effects – basically a no-win situation. I often got grief from parents looking for a quick fix, or at least some sort of intervention (to make the parents feel better, if anything), but I refused to budge. “Your child’s immune system is strong enough to fight this off on its own,” I would explain. “All we need to do during this time is to support her by keeping her well hydrated and her fevers under control.” I did feel bad that at least some of my parents were less than satisfied by this, but I couldn’t in good conscience do otherwise.

You can imagine my inner feeling of vindication, then, when the FDA recommended against the use of OTC cold meds in kids under 2 and announced investigation into use in kids over 2. It was one of those silent fist-pump moments. Now the FDA has announced some of the early results of that investigation, calculating that over 7000 kids under 12 visit ERs each year because of adverse drug events from OTC cold meds. While in the grand scope, this isn’t a huge number, it does seem like an enormous number once you realize that these events are – essentially – completely avoidable. We’ll see what comes next.

Remember “Super Size Me” with Morgan Spurlock, that self-sacrificing documentarian who ate nothing but McDonald’s food for a month?  (Ick – makes me shudder just thinking about it.)  Well, Gut (great name for a journal, don’t you think?) recently published an article that illustrates some of the biochemical effects of fast food consumption.  Subjects were instructed to eat at least two fast food meals a day and limit their daily exercise to less than 5000 steps (not a hell of a lot).  Even after just a week of this, over half the group showed abnormally elevated levels of a liver enzyme (ALT, for those who care).  These levels persisted for the rest of the 4-week study.  If I remember the documentary correctly, Spurlock experienced elevation in his liver enzymes, as well.  In fact, I think I remember his PCP seeming rather concerned by it.  Oh – and the average weight gain by the end of the study?  14 pounds.  As if we needed any more reason to shy away from those Big Macs.

Today marks the 199th anniversary of the birth of Charles Darwin, a man who came to mean much in his day and even more so now. Whether you dine with fellow evolutionists at a “Phylum Feast” complete with “primordial soup,” or you just ponder for a moment how much of modern science has been shaped by the theory of evolution, I hope you are able at some point to stop and appreciate this one man’s work.  I’ll admit to still be slogging through Origin of Species, but I’m undoubtedly a fan for life.  Happy Birthday, Chuck.

Read more at http://www.darwinday.org/

Having lived just two blocks from the Scientology branch mentioned in this article, this strikes close to home. I would pass by the building a couple times a day on my way to and from classes, and I admit to some curiosity about what went on inside the building. The people milling around outside always seemed so nice and happy – a little too nice and happy. When I later learned about the true nature of Scientology, my inner fears were confirmed and then some. Those cute kids walking around on marathon day with bunches of yellow Dianetics balloons became suddenly very sinister and sad. People should never be sad about seeing a kid with a balloon.

(thanks to Benjamin Gleitzman for the photo)

When I heard about anonymous’ declaration of war on Scientology a couple weeks ago, I became very interested. I was glad that the true bad news about Scientology was spreading, but I frankly wasn’t sure if anonymous’ tactics were the best way to approach the problem. Still, I rooted them on, not sure the effort would last more than a week or so. So I was happy this morning to see the Globe’s report about the protest outside of my very own branch of the Church of Scientology. Good work!

I was asked recently to contribute to an article in our hospital’s medical staff news. The article is intended to take a brief look at the use of blogs in medical practice. Since I’m one of the younger staff members and also one of the more tech-friendly, I was pinpointed as someone to approach about this topic.

Now frankly, I can’t imagine practicing medicine without the internets. I rarely have to reach for a reference text anymore since I usually have a computer terminal readily accessible. I get regular emails updating me on the latest medical developments and studies. But as for blogs – well, I can’t say I get a heck of a lot of medical info from them. Sure, Medgadget is fun for the technophile in me, but I don’t get nearly as much relevant medical info there as I do from – say – Up to Date. And most medically-oriented blogs talk predominantly about patient anecdotes as opposed to the overarching studies that drive their care. But as I thought more and more about the usefulness of medical blogs, something occurred to me. I can read about meta-analyses and health care policy all day, but it’s still nice to hear about the actual practice of medicine from another human being in the trenches.  Medicine is still practiced between individual human beings with all their emotions, personality quirks, and biases, and these blogs help remind us of that.  So thanks to Orac, Shadowfax, and all those others out there who tell it like it is.  Keep up the good work.

Respectful Insolence

Movin’ Meat

Ten out of Ten

WhiteCoat Rants

Side note: Why is it that ER docs seem to blog more than any other specialty?