Stop the presses: ice cream makes us happy

From the Guardian:

Scientists have found that a spoonful of the cold stuff lights up the same pleasure centre in the brain as winning money or listening to your favourite music.

Neuroscientists at the Institute of Psychiatry in London scanned the brains of people eating vanilla ice cream. They found an immediate effect on parts of the brain known to activate when people enjoy themselves; these include the orbitofrontal cortex, the "processing" area at the front of the brain.

The research was carried out by Unilever, using ice cream made by Walls, which it owns. Don Darling of Unilever said: "This is the first time that we've been able to show that ice cream makes you happy. Just one spoonful lights up the happy zones of the brain in clinical trials."

The scientists used a functional magnetic resonance imaging machine to watch blood flowing to activated brain areas when people swallowed ice cream.

Developed to investigate the effects of brain damage and disease, the scanners are being increasingly turned to non-medical uses.

Experts are gathering in Cardiff today to discuss how magnetic resonance imaging could investigate how the brain handles situations including disappointment and loneliness. The jokes just write themselves, don't they? I've already deleted one about the Guardian's "scoop" (groan).

Sorry, Martin...

In the New Yorker: Nervous med students send "Martin," their training mannequin, to an untimely death.

“It hurts!” Martin cried as the students reviewed his chart. “They told me you’d give me something for the pain.”

“Should we give him something?” one student asked.

“I guess so,” another replied.

The first student emptied a syringe of morphine into an intravenous line attached to Martin’s arm. Within a few seconds, Martin stopped moaning. Then the monitor started to beep rapidly. Martin had stopped breathing. The syringe had contained twenty milligrams of morphine, a potentially lethal dose for someone in his condition...

The students then perform CPR, but they don't give the antidote for morphine overdose. They miss the diagnosis, too: acute pancreatitis. “When the patient is in that much pain, the students’ minds go blank,” their professor explains.

The session that I observed was hardly unusual. “Every group overdosed the patient,” Oriol said.

"Martin" is a sophisticated, high-tech simulated patient. Similar robots may soon teach essential skills to interns and residents. (Will there be mannequins that do this?)

The ad said "Ask your doctor..."

In the Washington Post: Doctors Influenced By Mention Of Drug Ads

"Actors pretending to be patients with symptoms of stress and fatigue were five times as likely to walk out of doctors' offices with a prescription when they mentioned seeing an ad for the heavily promoted antidepressant Paxil, according an unusual study being published today.

The study employed an elaborate ruse -- sending actors with fake symptoms into 152 doctors' offices to see whether they would get prescriptions. Most who did not report symptoms of depression were not given medications, but when they asked for Paxil, 55 percent were given prescriptions, and 50 percent were diagnosed with depression.

...More than half of those without simulated depression who mentioned Paxil got a prescription, underscoring how willing doctors are to go along with patients' requests."

Paging Dr. Kevin! He'll have a lot to say about this. (Update: He says it!)

For advice about choosing a treatment for depression, consider this article from MayoClinic.com:

Medication might be all that some people need to restore their brain chemistry to a more normal state. But for others, medication, although effective, doesn't alter the way they cope with the stress that might have contributed to their illness. Psychotherapy and education can help change coping behaviors and offer strategies to help understand and modify risk factors for illness.

Very often, a combination of medication and psychotherapy is most effective. And in some cases, medication is entirely ineffective and psychotherapy alone can help.

Is it safe to indulge?

Last week, we learned that modestly overweight people outlive those who are thin. Dr. Stuart Henochowicz, at Medviews, is dismayed by the media's take on this news:

It seems as if people have taken the findings to mean that they are off the hook, that they have been right all along about their eating habits. They are happy to proclaim that those in the nutrition police who have been harassing them for years have been wrong. Well, before you go out and buy extra lard and cases of whipped cream, take a step back and examine the facts. The CDC study, as well as numerous other studies, show that obesity (that is, having a Body-Mass Index, or BMI of 30 or greater) poses significant health risks. Obese patients have a higher risk of developing diabetes and cardiovascular disease. People may be thin not because of having a successful dieting program, but rather because they are chronically ill with diseases such as cancer. If you separate out those who are thin and ill from the equation, the benefits of being in the normal weight range would clearly stand out more...

The collective sigh of relief on the part of the overweight does reflect one problem. There are those in our society who obsessively harangue people about every morsel that is placed in their mouths. Clearly, we have to lighten up a bit. And, we need to focus our resources on combating obesity, especially in the young . Obesity in this country has become increasingly a disease of the poor and the near poor, many of whom do not have medical insurance or other resources to get appropriate medical attention.

So, it’s o.k. to take that extra bite. But please don’t go hog wild.

Do doctors encourage their children to be doctors?

In MSSPNexus Blog:

"In a recent poll on DocsBoard physicians were asked whether they would encourage their children to go to medical school. At the moment the results are running 81% No, 19% Yes.

Among the comments:

Yes, but not necessarily for clinical practice... I'll need someone who knows something to protect me from all of the 'allied health professionals' when I get old.

OK, the social respect ain't what it used to be, and the pay isn't what hard-driving MBAs get nowadays, but the intangibles are terrific.

I would rather raise my children to get adequate life-satisfaction from some endeavor less likely to drain them or disillusion them.

In good conscience, I couldn't. There are simply too many negatives nowadays. Medicine has its rewarding moments, but they are fewer and farther between all the time and the future looks only worse. There are other careers that are as fulfilling and rewarding with less burdens and frustrations.

Doc, what are my chances?

NYT: Mix Math and Medicine and Create Confusion

Patients may not know it, but there are two questions that make doctors cringe. The most common is, "If you were me, which treatment option would you pick?" The tougher one is, "What are the chances that this treatment will help me?"

Both questions cut to the heart of medical decision making and involve assessing risk and probability, which does not come naturally to many people.

Dr. Bob Shmerling, at Harvard Medical School's Intelihealth, explains the use of statistics in medical decision-making:

How To Understand When Your Doctor Talks Statistics

Although you are an individual and each person is different, it is helpful to know about information collected from hundreds or thousands of people like you in a similar situation. The most likely diagnosis, the meaning of a test result, the reason for an examination finding, even how much you should weigh are based on statistical measures that often become a routine part of what your doctor is saying...

What Are The Odds? Understanding Risk

One of the most common areas of confusion comes with the difference between absolute risk and relative risk. Imagine that you are offered a choice of two medications to reduce your risk of a heart attack:

* Medication A will decrease your risk of heart attack by 20 percent.
* Medication B reduces your risk from 5 percent to 4 percent.

If you think that Medication A sounds better, you are not alone. Relative risk is described by comparing the new risk with the risk before treatment. Although vitally important, the actual risk with and without the medicine is not mentioned for Medication A. If you thought Medication B sounds less impressive, perhaps it’s because knowing that the starting and ending risks are similar — that is, knowing the actual, or absolute, risks — makes the change seem less dramatic. This is particularly true when overall risk is very low or very high in the first place. Although they provide a more accurate assessment of risk, expressions of absolute risk are often missing from news or ads.

Most of us would think that Medication A is better. But actually the two medications are equally effective. Both have a one-percent absolute risk reduction because reducing a risk of 5 in 100 to 4 in 100 is identical to a 20-percent relative risk reduction...

One more! Medical Doctors Versus Spin Doctors: Sorting Through Conflicting Information

Have you ever noticed that what your doctor says about a medicine is different from what you hear in advertisements or in the news? The differences may be subtle, perhaps the choice of words, or something more dramatic. In fact, it may seem like one of the sources of information — whether the media or your doctor — must be wrong. When these differences arise, it’s natural to wonder: If one medicine is clearly best in the television ads, why is a different course of treatment being recommended by your doctor? There are several possible explanations, and sorting them out may be helpful to you in understanding what your doctor is saying and how to make better health care choices.

A New York Times article that reads like a medblog post

A surgeon's nightmare case: Far From the Medical Trenches, It's O.K. to Laugh

Suspecting the worst, at the worst of times - 3 a.m., operating on a stab wound of the heart, where no heart surgery was done - I drove to the hospital. The weather, a storm, matched my expectations.

When I arrived, the patient's blood pressure was teetering at 70 over 40, and his pulse was ephemeral. It was too late to move him to our well-staffed and equipped cardiac surgical center.

He smelled awful, like a pericardial tamponade - a collection of blood between the fibrous sac enclosing the heart and the heart muscle. The blood leaking from the heart, having no place to go, was accumulating and compressing the heart so that it could not pump. Like a vise squeezing the heart.

Ordinarily, repairing a stab wound of the heart is a simple procedure, but at the Park Avenue, it was going to be like climbing out of a crevasse without a rope.

Quick, get this doc a blog!

On losing one's mojo

Where did this mom's mojo go? How can she get it back? In The Observer:

There might be some of you out there unsure as to what mojo is, and I'd have to admit that I don't know exactly either. It seems to be one of those words of rock'n'roll origin that describes the 'stuff' inside a person that gives them that extra bit of fizz and sparkle and swagger to get through life...

Anyway, whatever mojo is, I think I've lost it, maybe for good. I am mojo-less. I am sans mojo. You can tell by my 'sense of style'.

...My two-year-old was running around a shop picking out dresses the other day: it was so sweet. She wanted to look 'pretty' because she was going to see her aunt who was 'pretty'.

'Am I pretty?' I asked. 'No,' she said. The world seemed to stop, tumbleweed bounced past in slow motion, the words 'Et tu, Brutus?' crashed in my ears. It was the wake-up call every mojo-less woman needs. So I went home and ate five bags of Doritos.

Clearly, Mom's mojo has left the building. How to recover? She has some ideas, but I'm dubious:

Now the search for my lost mojo is on. Obviously this goes deeper than a mere grooming issue; you've got to find yourself again first. I always find watching the movie Spinal Tap very helpful, but it could be anything that really makes you laugh. Apart from that, blare out some music, gossip on the phone to your friends for hours, be a bit childish and silly, tell other parents you meet in the park you used to be an astronaut.

And if you're lucky, if you're very lucky, your mojo will return and you won't feel that your life has become that scary episode of The Simpsons where Bart sells his soul to Millhouse for $5 and subsequently discovers that he is all alone, without even 'himself' for company any more.

In the end, we are all cake and you've got to be generous handing out the slices; having mojo is remembering to keep the icing for yourself.

(barbara.ellen@observer.co.uk)

Grand Rounds #31 is up

at Dr. Tony's blog. He links to more than 30 health-related posts from across the blogosphere. Don't miss it!

A dreaded side effect

Via Kevin, MD:

A local man dies of neuroleptic malignant syndrome at a psychiatric hospital

NMS is an uncommon side effect of antipsychotic meds. It affects 0.2-0.5% of patients treated with conventional antipsychotics, and is less common with newer, second-generation meds (like clozapine).

Patients with NMS develop high fever and severe muscle rigidity. Flexing their limbs is like bending a "lead pipe." They appear acutely ill, with unstable vital signs. They can be agitated, lethargic, confused, or unarousable. Muscles and kidneys can be severely damaged.

These patients need emergency care. Deaths have been reported in 11-18% of NMS patients. Survival is improved if it's recognized and treated immediately. It's critical to stop the antipsychotic, start aggressive hydration, and reduce the fever. More on NMS here.


The risk of NMS is one of many factors that we weigh, when deciding whether to prescribe antipsychotics...

Egg No. 13

Duane Keiser has been painting and posting a new oil-sketch every day since last December. He finds beauty in almost every object that crosses his path: orange pieces, garlic cloves, flowers, gum wrappers, noodle soup...even peanut butter and jelly sandwiches. He has a fondness for cracked eggs, and recently sold the thirteenth in his series.

I love the idea of painting blog posts, but I can't imagine doing it. Each spring, I resolve to paint every day in the park behind my house. But I'm lucky if I can sneak back there once or twice a week. I search for inconspicuous spots that have decent light and a view. I've been caught in downpours, chased by bees, and pestered by curious onlookers (it's best to avoid eye contact). By the end of spring, I might have one or two paintings that I can actually show someone.

But Mr. Keiser shows us something new every day. How long will he keep this up?

A nurse rants

Today's must-read is a full-throated, no-holds-barred rant from an ER nurse: "Emergency Room Manners." This nurse works in "Triage," the first stop for anyone seeking emergency care. She must rapidly assess all comers, and determine their urgency. While illness may not bring out the best behavior in any of us, some behavior makes her job much more difficult, if not (almost) impossible.

Do NOT come up to the front desk of the Emergency Room, fling your health insurance card at me, tell me that your doctor told you to come in, stand there with a bored expression on your face and cross your arms over your chest. That is not helpful. When I ask what you are specifically here for do not repeat that the Doctor told you to come in. When I ask what SYMPTOMS caused you to come in; Do not say that it’s in the computer. Ahem;

And she's just warming up. She's had it. Patients react, over-react, and under-react to their crises. She meets denial and procrastination; threats and intimidation (er, attempts at intimidation). She meets prevarication, and she won't tolerate it.

She rails - as most of us do - at "peoples' sense of entitlement and instant gratification. Folks might as well say 'I have abused my body for decades and I'm here for you to fix me.'" (I have actually heard patients say that.)

Geena has also blogged about a patient's entitlement: "I felt like a handmaiden..." One feels the tension rising as she tells of her frustration with him, and his withering criticism of her. The interaction becomes so intolerable that a hasty change in caregivers is arranged. One lesson: if a caregiver's ego depends on patients' appreciation, then that ego will at times be bruised, or worse. (See Dr. Sanity's posts on narcissism, in this week's Grand Rounds.)

Some patients won't understand that you may be actively trying to save several lives, as well as changing the dressings on their toes. Does it help to say to these patients, "I think we have to try to see the situation through your eyes, and find out what you need"? (That's an "empathic" and problem-oriented phrase from my vault. It might defuse a battle of egos, by directing attention to the actual business of getting better and working together.) Such phrases might bring temporary relief - to the patient, if not to us - if we follow through, trying on the patient's perspective.

Geena trades away her frustrating patient. Will the triage nurse stay put? The nurse knows that this rant won't change anyone's behavior. There's no "pre-triage" desk, where patients are told, "Don't mess with the nurse." It doesn't take a shrink to diagnose the rage and burnout in this post. I wonder how this nurse does it, day after day, and how it could be better...

(via Gruntdoc)

Are you jacked up?

Head Nurse explains:

We occasionally use the phrase "jacked up" at work. This is somewhere between "on vulture precautions" and "train wreck", and is a source of confusion for those people not versed in the cynical and bitter humor of a neuroscience unit. Therefore, I present examples of "jacked up" and "not jacked up" for your perusal. It is to be hoped that they will clarify the issue.

Hole in your belly I could put my head through: not jacked up.
Hole in your belly secondary to an abcess that's been cooking for twenty years, ever since you had gastric stapling: jacked up...

Twinkies: total jacked-uppery.
Deep fried Twinkies with Hershey's syrup: not jacked up.

Fractured pelvis and dislocated hip: only semi-jacked-up.
Fractured pelvis, dislocated hip, history of polio: jacked. Up.

Nurse on day one of a three-day week: not jacked up.
Nurse on day three of a three-day week: jacked up.

Having a kneecap kicked off by a horse: jacked up.
Getting inadvertently stepped on by a one-ton bull: not jacked up.

I think I get it. Let's see:
Psychiatrist with 40 incomplete, undictated charts on her desk: not jacked up.
Psychiatrist on call, with 4 psychiatric emergencies in ER and only one available hospital bed: severely jacked up...

Grand Rounds #30 is up

at GrrlScientist's Living the Scientific Life (or Scientist, Interrupted). She's linked to some excellent posts from across the medical blogosphere, despite feeling under the weather herself (hope she gets well soon!).

"My Living Will"

In The New Yorker:

"If I should remain in a persistent vegetative state for more than fifteen years, I would like someone to turn off the TV...Do not resuscitate me before noon... Once I am allowed to die a painless and peaceful death, I would like my organs donated to whoever can catch them...I do not wish to be kept alive by any machine that has a “Popcorn” setting... I would like to die at home, surrounded by my attorneys."

Grrlscientist hosts the next Grand Rounds

...and she's calling all medbloggers. Her e-mail address is GrrlScientist AT yahoo.com. She wants "wonderful, gross, heartrending, heartwarming, funny or medically correct stories."

The sooner that you get your links to me, the happier I will be because I am fighting some sort of evil feverish aching sickness that has stopped my own writing efforts, thus, it is likely that I will not be able to contribute my own material to this week's effort.

So, this is an emergency! Calling all blogging doctors, nurses, medical scientists and other medical peeps, please make this poor, sick girl feel better by contributing your experiences to this week's Grand Rounds!

Anger management online?

Do not, repeat, do not allow HMO's or insurance companies near this link: "Intermission: for when things just get a little too infuriating." It presents a series of cute animal photos (kittens, baby penguins, etc.). It only stops when you, the furious viewer, indicate that you have calmed down. How long before this is deemed a cost-effective treatment for rage and explosive outbursts?

The author of "Intermission" has another webtoy, called "The Boiled Egg Game." This game may fit comfortably in Dr. Sanity's weekly "Carnival of the Insanities." (Actually, I've had interactions that reminded me very much of the "Boiled Egg Game"...with aphasic, perseverating patients, among others.) People who've lived and worked in certain institutions, and possibly in totalitarian states, may recognize elements of the Boiled Egg Game, as well.

For a hint of what many physicians are feeling these days: play the game for one minute, substituting either of these phrases for the words "Boiled Egg!"
(a) "Your work is not valued as much, these days." Or, (b) "Your sacrifices were not worth it."

Addendum: This morning, a patient told me, "Talking to a doctor is like talking to a damn doorknob. You can't ever get an answer that makes sense." Sounds like a "Boiled Egg" experience...

On selling, and moving on

The sound drifted into our bedroom at 4 am, not long ago - someone in the park behind our house, playing "Mary Had A Little Lamb" on an accordian. Great fun, for some, but we asked ourselves: is it time to sell our home, and move on?

For years, we've perched on a lush hillside in Eugene. Our house has a two-story window wall, and the view is eye-popping: city lights and fir-covered hills. We glimpse the South Sister from the front deck. Behind our house, a rhododendron garden blooms, and hiking trails wind through acres of Douglas firs.

The house itself is eye-popping for different reasons. It's a "fixer." College students had rented it for years before we bought it. They chopped firewood on the hardwood floors, and carved initials in the walls. The inspector found evidence that they had once left town for quite a long time, with the bathwater still flowing.

But when I first stepped into this house, I barely noticed the structural problems. I looked out the huge windows, took in the view, and said, "I'll take it."

Five years later, it's still a "fixer." We've repaired the rotted subfloors, leaky plumbing, and frightening electrical problems. There is so much more to be done...but the funky charm of our "fixer" has won me over. I love this house.

Still, we have outgrown it...and the park isn't getting any quieter. Could we really sell our home? I persuaded myself that no one else would want it. (After all, it is...funky! The fireplace, "hand-crafted" in the sixties, has astrology symbols engraved on it. Very groovy, very right-on...but will the design world embrace the sixties again? It didn't seem likely...)

We didn't know that, simply by muttering the words "sell" and "home" in the same sentence, we would attract a thundering herd of agents, bankers, brokers, and buyers. Eugene is apparently a "hot market." Our house was listed for a grand total of five minutes when we got a good offer. A stranger walked into our house, looked at the panoramic view of valley and hills, and had to own it. Surely there are other houses for us to love...and is that my real estate agent in the background, nodding her head vigorously in agreement?

But buying in this market...now, that's a challenge. You need some thunder in your herd, to find potential buys before someone else does. The ink is hardly dry on an offer when the cell phone rings: "Sorry, they've just accepted another offer, for full price, and for cash. Just wanted you to know..."

The cheery agent is undaunted. We will find something terrific, and we will love it. Is she right? To be continued...

"I've visited the future, and it isn't pretty"

In NYT: Maureen Dowd, on aging, dementia, and nursing homes:

My mom fell and fractured her neck one night a couple of winters ago. She was sent to a nursing home to recuperate. It was the third circle of gloom. Residents sat around, zombie-like, or slowly maneuvered in wheelchairs or with walkers. I suddenly understood why all of my mom's friends who had gone into nursing homes had become listless and died soon after. The facility was depressing, with bad food and impersonal attendants who seemed inured to their surroundings.

It seemed like the sort of place people checked into but not out of. My mom's hazel eyes were filled with dread, so I bought a sleeping bag at the nearest R.E.I. and slept on the floor beside her bed for four weeks.

There were blizzards outside and lethargy inside. All through the night, Alzheimer's patients would moan: 'Help me! Why doesn't anyone come to help me?' They were unable to remember the last time an attendant stopped by. After a while, there didn't seem much point in getting dressed. I put on one of my mom's extra-large flannel robes and some slippers and started shuffling around the nursing home. I felt like one of those cursed women in Grimm's fairy tales who turn into crones in a blink. Soon the residents began acting as if I were one of them, just one with better mobility. They would call out for me to fix them tea in the microwave - 'Just Sweet 'N Low,' one woman ordered briskly.

One night an elderly woman asked if I would come into her room and dial her daughter's number for her. 'I haven't heard from her in so long,' she fretted. I called the number and left a message on the answering machine: 'Your mother misses you.'

As I hung up, the old woman looked up at me with big suspicious eyes. 'What are you doing in my room?' she demanded in a hostile voice. She had forgotten me already.

Most nights, I watched two sweet-looking old ladies sneak down the hall to purloin supplies at the nurses' station - cat burglars heisting Depends.

In my old life, I read glossy catalogs from Bliss Spa and Bergdorf's. Now I sat in the drab community room reading Dr. Leonard's 'America's Leading Discount Healthcare Catalogue,' which promotes the notion of senior superheroes with vision-enhancing Eagle Eyes sunglasses; Sonic Earz, to amplify sounds up to 60 feet away; and Frankie Avalon's Zero Pain roll-on pain reliever...

Toxic houses

Imagine a sheriff at your door, informing you that your house was once a meth lab, and that he must evict you. From the Oregonian:Did you buy a meth house?

Scattered throughout Oregon, 337 houses, apartments, hotel rooms and storage units are classified as "unfit for use" by state health authorities. Once used for meth production, the sites need to be tested for hazardous residue, decontaminated and cleared by the state before they can be inhabited again.

Yet many of the homes on the drug-site list have been purchased by unknowing buyers, some of whom have been evicted for trespassing.

In December, the Department of Human Services started a "cold case unit" to finally clear the list of properties, some dating back to 1990. As soon as the agency started sending out letters, they heard from new owners living in meth houses. A few weren't even that new. One family had been living in a house for seven years.

"We have to break it to them softly," said Jennifer Allen, who oversees the DHS cold case unit.

The letters inform property owners of their legal obligation to clean up hazardous residue left by meth cooking.

Over the phone, the homeowners insist that no one told them they were buying a drug house. They raise their voices, threaten lawsuits, tell Allen they won't pay for a decontamination bill from a licensed contractor, which typically costs as much as $12,000.

And they're certainly never willing to move out.

Allen's usual response is a calm explanation of Oregon law: Once police find evidence that a property has been used to cook meth, no one can occupy it or rent it until the state says it's safe...

From the "Anti-Meth Site FAQ's":

Any number of solvents, precursors and hazardous agents are found in unmarked containers at these sites. These potent chemicals can enter the central nervous system and cause neural damage, effect the liver and kidneys, and burn or irritate the skin, eyes and nose. Environmental damage is another consequence of these reckless actions, and violence is often a part of the process as well.

Q. What are the most serious environmental consequences of meth labs?

A: Each pound of meth produced leaves behind five or six pounds of toxic waste. Meth cooks often pour leftover chemicals and byproduct sludge down drains in nearby plumbing, storm drains, or directly onto the ground. Chlorinated solvents and other toxic byproducts used to make meth pose long-term hazards because they can persist in soil and groundwater for years. Clean-up costs are exorbitant because solvent contaminated soil usually must be incinerated.

Q: What is the cost of a cleaning up a clandestine meth lab site?

A: Cleanups of labs are extremely resource-intensive and beyond the financial capabilities of most jurisdictions. The average cost of a cleanup is about $5,000 but some cost as much as $150,000.

They also link to some guidelines for cleaning up former meth labs.

MedBlogs Grand Rounds XXIX is up...

at GruntDoc. (Warning: a few posts are not for the squeamish!)

Sleepdoctor, on narcolepsy

Liz Ditz, of I Speak of Dreams, asked: "...who is the genius, the dab hand, the magister of narcolepsy?"

Whenever I've had a patient with narcolepsy, I've always worked with a sleep specialist. I forwarded her e-mail to the sleepdoctor. He posts a long response, and promises more:

Narcolepsy is a chronic (long-lasting) neurological (affecting the brain or nerves) disorder that involves your body's central nervous system. The central nervous system is the 'highway' of nerves that carries messages from your brain to other parts of your body. For people with narcolepsy, the messages about when to sleep and when to be awake sometimes hit roadblocks or detours and arrive in the wrong place at the wrong time. This is why someone who has narcolepsy, not managed by medications, may fall asleep while eating dinner or engaged in social activities - or at times when he or she wants to be awake..."

Thanks, Dr. Rack (it's good to hear from you again!).

Never too old for sex education

From the Guardian: "...middle aged people may not have had the same quality of sex education as their children receive." They may be particularly ill-informed about STD's, including chlamydia.

While previous health campaigns have been geared towards inexperienced young people, a new study aims to find out how widespread the problem is among this "increasingly significant" group.

Dr Gordon Scott, head of department at NHS Lothian's genito-urinary clinic, said: "Sexual health services tend to concentrate on young people, and there is a scarcity of information about the needs of those aged 40 and over, many of whom may be coming out of long-term relationships.

"This survey will hopefully give us valuable insights into this important sector of the sexually active population."

Have you visited the Tangled Bank?

Our own Orac is hosting the Carnival of Scientists, and does a marvelous job.

He also has an exceedingly charming post today, about a throng of Polish bikers rallying for the Pope at a Chicago church. Orac is one of our best medical bloggers, and a driving force behind Skeptics' Circle. Be sure to take a look.

Frontiers of psych research

Will remote-controlled fruit flies advance our knowledge of human behavior? Via Newsday:

Yale University researchers say their study that used lasers to create remote-controlled fruit flies could lead to a better understanding of overeating and violence in humans.

Using the lasers to stimulate specific brain cells, researchers say they were able to make the flies jump, walk, flap their wings and fly.

Even headless flies took flight when researchers stimulated the correct neurons, according to the study, published in the April 7 issue of the journal Cell.

Scientists say the study could ultimately help identify the cells associated with psychiatric disorders, overeating and aggressiveness.

I think I know these scientists. Weren't they my lab partners in high school biology? They eagerly passed electric currents through frogs' legs, causing them to dance (and in one instance, jump to the ceiling, where they stuck for 36 seconds...long enough to earn detention for all of us.) It's nice to know that they have found a way to use their prodigous scientific talents for good, rather than for evil...

These experiments may reveal more about the behavior of those holding the remote controls, rather than their hapless, headless victims (er, subjects). Remember "Subservient Chicken?" One of our Eugene columnists wrote, "Last April, Burger King launched this silly bit of advertising featuring a guy in a chicken suit who appears to do your bidding. Just type in simple commands, click the "submit" button and watch him: jump, kneel, clean, fly, dance, even wag a finger should you request something naughty. Some of us are embarrassed by how long we found this amusing."

Former NASA physician blogs

She watched Challenger explode. She cared for the shocked, grieving families of the shuttle astronauts. In her blog, Dr. Sanity, she writes:

"Challenger - A Flight Surgeon Remembers"
On January 28, 1986, I was at Cape Canaveral in Florida. As a NASA Flight Surgeon, I had been assigned as the Crew Surgeon for Mission 51-L (no one really wanted the job since many disapproved of having a civilian--the teacher in space--fly on a space mission). The crew had trained together for over a year, and I had come to know them all very well in the course of the training and medical preparation...I watched (the launch) with my usual awe, that humans had been able to contain such energy and put it to use in escaping the planet.

My awe was short-lived as we noticed an anomoly. Something seemed to have gone wrong with the SRBs (solid rocket boosters) and they detached from the ET (external tank) too soon. There seemed to be a big explosion, but none of us were certain what might have happened...I made a few commands to my emergency team, who were outside in ambulances, as I continued to watch the growing cloud of the explosion, waiting for the Challenger to appear from behind it heading back to the landing site, not far away. I waited and waited. The orbiter did not appear. I felt a momentary confusion, and then I think all the blood must have rushed out of my head as I realized what it meant. I knew they must have been killed. All of them. I had to hold onto the console for support. All I could think of was oh my God, oh my God...

I was desperate to get to the families and do something useful. I wasn't sure what, but I felt they might need me there. I drove my car on the center divider and the grass between the lanes, and made my way through the crowds who had stopped to watch the launch. It took me some 20 minutes to get to Crew Quarters.

The next 12 hours were something of a blur. I had read about mass hysteria in textbooks, but that description was far too mild for what I found when I reached the place the crew called home prior to a launch. All the members of the immediate and extended family were there. Women were screaming; babies crying. People thronged around me, wanting to know if the crew had parachuted to safety. I was stunned that they had not yet grasped what had happened...

Today, she's a psychiatrist (yes, another one!). She is fearlessly outspoken. Each week, she hosts a "Carnival of Insanities" (I guess there's not enough material for a "Carnival of Sanities").

She's creative, too. Here's her message to Kofi Annan, with a nod to Dr. Seuss:

The time has come.
The time has come.
The time is now.
Just go.
Go.
GO!
We don't care how

* * *

You can go to Iraq
You can march with the Lebanese
You can go to Iran or Sudan,
But please go. Please!

* * *

Kofi Annan, we don't care how.
Kofi Annan, will you please GO NOW!

Welcome to my blogroll, Dr. Sanity.
P.S., hope your wrist heals soon!

"In the end, he was alone..."

Derek Lowe, on the death of his brother, from alcoholism:

Each year, my brother slipped further and further away from the possibility of a normal life.

Eventually, there wasn't much left of the person I grew up with. He died in stages. His memory, his motor skills, his speech and his personality had all been eroded by drinking. Despite his own attempts to break free, despite stays in rehab and AA, despite terrible convulsive bouts of delirium tremens and nearly dying of pancreatitis at least twice, he was never able to find a way out. In the end, he was alone, on a couch, in a littered room that he was unable to summon enough strength to clean.

All I can do is honor his memory, especially the memories of the times before he was a damaged shadow of what I think of as his real self - the days when there was still a real self left. And I can hope to warn others of what could be waiting for them. If any of you reading this think that you might have a problem with alcohol, then you very well might. And the sooner you try to do something about it, the better your chances of succeeding.

Don't wait. Don't end up on that couch. Please.

My condolences, Dr. Lowe.

Spotlight on medblogs

GruntDoc, jump up on this stage and take a bow! Emergency Physician Monthly is impressed with your blog:

When Allen Roberts sat down to create an online medical journal three years ago, he didn’t think of himself as a “blogger.” He was just an Emergency Physician in Texas sharing his thoughts with whoever happened upon his website. Sometimes he wrote about trivial things, like a funny gift from his nursing staff. But he also posted his thoughts about real ED issues, like tort reform and ambulance diversion, and pretty soon he had created an online dialogue. Roberts’ website became a place for EPs to swap stories, complaints and medical advice in a casual and exceedingly convenient environment. Thus Gruntdoc.com was born, and much to Roberts’ surprise, became a gold standard among medical web journals. But don’t take our word for it; Gruntdoc.com was recently voted Best Medical Weblog of 2004.

Also featured in their report: RangelMD.com; Symtym; richardwinters.com; and Medpundit (but why do they call her Webpundit?).

This isn't GruntDoc's first brush with fame. Blog-historians will recall that GruntDoc won praise from Forbes Magazine in 2003:

Allen Roberts is a 40-year-old emergency room doctor in Texas, who works in a trauma center that sees about 65,000 patients each year. A U.S. Navy doctor, he was for four years deployed with the U.S. Marine Corps. This experience--as both a doctor and military man--lends an interesting color to his posts..."Blogging combines my interest in computers and medicine, and just venting my spleen," he says. Recent post (on a news story that Marines may not have taken their anti-malarial medications): "I genuinely admire Marines, but their inability to accept the germ theory of disease (or the protozoal theory of malaria) boggles my mind."

(Other favorites were Medpundit, Family Medicine Notes, In the Pipeline, and Living Code.)

(So GruntDoc, what are you going to do next? Is there a guest appearance on ER in your future?)

More praise for my medblogging colleagues:

USA Today calls bookofjoe a "Hot Site:"

...we’re pretty sure that even if there are more blogging anesthesiologists out there, Joe’s blog would still stand out, with prose combining the elegance of a fine writer with the terrific content of someone who’s actually got interesting things to say. Joe celebrates life’s small good things, and we celebrate this blog.

CodeBlueBlog won Best Clinical Sciences Medical Weblog for 2004, and was a finalist in the 2004 Weblog Awards, Best of the Top 2500-3500 blogs.

Guardian Online has named "Six of the best health and medicine blogs:" The Examining Room of Dr. Charles; Random Acts of Reality; Code Blog: Tales of a Nurse; A Chance to Cut Is a Chance to Cure; In the Pipeline; and Doing Less Harm (which, alas, has perished).

Medical journalist Saint Nate has successfully launched "Skeptics Circle," which recently hit the big time.

Other Best Medical Weblog winners: Cancer Blog, for Best New Medical Weblog; and Symtym, for Best Health Policy/Ethics Weblog.

Medical Grand Rounds is thriving, thanks to Nick and dozens of contributors. (Nick examines the comments on medblogs, and wonders if our casual readers are ready for "unfettered medical blogging.")
Today's edition of Grand Rounds is sponsored by Polite Dissent, and next week, it's...Gruntdoc.com!

Sincere congratulations to you all. When is the official Awards Dinner, and what will we be wearing?

Blind student earns M.D.

and he's thinking of becoming a psychiatrist. Yes! Via Kevin, MD, and CNN:

Without sight, Cordes had to learn how to identify clusters of spaghetti-thin nerves and vessels in cadavers, study X-rays, read EKGs and patient charts, examine slides showing slices of the brain, diagnose rashes -- and more.

He used a variety of special tools, including raised line drawings, a computer that simultaneously reads into his earpiece whatever he types, a visual describer, a portable printer that allowed him to write notes for patient charts, and a device called an Optacon that has a small camera with vibrating pins that help his fingers feel images.

"It was kind of whatever worked," Cordes says. "Sometimes you can psych yourself out and anticipate problems that don't materialize. ... You can sit there and plan for every contingency or you just go out and do things. ... That was the best way."

"Duck and cover," circa 2005

From the Department of Homeland Security: "What to do during a nuclear or radiological attack." Some helpful tips:

1. Do not look at the flash or fireball-it can blind you.
2. If you hear an attack warning:
* Take cover as quickly as you can, BELOW GROUND IF POSSIBLE, and stay there unless instructed to do otherwise.
* If you are caught outside, unable to get inside immediately, take cover behind anything that might offer protection. Lie flat on the ground and cover your head.
* If the explosion is some distance away, it could take 30 seconds or more for the blast wave to hit.
* 3. Protect yourself from radioactive fallout. If you are close enough to see the brilliant flash of a nuclear explosion, the fallout will arrive in about 20 minutes. Take shelter, even if you are many miles from ground zero-radioactive fallout can be carried by the winds for hundreds of miles. Remember the three protective factors: shielding, distance and time...
If in a fallout shelter, stay in your shelter until local authorities tell you it is permissible or advisable to leave. The length of your stay can range from a day or two to four weeks...
* A 'suitcase' terrorist nuclear device detonated at or near ground level would produce heavy fallout from the dirt and debris sucked up into the mushroom cloud.
* A missile-delivered nuclear weapon from a hostile nation would probably cause an explosion many times more powerful than a suitcase bomb, and provide a greater cloud of radioactive fallout.
* The decay rate of the radioactive fallout would be the same, making it necessary for those in the areas with highest radiation levels to remain in shelter for up to a month.

Here's the last item:

5. Cooperate with shelter managers. Living with many people in confined space can be difficult and unpleasant.

"Difficult and unpleasant!"

At least there's some faint acknowledgement of the emotional aspects of the described circumstances. It's not simply "Duck and cover, kids. Crawl under your desks!" (That was our drill, in grade school.) Who can imagine how "difficult and unpleasant" this would be, if we were attacked?

Dying, but not alone

While thousands attend the passing of the Pope and Terry Schiavo, Ann Althouse thinks of those dying with no one near:

I imagine them watching the TV reports, seeing all the people lavishing care on these two souls, and feeling terribly sad and lonely. These throngs of people standing in high-profile vigils could disperse and go individually to thousands of bedsides and visit those who suffer in isolation.

A Eugene nurse has started a program that puts volunteers at the bedside of dying patients. It's called "No One Dies Alone." She writes:

One rainy night...I had a brief encounter with a man whose name I cannot recall; a man I shall never forget. He was one of my seven patients, near death and a DNR. During my initial rounds, he asked, barely audible, “Will you stay with me?” He was so frail, pale, old, and tremulous. I said, “Sure, as soon as I check my other patients.”

Vital signs, passing meds, chart checks, assessments, and bathroom assistance for six other patients took up most of the next hour and half. When I returned he was dead. I reasoned he was a DNR, no family, very old, end-stage multi-organ disease; now he was gone, and I felt awful. It was okay for him to die, it was his time - but not alone.

I looked around, scores of people were nearby providing state-of-the-art patient care. For this man state-of-the-art should have been respect and dignity...

Speaking with nurses from other ICUs, there seems to be an unwritten universal protocol for the patient who is dying without the presence of friends or family. One’s other patients’ care will be taken over by nearby nurses. Rituals of passing are acted out: I’ve seen nurses quietly singing, holding the hand of the dying, and, in other manners of behavior, showing care and respect while an individual passes on to death. Nurses know the awe of being present at the birth or the death of another human. I believe awe and privilege is an innate human response at these times, the very essence of humanity...

“No One Dies Alone” has been up and running since November 2001. It is still a work in progress with a few things that need to be tweaked, but overall it fills the void for which it was intended...

A staff nurse generally initiates “No One Dies Alone” by calling pastoral care or, after 5 pm, the nursing supervisor. The person who has signed up for that date is called. It is totally a volunteer program, and no minimum or maximum time has been set. The“compassionate companion” is provided with a parking pass and a meal ticket. We have a gym bag with a CD player, various CDs, a journal, and a Bible. We emphasize that any religious behavior will be initiated by the dying patient and not by the companion. Staff and the “compassionate companion” use an evaluation form in an ongoing effort to improve the program.

The reasons individual employees have volunteered are fascinating and as varied as their departments. Hospital carpenters, administrative heads, maintenance workers, nurses, secretaries, and kitchen workers have come forward. Some come from large families who cannot imagine someone being alone; others are alone themselves. One nurse from the cardiac cath lab has seen many die in spite of the high tech environment and care. He wanted to experience once again “why I became a nurse in the first place—to care for those who can no longer care for themselves.”

Other hospitals have adopted her program. (See this article, which links to the program's manual.)

Surviving the jump

...from Golden Gate Bridge. Kevin Hines, 19, describes his suicide attempt.

Only a tiny minority—not more than 2 percent—survive the jump. Contrary to what many jumpers imagine, it is not a graceful, trauma-free way to go: the impact with the water is violent, shattering bones and dismembering limbs.

"I was falling head first. It was so fast the air pressure on my body made it impossible to breathe," he recounted for Psychiatric News. "By the grace of God, somehow I turned and went in feet first. When I hit the water, I went down probably 50 feet before I started to come back up again, all this time without breathing. I thought I was going to pass out. When I came to the surface, I thought I was dreaming, and I said to myself, `Oh, my God, I'm alive.'"

Something—it turned out to be a seal, he said—bore him up in the water during the few minutes that passed before the Coast Guard picked him up. He suffered shattered vertebrae, requiring him to wear a back brace for the rest of his life, but Hines survived to tell his story to youth and other groups, and to the media (including CNN and the New Yorker magazine, among others).

("Saved by a seal..." ??! The article doesn't challenge this statement. We need more benevolent seals under that bridge!)

More on suicide here.

"Doctors and dollars"

In The New Yorker, surgeon Dr. Atul Gawande is startled when his first employer asks what he'd like to be paid. How should he answer?

...I tried asking various members of the surgical staff. These turned out to be awkward conversations. I’d pose my little question, and they’d start mumbling as if their mouths were full of crackers. I tried all kinds of formulations. Maybe they could tell me how much take-home pay would be if one did, say, eight major operations a week? Or how much they thought I should ask for? Nobody would give me a number.

Most people are squeamish about saying how much they earn, but in medicine the situation seems especially fraught...

He explores the byzantine rules that govern doctors' reimbursement. He also meets a "financial-disaster specialist for doctors":

Roberta Parillo...is called by physician groups or hospitals when they suddenly find that they can’t make ends meet. (“I fix messes” was the way she put it to me.) At the time I spoke to her, she was in Pennsylvania, trying to figure out where things had gone wrong for a struggling hospital. In previous months, she’d been in Mississippi, to help a group of a hundred and twenty-five physicians who found they were in debt; Washington, D.C., where a physician group was worried about its survival; and New England, for a big anesthesiology department that had lost fifty million dollars. She’d turned away a dozen other clients. It’s quite possible, she told me, for a group of doctors to make nothing at all.

Doctors quickly learn that how much they make has little to do with how good they are. It largely depends on how they handle the business side of their practice. “A patient calls to schedule an appointment, and right there things can fall apart,” she said. If patients don’t have insurance, you have to see if they qualify for a state assistance program like Medicaid. If they do have insurance, you have to find out whether the insurer lists you as a valid physician. You have to make sure the insurer covers the service the patient is seeing you for and find out the stipulations that are made on that service. You have to make sure the patient has the appropriate referral number from his primary-care physician. You also have to find out if the patient has any outstanding deductibles or a co-payment to make, because patients are supposed to bring the money when they see you. “Patients find this extremely upsetting,” Parillo said. “ ‘I have insurance! Why do I have to pay for anything! I didn’t bring any money!’ Suddenly, you have to be a financial counsellor. At the same time, you feel terrible telling them not to come in unless they bring cash, check, or credit card. So you see them anyway, and now you’re going to lose twenty per cent, which is more than your margin, right off the bat.”

Even if all this gets sorted out, there’s a further gantlet of mind-numbing insurance requirements...

No surprises here for my medical colleagues...