A Revolutionary Experience!

Listen as renowned surgeon Leo Gordon reads his epic story about pancreatic insufficiency and the American Revolution. Based on a true story. The podcast is 15 minutes long and worth every second of it.

Parathyroids Anonymous

A One Act Play by Leo Gordon, MD

Dedicated to Parathyroid Surgeons

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All proceeds from the production of this play go to Parathyroids Anonymous--An international organization dedicated to the well-being of those who perform parathyroid surgery

Scene: A sparsely furnished church basement. Rain is beating against the window panes. Folding chairs are arranged in a semi-circle. Participants are drinking from plastic cups. Some are in scrub suits. All appear tired.

Don: Hello. My name is Don and I’m a parathyroid surgeon.

All: Hello Don

Don: I will be your facilitator tonight. We have a new member so let me set the ground rules. All of us in this room are parathyroid surgeons. We maintain our anonymity as we discuss the mental and physical distress that parathyroid surgery engenders. There are no boundaries at our meetings. We speak openly and freely. Use your first name only. And of course, no patient names. Who wants to begin?

Miriam: (Nervously) Hello. My name is Miriam and I am a parathyroid surgeon.

All: Hello Miriam

Miriam: I’ve been here a few times but I’m a little bit nervous.

Don: Don’t be nervous Miriam. We all share the same problems.

Miriam: Well… last week. (Begins sobbing)

Don: Now Miriam, just relax. Please continue.

Miriam: I had a 56 year old woman referred to me with hypercalcemia. She had had elegant localizing studies at our hospital. Both studies – nuclear and sonographic - stated with metaphysical certainty that there was an adenoma of the right lower gland. Yet (sobbing) when we explored the area, there was no adenoma present. All we found was a normal sized parathyroid gland!

Al: (Hands Miriam a handkerchief)

Don: Go on, Miriam

Basketball is still an awful sport to watch

From the current issue of Sports Illustrated:

So why do I care about this?

Four years ago, I said the same thing in a blog post called "Basketball is an awful sport. Here's why." If you don't want to read the whole thing, I will summarize.

Basketball is the only sport I can think of where a team can be rewarded for breaking the rules. Specifically, by deliberately fouling and opponent's weaker free-throw shooters, a team that is losing can catch up when the weak free-throw shooter misses and the team that is losing gets the rebound.

All of the fouls and free throws plus the seemingly unlimited number of timeouts that each team has result in the last two minutes of the game taking 20 or more minutes.

To me, it's unwatchable.

Pertinent to Van Gundy's comments is that Detroit Pistons center Andre Drummond, who will play in the All-Star game, set an NBA record by missing 23 free throws in a single game on January 20.

This was part of a deliberate strategy by the Houston Rockets who were losing the game by nine points at the start of the third quarter. Houston's K.J. McDaniels fouled Drummond five times within nine seconds and the team fouled Drummond on seven straight Piston possessions. During that stretch, Drummond made 5 of his 16 free-throw attempts.

It must have been quite an exciting couple of minutes of play.

The All-Star Drummond had to be taken out of the game in the fourth quarter so that Detroit could hold on and win the game.

Yahoo Sports reporter Eric Freeman said: "While it's a little inexact to say that sending a player to the line over and over again 'isn't basketball' given that the rules allow it, it's downright enervating to watch and not an ideal product for a league that ultimately sells entertainment above all else. Intentional fouling is also increasingly common, with seemingly each team having at least one player who gets sent to the line in opportune moments."

He suggested that NBA commissioner Adam Silver is going to have to do something about the issue.

Here's what I've done about it. For the last few years, I haven't watched basketball.

What's in a name? Med schools sell to the highest bidder

The 12th oldest medical school in the United States, Jefferson Medical College, has just changed its name to Sydney Kimmel Medical College after Mr. Kimmel donated $110 million.

Declining tuition revenues (ha!) and the reluctance to refuse such a large donation were important factors in the renaming.

When I checked, I found that several other allopathic and osteopathic medical schools are named after benefactors. The oldest medical school in the country, at the University of Pennsylvania, changed its name to the Perelman School of Medicine in 2011.

Some of the names are at least related to medicine like the Frank H Netter MD School of Medicine at Quinnipiac University in Connecticut. Dr. Netter was a famous medical illustrator and author. There's also the Dr. Seuss Theodore Geisel School of Medicine at Dartmouth University.

Three years ago, I blogged about the increasingly forgettable names being attached to stadiums such as M & T Bank Stadium [aka Ravens Stadium at Camden Yards, PSINet Stadium, Ravens Stadium], O.com Coliseum [aka overstock.com Coliseum, Network Associates Coliseum, McAfee Coliseum, Oakland-Alameda County Coliseum], and Sun Life Stadium [aka Joe Robbie Stadium, Pro Player Park, Pro Player Stadium, Dolphin Stadium, Dolphins Stadium, and my favorite—Land Shark Stadium.]

How much money would it take to get a school to change its name to The Tostitos School of Medicine or Yahoo Medical College?

Taking a cue from all of this, I am willing to sell the naming rights to the Skeptical Scalpel blog for the right offer. Operators are standing by.

Oh, no. Not another medical TV drama

A show called "The Night Shift" has surfaced on NBC. The pilot is available for viewing on line. I'll post the link in a minute.

But first, let me warn you. Here's what happened in the first 13 minutes of the show.

The hero doctor, named TC, awakens in jail after a bad night, and while riding his motorcycle to work he comes across a roadside accident.

A man impaled by a tree branch is in shock. Paramedics are in attendance, but don't know what to do.

The doctor suggests removing the branch, which he promptly does. Blood pours out of the wound.

ED Doc clamps renal artery at accident scene

The medic says, "He's gonna bleed out."

TC says, "No, he's not. His renal artery is cut. I'm gonna clamp it." How he knows it's the renal artery I couldn't tell you. He places a clamp through the 3" long impalement wound and the bloody field.

Then he makes an incision at the umbilicus and puts in a peritoneal dialysis catheter, which fortunately the ambulance crew has handy. They also have an empty IV bag, which is used to collect the blood for auto-transfusion.

Did I tell you that this is all taking place on the ground by the highway?

On to the ED.

A two-week-old baby arrives in presumptive renal failure. Another ED doc subdues a large violent man with a "sleeper hold" reminiscent of Worldwide Wrestling. A man positioned on his hands and knees is having a scrotal laceration sutured.

Of course, there's a blossoming love affair between TC and a beautiful female colleague who both pretend they aren't hot for each other.

A new intern was juggling some things he picked out of the "lost and found" box to try to impress a woman doctor when he found out the box actually contained objects removed from people's rectums.

The hospital is having financial trouble. At a meeting, our hero insults a realistically smarmy administrator who told him a patient could have been transferred by pointing out that he wasn't a doctor.

While on break, the docs pass the time by playing basketball just outside the ED where a number of hospital personnel seem to be socializing. Perhaps this could be why the hospital is losing money.

TC puts the two-week-old baby on hemodialysis without consulting pediatrics or nephrology, mentioning how vascular access was obtained, or speaking to the parents, who apparently were not present.

That's about all I could take.

If after all that, you really must have the link, it is here.

Preventing infection: The "bare below the elbows" rule for doctors doesn't go far enough

Here's a post about a paper on the possible transmission of bacteria on doctors' clothing that drew over 1000 comments on reddit in 24 hours.

It linked to a blog by an infectious disease/hospital epidemiologist physician. He discussed a small study which showed that bacteria could be transmitted by neckties.

The study looked at four different combinations of dress—long sleeves with and without ties and short sleeves with and without ties worn by a single physician who rounded on five mannequins simulating patients.

From the Methods section of the paper. "Micrococcus luteus (ATCC) was suspended in sterile saline and adjusted turbidometrically to a concentration of ~1.5X10 8th colony-forming units (cfu)/mL .A Dacron swab was dipped into the bacterial suspension and was rubbed over the terminal 6 cm [about 2.4 inches] of the tie for those tests involving the tie and the corresponding location on the front of the shirt for tests involving no tie. The terminal circumferential 2 cm of the cuffed portion of long and short sleeve shirts were inoculated in a similar manner."

The study found that wearing an unsecured (I guess meaning no clasp) tie was significantly associated with elevated level of contamination of the mannequins. The degree of mannequin contamination was not significantly different whether long or short sleeves were worn.

The blogger concluded that everyone should wear short sleeves and no ties.

But wait a second—6 cm of tie covered with bacteria? How many people are getting that much contamination on their ties? If you are, then you need to reassess your approach to not only infected patients, but maybe activities of daily living in general.

Some might counter that even though the short sleeve portion of the experiment was not conclusive, what is the harm of having everyone wear short sleeve shirts and no ties?

In a recent editorial in the BMJ, Stephanie J. Dancer, a consultant microbiologist in England, wrote that there is no evidence to support the "bare below the elbows" rule [which has been in effect in the UK for several years], and it may be having some unforeseen consequences.

From her piece: "It could be argued that ditching the white coat and tie for hygiene purposes has had the converse effect, in that the informal attire now gracing our wards has encouraged a less robust view of infection control." She based this on the fact that since the bare below the elbows rule, junior doctors have adopted "scruffy" [her word] attire and slovenly personal hygiene.

She went on to say, "The dress code for UK doctors was imposed more as a political gesture than as an evidence based strategy likely to reduce infections acquired in hospitals."

A surgeon from the UK designed what he thought was the perfect uniform for doctors and published a description of it in the BMJ in 2012. Here is how it looked.

He said the "S" stands for "Surgeon." It was not accepted, probably because of the cape.

Maybe bare below the elbows doesn't go far enough.

I think all hospital personnel should dress like this.

Notice he has no stethoscope, no ID card, no cell phone or pager—they can harbor bacteria!

Is it a blog or a post?

Sometimes in the throes of temporary insanity, I call a blog "post" a "blog."

Luckily I have Twitter followers to set me straight. They have called me to task on several occasions for this linguistic gaffe. 

You see, calling a post a blog is like calling an article a  magazine. And it tends to upset people who are the arbiters of what is right and wrong on line (or is it online?).

For example, Paul Hutchinson, who posts blogs at the cleverly titled "Paul Hutchinson's Blog," says he is "getting very annoyed" at what he sees as a redefinition of the venerable (since 1999 when it was coined from "weblog") word "blog".

There's Kristen Havens, who wrote an interesting blog on semantics, at her "Writing and Editing" site. Using just 485 words, Kristen mentions different ways to use post and blog correctly and incorrectly. This particular blog of hers originally appeared on a site called MySpace, whatever that is.

But the real winner is Forrest Wickman writing in Slate's Culture blog. In a blog entitled "This is a blog post, not a 'blog,'" he excoriates people like Arianna Huffington and late Roger Ebert for using "blog" when they should have said "post."

Wickman says, "I hit my breaking point a few weeks back with—who else?—Amanda Palmer."

Who else indeed? I will save you the trouble of googling her name. She is some kind of singer and performer who gave a TED Talk, which actually is pretty interesting. She drove Wickman to the breaking point by calling a post of hers a blog! Can you imagine?

Suitably censured, she now calls her blogs posts as you can see on her website. 

I hope you enjoyed this blog post.

More baffling stuff about ICD-10 codes

The ICD-10 list may be inadequate.

ABC News reports an actor was hospitalized after his foot became caught in an elevator raising the stage during a performance of the Broadway show "Spider-Man: Turn Off The Dark."

As a connoisseur of ICD-10 codes, I decided to see if I could classify this injury correctly.

To my surprise, I could not.

The only codes having to do with elevators are the W303XXs Contact with grain storage elevator.

Since I had once read that the codes were originally developed in Europe, I even searched for "lift." But all I got were Y93F2 Activity, caregiving, lifting and W240XXs Contact with lifting devices, not elsewhere classified.

Contact with lifting devices, not elsewhere classified hardly seems appropriate for elevators, which are so common. People are frequently hurt on them or by falling down their shafts. All you get when you search "shaft" are hundreds of codes dealing with bones.

We know that ICD-10 has given us such gems as

V9027XA Drowning/submersion due to falling or jumping from burning water-skis, 

V982XXA Accident to, on or involving ice yacht,

W5609XA Other contact with dolphin,

V9542XA Forced landing of spacecraft injuring occupant and

V9733XD Sucked into jet engine subsequent encounter.

[Click on the links to read my comments about those codes.]

So how is it that there's no code for contact with an elevator? For that matter, what about injury during a Broadway show? Surely both elevator and Broadway show injuries are much more common than say V8022XA Occupant of animal-drawn vehicle injured in collision with pedal cycle.

Filippe Vasconcellos ‏(@fvguima), a Twitter follower, suggested W230XXA Caught, crushed, jammed, or pinched between moving objects, initial encounter, but it is not clear that there was more than one moving object. And the stated aim of ICD-10 is to introduce much more specificity into the codes for better tracking of things like injuries.

What we need is even more codes. Maybe we need to get going on ICD-11 sooner than we thought.

What is the purpose of research?

There a number of excellent answers to this question. Here are a few—exploration, description, and explanation; to learn something; to gather evidence; documentation, discovery, and interpretation; the advancement of human knowledge

Here’s a nice one from TheLancet about why medical research is done: "to advance knowledge for the good of society; to improve the health of people worldwide; or to find better ways to treat and prevent disease."

I’m sure you could come up with a few responses to the question yourself.

But I don’t think you would get it, nor do I think the lofty answers I listed above are correct either.

What's the real reason to do research?

To get published.

In my next life, I want to be a management consultant

I once blogged that in my next life, I wanted to be reincarnated as a weatherman. You get to make predictions and have no accountability when they are wrong (except for one Washington, DC weatherman who was given a "time out" after an erroneous forecast).

I know it can be stressful when you have to stand on the beach in front of a TV camera and try to keep your cap on during a hurricane.

But even so, it seems a bit easier than being a surgeon, a job which is very stressful and carries strong penalties for errors—especially for the patients.

Another occupation that is similar in circumstances and results to meteorology is that of management consultant. They advise, and they leave. They don't see the aftermath of their actions nor do they suffer the consequences. They also make a lot of money.

The ultimate hospital rating system

Finding out which hospitals are best is like "a riddle, wrapped in a mystery, inside an enigma."

Are you tired of seeing conflicting ratings from such once respected sources as Leapfrog, Medicare Compare, HealthGrades and Yelp?

Does it confuse you when a hospital is ranked in the top 10 by US News and World Report, but is "god-awful" according to Consumer Reports?

The Skeptical Scalpel Institute for Advanced Outcomes Research is proud to unveil a new rating system for hospitals.

Advanced metrics and creative statistics are linked with secret Bayesian methodologies, patient surveys and publically available databases to yield the most powerful and accurate hospital ratings ever imagined.

Just kidding.

Based on word of mouth, innuendo and rumors that have come to our attention through the back channels of the Internets, Skeptical Scalpel Ratings Plus offers unparalleled accuracy in hospital ratings.

For the low, low price of only $29.99, you will receive the Skeptical Scalpel Hospital Ratings Guide.

But wait, there's more. Here's the plus. At no extra charge, we will send you information about a weird trick that will enable you to undergo open heart surgery for just $8.00. Insurance companies are furious.

That's not all. The first 127 people to buy the guide will get a set of the sharpest kitchen knives known to mankind as our gift.

Are you a hospital administrator? Be advised of some special features of our ratings just for you.

If your hospital's ranking is not what you think it deserves, don't do what all the others do and waste time with in-house task forces or ad hoc committees. And don't claim we used bad data. Since we don't use data, that won't work.

Instead, try an on-site consultation from the Skeptical Scalpel Institute. We can show you ways to improve your standing without the need for expensive new patient safety programs.

If you are pleased with your ranking and want to advertise your Skeptical Scalpel designation, you must first contract with us. We sell banners, plaques and lobby displays. Call to discuss details. Operators are standing by.

Fee schedules for consultation and advertising will be provided upon request.

Dial MY-RATINGS.

Is a woman's purse really more contaminated than a toilet seat?

I've been wondering ever since this revelation splashed across the Internet.

Like most of these groundbreaking discoveries, this one got plenty of media attention. Despite the numerous articles mentioning the purse-toilet seat connection study and its sponsor, the Initial Washroom Hygiene Solutions company, I wasn't able to locate the full text or even an abstract of the investigation itself.

What I have pieced together from several different reports and the company's press release is that 25 handbags were examined and 100 objects were swabbed.

It seems that only one in five of the purses had excessive contamination.

And here's more interesting stuff from the press release: "Initial Washroom Hygiene, one of the UK’s leading hygiene and washroom services companies, today unveiled research showing that the handles of women’s handbags are home to more bacteria than the average toilet flush." [emphasis added]

So the contamination was with the handles of the bag and the comparison was to a toilet flush, not the toilet seat, which was the focus of many headlines. For example, this is what New York's CBS News outlet said, "Study: Handbags May Have More Bacteria Than A Toilet Seat." 

Or here's video from Slate which compares handbag contamination to both a toilet seat and a toilet (exact area of comparison not stated).

Let's talk about some problems.

The study was small. It was sponsored by a maker of hygiene products. How does one measure the amount of bacteria in a toilet flush? Wouldn't that depend on what was in the toilet bowl at the time? How many flushes were analyzed? The reporting was somewhat crappy since a flush was somehow conflated with a seat.

Finally, the press release was dated August 5, 2012. Why did this suddenly become news almost a year later?

It is possible that a woman's purse is more contaminated than a toilet flush, a toilet seat or even a toilet, but this "study" doesn't prove anything. It simply serves to confuse lay people.

It is one of a new genre of studies that apparent consider the toilet seat as the "gold standard" for contamination.

Here are some items that have been allegedly found to contain more bacteria that a toilet seat: cell phones, barbecues, desktops, kitchen sponges, light switches, computer keyboards, money, motel bedspreads, ATM keypads, office telephones, restaurant menus, grocery carts, steering wheels, gym equipment, and kitchen faucet handles.

As far as I know, disease transmission has not been linked to the handles or any other part of a woman's purse or any of the other objects said to be more contaminated than a toilet seat.

Come to think of it, what about disease transmission from a toilet seat?  Although a recent study linked over 9000 penile crush injuries over an 8-year period to falling toilet seats, there is no evidence that you can catch any infectious disease from a toilet seat.

Here's a quote from a WebMD article on the subject: "To my knowledge, no one has ever acquired an STD on the toilet seat—unless they were having sex on the toilet seat!" said Abigail Salyers, PhD, president of the American Society for Microbiology.

So can we please stop comparing things to toilet seats?

What we should be comparing things to is shower heads. See "Did Your Morning Shower Spray You With Bacteria?"