Wednesday, June 30, 2010

Catching On

Every now and then you realize you’re way too deep in what you do for a living…

Have you ever played Catch Phrase? It’s a great game. The electronic version is a fat disc that shows unusual word or phrases on a screen, and teams of two or more players try to guess the word or phrase. When one team gets it right, the disc is passed to the next team. There’s a timer in the device that beeps with ever-increasing urgency, and the team holding the device when the buzzer goes off loses the round. You can guess that this leads to the disc being flung about like a hot potato as time grows short. It’s kind of like Password on steroids.

Anyway, I’m over at a friend’s house the other night, and a bunch of us ED folks are playing Catch Phrase. It’s my turn to guess the answer, and my partner Kristin is looking at the screen. She turns to me and says “People do this all the time in the ER,” and she starts to gag and make a gesture with her hand like things are coming out of her mouth.

I knew exactly what she was doing. It is something people do all the time. It’s one of my least favorite bodily functions that expels one of my least favorite bodily fluids. (Blood, urine, lung stuff I can handle. GI secretions? I’m outta there.) But I know too many words for it, including:

Vomiting
Vomicking
Nauselated and Vomicking
Barfing
Upchucking
Regurgitating
Worshipping the Porcelain God
Producing the Technicolor Rainbow
Aspirating
Aspiration Pneumonia
Aspiration Pneumonia in a Nursing Home Patient
What you do when Administration Comes by

After about a minute and a half of this, with the beeping growing more intense and frantic, she grabs me by the collar. “WHAT AM I DOING?” she shouts?

“You’re throwing up, right?”

“RIGHT! IT’S THROW UP. THROW UP! LIKE NORMAL PEOPLE SAY! THEY THROW UP!”

And the disc was passed.

True Creepy Story

This is absolutely true. I’m driving down the street taking my son for an overnight visit with his grandparents. As I pass by one of the homes on their street, I noticed there are huge black birds circling over the house. I slowed down to find that they were also perched along the eaves, standing on the concrete facing of the garden wall, and even pacing up and down the driveway, driving their hooked beaks into the pavement with a mixture of determination and boredom. It was like something out of a Hitchcock film, but all the more scary because you knew…beyond a shadow of a doubt…that there was neighbor inside who hadn’t been seen in quite a while.

Don’t look for a punchline here, because there isn’t one.

Tuesday, June 29, 2010

A Soccer Suit

…I am the armchair fan who desperately wants to love this game, and, like untold thousands (millions?), had no choice but to curse it out, turned off by incompetent refereeing, a situation exacerbated by a governing body so intransigent and arrogant it makes British Petroleum look like a warm and cuddly quilting circle. "I am very, very satisfied," Jose-Maria Garcia-Aranda, the head of FIFA's referees, said of the quality of officiating in the World Cup matches…

…Even the most tradition-bound purists must agree that a goal should be a goal. So when referee Mauricio Espinosa mistakenly disallowed Frank Lampard's goal on Sunday, a score that would've enabled England to tie Germany 2-2, it was a very big deal. And when FIFA general secretary Jerome Valcke all but ruled out the use of video replay that would correct such situations, it exposed a sport crying out not just for visionary leadership but for leadership with some grasp of reality. Not counting a goal for fear of dehumanizing a sport with replay is not in the tradition of anything besides the tradition of ignorance.

Jack McCallum, sportsillustrated.cnn.com, June 28, 2010


The Fédération Internationale de Football Association (FIFA) officiating problem is really pretty easy to solve. Take a lesson from American medicine and make both the referees and the governing body legally liable for bad decisions. After all, it’s not like the actions of the referee go without consequence. A decision to allow, or disallow, a goal has a major impact upon the ratings of individual players and their ability to make a living at their chosen sport. Similarly, football clubs depend on proper officiating to ensure that both game results and overall standings are true and correct. With low-scoring games, a single inappropriate goal can cause a large change in the standings, which in turn affects a club’s ability to attract players, fans, and advertising. In addition, many football leagues feature end-of-season “relegation,” in which the lower performing teams and sent down to a lesser level league, and the best of the minors is promoted to the big time…and big money. The revenue impact of relegation on a team, let alone the psychological hot on a community, is staggering. If doctors can be sued for errors in decisions that affect the livelihood of others, even in those cases when these decisions can’t be made on any objective evidence at all, why shouldn’t FIFA?

The threat of liability, of course, will drive a headlong rush to embrace as much technology as possible to put error out of the realm of possibility. That is the current unreasonable standard in medicine…that there is perfection in an inherently unstable art…and one of the main reasons why doctors do so much testing and imaging and so little talking and educating. But if referees knew that they could be held personally liable for a missed goal or allowing an illegal play, I don’t know any that would participate at the sport’s highest level. They might if they were indemnified by FIFA itself, but would the organization want to take on the question of liability? I don’t think so. Like medicine, they will rush to a technologic solution and install goal cameras, mandatory instant replay of all scoring plays, and maybe even a coach’s challenge to eliminate their own risk. Because World Cup soccer is not about fair play or making sure that the better team wins at the end of the day, but all about FIFA.

FIFA president Sepp Blatter has apologized to England and Mexico for the refereeing errors that helped eliminate them from the World Cup…

The English said 'thank you.' The Mexicans, they just go with the head,'' Blatter said, indicating that they nodded. "I understand that they are not happy. It was not a five-star game for refereeing.''

England was denied a clear goal that would have leveled its match against Germany at 2-2, while Argentina took the lead against Mexico with a goal that was clearly offside.

Associated Press, June 28, 2010

If you still had any doubt about the arrogance of FIFA, this should resolve that quandary. I would think that the Swiss Mr. Bladder (intentional error, because the lines he spouts sound a lot like the organ’s contents) would be grateful that he got a “Thank you” from the English. It would have been a lot easier, and probably more appropriate, for the Red and White to say something like “Still got those hidden Nazi bucks bankrolling your election?” (Blatter’s 2002 election to the Presidency in FIFA was surrounded by charges of bribery and corruption.) And as for the Mexicans, I think a head nod was the most gracious gesture possible to someone who clearly feels he lives on a plane far above these mere dark-skinned colonials. I can think of a few other motions that might have gotten the message across more clearly. I’d probably even be willing to help.

In the early 1970s, Blatter was elected president of the World Society of Friends of Suspenders, an organization which tried to stop women replacing suspender belts with pantyhose.

“Sepp Blatter,” Wikipedia, June 28. 2010

Ah, well, that explains it all. If you can’t talk a woman out of her pantyhose, you’ve got to find something else to screw.

Monday, June 28, 2010

Newtonian Sex

There were plenty of starry nights, but a NASA commander says there was absolutely no sex in space during a mission that brought three female astronauts to the International Space Station.

Space Shuttle Discovery commander Alan Poindexter spoke definitively today on the outer space romance ban during a trip to Tokyo, where he and his team discussed their two-week resupply mission in April.

"We are a group of professionals," Poindexter told a reporter when asked about consequences for space sex. "We treat each other with respect and we have a great working relationship. Personal relationships are not ... an issue. We don't have them and we won't."

Michelle Ruiz, AOL News, June 28, 2010


At one point in my life, I played Professor at Embry-Riddle Aeronautical University here in Daytona Beach. I taught a couple of courses, most notably a three-hour extravaganza called “Human Factors in Space.” The course was designed to explore the physiologic and behavioral aspects of space flight for budding engineers and, like most university courses, I was able to take twenty minutes of material and turn it into twenty weeks of work, plus papers and a two-hour final exam.

(As you can guess, the ERAU curriculum is aviation-focused, with most students getting degrees in aeronautical science…pilots…aerospace engineering, aviation management, meteorology, that sort of thing. It’s a very good school, and if The Child chooses any of those career fields I’d be happy to have him go there, despite the added burden of doing his laundry for yet another four years. But knowing the students well does create some problems when they graduate. About eight years ago I was on a commuter flight from Daytona to Atlanta when I heard a voice in the cockpit say, “Hey, doc!” It turned out that the First Officer was one of my students, one who had gotten a C minus only out of my good graces because I figured he was such as slouch that he’d never wind up in a position of responsibility and he was so good spirited about the whole thing that I felt bad giving him a D. To his credit, the flight was about as tranquil as it could have been. It was also the most unnerving fifty-two minutes I’ve ever had in an aircraft.)

Being that the class is full of hormone-addled collegians, it was obvious that they were going to ask about sex in space. That’s why I made sure the lecture was noted on the syllabus, so I could avoid having to keep answering the question until the appointed time. But Isaac Newton could have predicted all you have to know about having sex in space.

Think about sex. Now wipe the smile off your face (assuming you are smiling…I do extend my best hopes for you) and think about the mechanics of sex. Not only do two people have to come together in an intimate way, but they have to be able to stay together and they have to be able to move against one another. On earth, that’s not a problem. If one partner is on top of the other, in whatever configuration might be, gravity keeps them in place; and even if the partners are on the same level, if you will, gravity keep them pinned to whatever surface they happen to be on, whether it’s a bed, a floor, or the backseat of a 2003 Saab 9-3.

In space, gravity is not a factor. (Technically, it actually is a factor, but not to the extent where it’s noticeable on most routine activities. If gravity weren’t in play at all, spacecraft wouldn’t orbit a planet, but would just shoot straight out into space. The more appropriate term is microgravity, not “zero-G.”) So if two people come together, they will not do so on a surface because there is no gravity to keep them there. Instead, they will tend to “float” within whatever enclosed space they inhabit at the time. Floating sex sounds like a lot of fun, and I suspect that it would be. However, if you’re floating abut, and one partner thrusts forward, Newton’s Third Law (the “equal and opposite reaction” one) suggests that there will be a corresponding movement in which the other partner will be pushed backwards, not only seperating themselves from their desired but also slamming against whatever wall, container, or overhang happens to be nearest in the direction of flight. They way to avoid this, and biomechanically the only way to have efficient sex in space (this was a human factors engineering course, after all) is to indulge in a bit of goal-oriented bondage play, restraining one partner to a solid surface with straps or tapes while the other secures his or her position through the use of brackets, handholds, or some other way to hold the body in place.

So what’s the real answer to the question, “Has anyone ever had sex in space?” We know the official answer, as well noted by Commander Poindexter. The real answer, of course, is “Not that we know of.” Let’s be frank…there have to have been times when there was some definite attraction between members of mixed-gender flight crews. (I’m excluding pathological attraction involving cross-country drives and the use of astronaut diapers to stalk your beloved.) So if I’m really attracted to the girl working the robot arm (and you can take that any way you wish), do I want to give it a shot, especially with the radio to Houston off and the good graces of my crew members? You bet I do. And if I was not one of the involved parties, would I be willing to go down to the middeck, close the hatch, and put on some earplugs so my colleagues could have a half hour to themselves? Absolutely. (Although the ear plugs might prevent me from hearing some really good lines, like “I felt the earth move,” because it is, and “I feel like I’m floating on air,” which you are. Which are better lines than “I hope this duct tape peels off,” and, “Gee, when we’re locked up here together for two weeks without a shower, you do pretty much smell like a gym locker.”

I think we should explore these issues with the same intensity we devote to learning the hidden story of Jake and Vienna (whom I do not know personally, but have seen on three magazine covers this morning at the local bookstore and found myself intrigued that a girl should be named after a sausage). Personally, I want to know these things not because I am a voyeur, but a scientist. When our sun goes supernova in a few billion years, the continued existence of the human race may depend on our interstellar procreative prowess. And how else to you learn stuff besides experiment and observation? I hereby volunteer to go up and try it. I’ll take notes. You can even make a video. But that astronautess had better be smiling.

Sunday, June 27, 2010

Basic Instinct

A 2-year-old octopus oracle — born in England, but raised in Germany — has predicted a German win over England in Sunday's World Cup game.

The mollusk named Paul chose a mussel out of a water glass marked with the German flag over a mussel in a glass with the English St. George's Cross, said Tanja Munzig, a spokeswoman for the Sea Life Aquarium in the western city of Oberhausen, on Friday.

Paul has proven to be a reliable oracle in the past — he predicted Germany's win over Australia and Ghana and its loss to Serbia. During the 2008 European Championship, he predicted 80 percent of all German games right, Munzig said.

Associated Press, June 26, 2010

Being of a medical mind, this animal prognosticator made me think of Oscar the Cat. As you may know, Oscar has been written about in the New England Journal of Medicine:

Since he was adopted by staff members as a kitten, Oscar the Cat has had an uncanny ability to predict when residents are about to die. Thus far, he has presided over the deaths of more than 25 residents on the third floor of Steere House Nursing and Rehabilitation Center in Providence, Rhode Island. His mere presence at the bedside is viewed by physicians and nursing home staff as an almost absolute indicator of impending death, allowing staff members to adequately notify families.

David Dosa, MD MPH, NEJM, July 26, 2007

Oscar is even the subject of a book which not only tells his story, but also offers lessons in caring, compassion, and end-of life care. That being said, I think the best end-of-life lesson I can learn from a cat is not to smell like tuna, and I will shortly be adding to my medical power-of-attorney form a codicil specifying that should I be placed in a nursing home, an attendant will be paid to place an open can of Little Friskies at the other end of the hallway three times each day (once per shift).

Oh, wait, back to the AP article:

Other animal oracles in German zoos cannot claim such a strong track record.

Nineteen-year-old hippo Petty falsely predicted a German win over Serbia last week. She had to choose between two piles of hay with red apples on top at the Chemnitz zoo in eastern Germany and nibbled from the wrong pile.

Tamarin Anton, a monkey at the same zoo, chose the wrong raisin a few days ago, incorrectly claiming that Ghana would beat Germany, kicking it out of the World Cup.

Not to mention the schnauzers that predicted the outcomes of the last two World Wars. As memory serves, Germany didn’t fare too well in those matches, either.

Rule Britannia!

Saturday, June 26, 2010

A Lego Note

Yesterday in the car The Child was telling me he had read that if you have 16 Lego bricks, each of them a little square with four studs on the top, there are enough combinations to keep you busy for a lifetime. So I’m not surprised by the infinite variety of things he comes up with given his three full drawers of pieces and parts collected over the past decade. In fact, this weekend he built a Lego museum, complete with exhibits on zoology, the wild west, life on Mars, an armory, a pirate ship, and a gift shop.

Yesterday he was puttering around with his toys…actually, he was stalling because I had asked him to clean up his room before going on a mission to seek pizza…and he brought out a small pink and yellow helicopter to show me. “What do you think, Dad?” he asked. “I call it the Chopper of Doom.”

I looked at the model, which was indeed a very convincing helicopter. He had, however, constructed it from pink and yellow bricks that I think came to us as some kind of Happy Meal toy. The sloped brick that represented the front window of the cockpit had an imprinted picture of a female being with blond pigtails, yellow flesh, and a bill.

“Son, you can’t call it a Chopper of Death. It’s pink and has a girl duck for a pilot.”

“What can I call it, then?” he asked, whipping it up and down in a flight path designed to poke out an eye.

I thought for a moment. This is a formative stage in his life, and I don’t want to say anything negative about the female end of our species. I want him to inculcate a sense of respect towards women, as well as a secure sense of his own gender identity. So I settled on something that I thought was pretty clever.

“You can call it the Chopper of Feminine Quack.”

He liked this a lot, and soon we came up with a theme song for the inevitable television show that will result when news of his creation spreads to the coast:

It’s the Chopper of Feminine Quack!
It’s the Chopper of Feminine Quack!
It’s pink and it’s yellow and it’s flown by a duck.
It’s the Chopper of Feminine Quack!

Because this is Lego, however, the chopper soon became boring. Which is why, within minutes, there was also the Killer Robot of Feminine Quack, the Airplane of Feminine Quack, the Speedboat of Feminine Quack, the Other Slightly Different Helicopter of Feminine Quack, The Seaplane of Feminine Quack, and the Guided Missile of Feminine Quack.

Thank the Lord there were only 9 pieces in his model, or this could go on forever.

Friday, June 25, 2010

Bored by the Board

Libertarian ideology rejects most of the modern regulatory systems that protect consumers, because everyone should be responsible for determining whether the hamburger contains E. coli on his own. But does that do-it-yourself dogma apply to the regulation of medicine, too? If you're Dr. Rand Paul, practicing ophthalmologist, the answer is emphatically yes.

According to an amusing story in today's Louisville Courier-Journal, the Kentucky Republican Senate candidate bills himself as a "board-certified" physician even though he is not actually certified by the American Board of Ophthalmology -- the only recognized body that certifies doctors in his specialty.

Paul's only certification was provided instead by something called the National Board of Ophthalmology, which is very convenient because he operates that organization himself.

Joe Conason, Salon.com, June 14, 2010

Most doctors in this country are board certified in something. In a nutshell, board certification means you have met certain training requirements and passed some kind of exam that qualifies you as a specialist in the field. In my case, becoming certified by the American Board of Emergency Medicine (ABEM) means I completed a three-year specialty training program and passed both a multiple-guess written exam and an oral exam consisting of a wide variety of patient scenarios. (Needless to say, the issue of being board certified and being certifiably boring are two separate discussions.)

ABEM was one of the first boards to require recertification. It was easy for them to do, as it was a relatively new specialty with no one who had been certified very long when the decision was made. As a result, nobody felt too inconvenienced. It was different for organizations like the American Board of Internal Medicine (ABIM), where there were already thousands of physicians out there who were certified once under a “one-and-done-for-life” agreement. If they suddenly required 20,000 physicians who had been functioning just fine for the last 40 years to spend their time and money on a new exam, they would have had a wholesale rebellion on their hands. So according to one of my ED colleagues who started life as an internist (he’s much better now), the ABIM sent everyone who was already certified a postcard that had two boxes on it. If you checked one box, you could take the exam again every decade or so, paying a hefty fee for the privilege. If you checked the other, you never had to see the inside of a test booklet for the rest of your natural life. Guess which one most people chose.

The next step is to add a component of continuous learning to the certification process. Most states already have Continuing Medical Education requirements, where you need to be able to document participation in so many hours of CME each year. But these requirements are written for physicians in general and do not relate to the individual specialty. Organizations such as ABEM are looking to fill this gap. For example, I am now required to read a selected panel of articles each year (for no CME credit, by the way), and then pay a fee ($95.00) to take an on-line test. If I do this successfully eight out of the ten years of my certification, I get to pay another fee to take a longer 205 question on-line comprehensive exam, which may or may not have anything to do with the articles I’ve read, for the low, low price of $1,715. If I miss one of the yearly exams, I can take an even longer written 305 question exam for the bargain price of $920. If I miss two or more, then I get to take the longer written exam and an oral recertification at a total cost of $2060. (But wait! There’s more! If you act now, we’ll throw in an amazing spiral slicer!) Interesting to note that it’s cheaper not to do the continuing process…there’s not exactly an incentive to participate.

The recertification process can be a pain, but I really don’t have a problem with it, at least in theory. (That being said, I’ll be perfectly happy to trash the system in the few months before I take the higher-priced exams with my money going to who-knows-where to do-who-knows-what except to make my life more miserable than it has to be, and Lord help me if I don’t use a number two pencil or blacken the oval completely.) But the next step in the evolution of board certification in emergency medicine is clear argument against intelligent design. It’s called Assessment of Practice Performance, or APP, and on the surface it’s not too bad. It’s supposed to assess competence in patient care, communications, professionalism, and practice-based learning through participation in quality improvement programs. Clearly, these are good things to know.

The part that bothers me is that these APP requirements apply only to “clinically active” diplomats of the board. What this means in practice is that if you’ve you’ve managed to get yourself out of the ED and into a comfy executive chair on the administrative floor, there’s no need to ever prove your clinical competence again. I have a real issue with this, as I have always been of the belief that no matter how high you rise in an organization, at some level you should still be able to do the job you were originally trained to do. So if you started out as a copier repairman and are now Chairman of IBM, you should still be able to fix a copier. I wouldn’t expect you to become a corporate accountant or a software engineer, even though your position in the food chain may be over those departments. But you ought to be able to fix the copier, and should go out of your way to do so every now and then. It “keeps it real,” as it were, and it’s incredibly difficult to lead with credibility when you are no longer able to work under the same conditions as those you‘re trying to direct. (That’s one of the main reasons I continued to do ED shifts while working full-time positions in public health.) If you’re unable to continually demonstrate competency in your original position, why should anyone assume you are competent in a higher post? And it certainly seems disrespectful, if not arrogant, on the part of non-practicing physicians to hold those doctors who actually see patients to a higher level of qualification despite the fact that they all present the same credential to the outside world.

And that’s the problem with the new scheme. Allowing those physicians who no longer see patients to hold themselves out as clinically competent ED docs (as the board certification would suggest they are) is contradictory at best and, in my mind, frankly disingenuous. But even if ABEM does the right thing and makes all diplomats meet the same standards, there’s always hope for those NPC (No Patient Care) docs. We can just ask Rand Paul to come up with another board or two…