Wednesday, August 13, 2008

the case of the bloody poo

Mike and I were trading stories about medical cases that we've seen recently. My fault, really, since I'm obsessed with medicine and can't stop talking about work (since that's all I do anymore, anyway). After I told Mike about my current patient with weight loss of unknown origin and a recent case of Q fever endocarditis, Mike told me the following pediatrics case that he saw today:

"Six-year-old boy, the story is that he took a dump this morning and it was bright red. No stomach pain, might have had a similar poop last night, no vomiting, heart rate is stable, no signs of dehydration or shock, kid is in no apparent distress."


"No. So the resident does a digital rectal exam, and his glove comes out bright red and covered in poo. The resident smears his glove on a FOBT (a strip of paper that turns color when poo with blood gets smeared on it, even if the blood is not visible to the naked eye), and the strip never changes color."

"The strip should change color," I said, "so either the strip is defective or it's not really blood."

"Right, but what is it?"

"Meckel's?" I said.

"No. Then we asked the boy to pee in a cup. Why?"

"To check for hematuria or proteinuria?"

"No, even simpler."

"To see if his pee is red too?"

"Yes! Because eating too many beets can color your poop and your pee."

"Was it red?" I asked.

"No, his urine was not red."

"GI bleed?" I said, "he doesn't seem to be in distress. He's too young for colon cancer, diverticulitis, or ulcers.

"No. Give up?" Mike asked.


"So the resident is totally clueless. We talk to the attending, and the attending laughs. He says that a couple years ago, when RED HOT CHEETOS hit the market, there was a huge outbreak of kids with bright red poo. And this was the case."

Friday, August 08, 2008

"that's all i can do"

Mr. D suffered from the lung disease that killed Evel Knievel -- idiopathic pulmonary fibrosis (IPF). The word "idiopathic" in medicine is a code word that means "doctors have no clue what the cause of the disease can be." As a result, Mr. D couldn't breathe anymore -- his lungs were like a pair of old dishwashing sponges left in the sun to dry. Needless to say, there wasn't much oxygen exchange happening. So Mr. D got a lung transplant -- just one lung because organs are in short supply and that's actually sufficient for someone to live. When you have a new organ, you have to take lots of drugs to keep your immune system down so that it doesn't reject the new heart/lung/kidney, but that also renders you susceptible to millions of germs and bacteria that would otherwise be harmless. So Mr. D came down with a fungal infection -- Aspergillus -- and a bacterial infection -- Pseudomonas.

When Mr. D came to the hospital for a short procedure, he seemed okay. It was interesting listening to his lungs, because his right lung (the "native" one with IPF), sounded like tissue paper crackling. His left lung had normal breath sounds. It was listening to two different lungs in one person. I was immediately struck by how equanimous Mr. D was, especially when I asked him if it was okay for a group of medical students to come by and listen to his interesting physical exam. He was a quiet, scholarly guy in his 50s with graying hair -- the type of patient with glasses and a copy of the New York Times on his bed.

After I switched services, Mr. D was ready to go home when something nearly catastrophic happened. He developed a massive bleed into the space behind his back -- his retroperitoneal space. The bleed was idiopathic. Mr. D landed in the ICU and suffered from acute renal failure --- his kidneys were in trouble.

A few days ago, I saw Mr. D while walking through the ICU and dropped by to say hello. Mr. D looked pale and sick, his head was tilted to one side, but he was still conversant. I nervously eyed a length of tubing filled with blood emerging from his body -- he was on CVVH, which filters the blood and helps out by mimicking the kidney. The doctors were thinking that he might need to go on dialysis for the rest of his life.

"Hang in there, Mr. D," I chirped.

He looked at me with tired eyes filled with weary, stubborn resignation.

"That's all I can do," he said softly.

satire on intellectual pretension

NYT yesterday, the most amusing, hilarious, mockingly pseudo-intellectual satire that I've read in a while. There are some valid points...have we become a society that values the aggregator over the creator? Is the mode of information delivery more important or prestigious than the information itself?

Lord of the Memes

Published: August 7, 2008

Dear Dr. Kierkegaard,

All my life I’ve been a successful pseudo-intellectual, sprinkling quotations from Kafka, Epictetus and Derrida into my conversations, impressing dates and making my friends feel mentally inferior. But over the last few years, it’s stopped working. People just look at me blankly. My artificially inflated self-esteem is on the wane. What happened?

Existential in Exeter

Dear Existential,

It pains me to see so many people being pseudo-intellectual in the wrong way. It desecrates the memory of the great poseurs of the past. And it is all the more frustrating because your error is so simple and yet so fundamental.

You have failed to keep pace with the current code of intellectual one-upsmanship. You have failed to appreciate that over the past few years, there has been a tectonic shift in the basis of good taste.

You must remember that there have been three epochs of intellectual affectation. The first, lasting from approximately 1400 to 1965, was the great age of snobbery. Cultural artifacts existed in a hierarchy, with opera and fine art at the top, and stripping at the bottom. The social climbing pseud merely had to familiarize himself with the forms at the top of the hierarchy and febrile acolytes would perch at his feet.

In 1960, for example, he merely had to follow the code of high modernism. He would master some impenetrably difficult work of art from T.S. Eliot or Ezra Pound and then brood contemplatively at parties about Lionel Trilling’s misinterpretation of it. A successful date might consist of going to a reading of “The Waste Land,” contemplating the hollowness of the human condition and then going home to drink Russian vodka and suck on the gas pipe.

This code died sometime in the late 1960s and was replaced by the code of the Higher Eclectica. The old hierarchy of the arts was dismissed as hopelessly reactionary. Instead, any cultural artifact produced by a member of a colonially oppressed out-group was deemed artistically and intellectually superior.

During this period, status rewards went to the ostentatious cultural omnivores — those who could publicly savor an infinite range of historically hegemonized cultural products. It was necessary to have a record collection that contained “a little bit of everything” (except heavy metal): bluegrass, rap, world music, salsa and Gregorian chant. It was useful to decorate one’s living room with African or Thai religious totems — any religion so long as it was one you could not conceivably believe in.

But on or about June 29, 2007, human character changed. That, of course, was the release date of the first iPhone.

On that date, media displaced culture. As commenters on The American Scene blog have pointed out, the means of transmission replaced the content of culture as the center of historical excitement and as the marker of social status.

Now the global thought-leader is defined less by what culture he enjoys than by the smartphone, social bookmarking site, social network and e-mail provider he uses to store and transmit it. (In this era, MySpace is the new leisure suit and an AOL e-mail address is a scarlet letter of techno-shame.)

Today, Kindle can change the world, but nobody expects much from a mere novel. The brain overshadows the mind. Design overshadows art.

This transition has produced some new status rules. In the first place, prestige has shifted from the producer of art to the aggregator and the appraiser. Inventors, artists and writers come and go, but buzz is forever. Maximum status goes to the Gladwellian heroes who occupy the convergence points of the Internet infosystem — Web sites like Pitchfork for music, Gizmodo for gadgets, Bookforum for ideas, etc.

These tastemakers surf the obscure niches of the culture market bringing back fashion-forward nuggets of coolness for their throngs of grateful disciples.

Second, in order to cement your status in the cultural elite, you want to be already sick of everything no one else has even heard of.

When you first come across some obscure cultural artifact — an unknown indie band, organic skate sneakers or wireless headphones from Finland — you will want to erupt with ecstatic enthusiasm. This will highlight the importance of your cultural discovery, the fineness of your discerning taste, and your early adopter insiderness for having found it before anyone else.
Then, a few weeks later, after the object is slightly better known, you will dismiss all the hype with a gesture of putrid disgust. This will demonstrate your lofty superiority to the sluggish masses. It will show how far ahead of the crowd you are and how distantly you have already ventured into the future.

If you can do this, becoming not only an early adopter, but an early discarder, you will realize greater status rewards than you ever imagined. Remember, cultural epochs come and go, but one-upsmanship is forever.

Monday, August 04, 2008

Heart Attack? Do This Now.

Working on the cardiology service, here is my public service announcement on heart attacks adapted from,,20188758,00.html

"If you are having chest pain and you do not have nitroglycerin:
1) Call 911 or other emergency services now. Describe your symptoms, and say that you could be having a heart attack.
2) Stay on the phone. The emergency operator will tell you what to do.
3) After you call for help, chew one regular-strength uncoated aspirin. Aspirin helps keep blood from clotting, so it may help you survive a heart attack.

The best choice is to go to the hospital in an ambulance. The paramedics can begin lifesaving treatments even before you arrive at the hospital. If you cannot reach emergency services, have someone drive you to the hospital right away. Do not drive yourself unless you have absolutely no other choice."

Sunday, August 03, 2008


from BIDMC CEO Paul Levy's blog
Boston's Fenway Park on a bedroom mural! Can I get one for my future kid?? This mural is so awesome! You could get little sox player dolls and stick them on the bases -- too bad the Manny doll was lost. At least he went to my hometown Dodgers...