Author: MarkH

Trauma

I’ve almost come to the end of the core 8 weeks of my surgery rotation (4 more weeks follow in electives) and am currently working on the trauma service for another couple days before taking exams.

I don’t have a great deal to say, the hours stay long, the medicine remains interesting etc. I’m enjoying the decrease in laundry that wearing scrubs entails. I enjoy how much doctors tend to take joy in their work. Medicine is a great field that way, as it gives you a feeling of accomplishment as you see what you do day to day really can make a big difference in people’s lives. The debt may be overwhelming, the paperwork endless, and the insurance companies/health policy maddening, but you can see that the satisfaction from the practice of medicine gets them through all the hassles. I’m also amused by the tendency of my attendings to turn to me and say, “don’t blog about this” before saying something funny. Don’t worry guys, I won’t. I’ll just save it for my tell-all book.*

Trauma is an incredible field, and while I won’t comment on the workload (everyone on the trauma ward is a little superstitious – one never comments on things being slow or fast for fear things will become busy, or worse, crushingly busy) it has been an interesting couple of weeks. In particular, one of the attendings uses a unique teaching technique that I’ll write about later this week (with permission) using simulations that we refer to as War Games. I found it all very interesting and helpful so with luck we’ll have a video of me participating in one of these sessions by the end of the week. I’ll write a post on it then, as I hope it can be implemented more widely in medical education.

I’d also like to take this opportunity to ask a couple of favors.

One, I’d very much like people to stop shooting one another. It’s really terrible what bullets do to a body.

Two, it also might help if you all could wear helmets. If I thought you could avoid hitting your head that would be one thing, but the least you can do is take some precautions. Wear them a lot – riding bikes, motorcycles, skiing, etc. In fact, just wear them all the time. Sitting at your desk? Wear a helmet. Walking in the park? Wear a helmet. We’re going to start a new style right here and now. We’ll call it the “I’m either about to get on a bike or am prone to seizures” look.

It would make me feel better. Really.

* Kidding, kidding.

February 26, 2008
Science-based medicine – The good and the bad on a good new blog

I must say I’ve loved much of the writing at the new blog Science-Based Medicine. These guys are fighting the good fight and presenting very sophisticated aspects of evaluating the medical literature in a very accessible way. In particular I’d like to point out David Gorski’s critique of NCCAM and the directly-relevant articles from Kimball Atwood on the importance of prior probability in evaluating medical research. I mention these as a pair because lately I’ve really become highly attuned to this issue due to the research of John Ioannidis which is critical for understanding which evidence in the literature is high-quality and likely to be true. Atwood rightly points out that pre-study odds, or prior probability is critical for understanding how the literature gets contaminated with nonsense. Stated simply, the emphasis on statistical significance in evidence based medicine is unfortunate because statistical significance is ultimately an inadequate measure of the likelihood of a result being true.

The scenario goes like this. You have an test, let’s say, the efficacy of magnets in increasing circulation in rats. Because magnets are believed to have some health benefit according to some snake oil salesmen, you and 99 other researchers decide to put this to the test in your rat-based assay. Based on chance alone, as many as 5% of you may get a statistically significant result in your studies that appeared real simply due to chance. 95 of you will then say, “oh well, nuts to this” and shove the data in the file drawer to be forgotten. The other 5% may then say, “wow, look at that” and go ahead and try to publish your results. This is what is known as the file-drawer effect. Positive results get published, negative results do not, thus false positive results, especially ones with big effects will often sneak into the literature. Luckily science has a self-correcting mechanism that requires replication, but since we don’t delete the initial studies, they will always be there for the cranks to access and wave about.

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February 25, 2008
Some Generalizations

One of the few advantages of having no time is that when I do get around to sorting through my RSS feeds of various denialists is that I end up seeing patterns I didn’t observe as much when I tracked these jokers day-to-day. So, inspired by BPSDB I decided I’m going to share some generalizations.

For one, I feel rewarded by my previous study of denialists and cranks. Given that I have no time to deal with the incredible mass of BS that they generate daily, looking through their output I don’t feel particularly inspired to challenge anything in particular they have to say. After all, it’s just the same old nonsense every single day. One of the obvious generalizations you come to looking at a few weeks output of the DI, or a typical global-warming denialist is that one of the critical differences between a denialist and a real scientific site is that real scientists are interested in a synthesis or cohesive understanding of the world. Scientists are interested in making all the pieces fit, and if there is a new or challenging piece of information they are interested in finding a way to include it in an existing framework of knowledge. As we discussed in the Crank HOWTO and Unified Theory of the Crank almost a year ago, the denialist is quite different. All you see out of them is a haphazard assortment of ideas, and the only unifying theme is that, at least to them, it all contradicts scientific theories they are unwilling to accept.

It may be hard to explain but my current approach to my RSS feed is quite different than it used to be. I think that we’ve been successful in communicating to the blogosphere the importance of standards in writing about and critically understanding science. When I see many of the other sciencebloggers (both inside and outside of the sb network) writing about pseudoscience they’ve adopted much of our language because I think they implicitly understand the divide between those who are interested in honest debate and the scientific method and those who strive only to challenge that which they fear or misunderstand.

I think it’s a subtle point, and something you only see when you see the work of a group in aggregate, but it’s one of the more powerful indicators of whether someone is an honest actor interested in the truth and the scientific method. When you look at their output over time, is it just a haphazard set of attacks on that which they dislike, or is it an enthusiasm for exploration and accumulation of knowledge with an emphasis on making the world fit together in a logical and consistent way?

It also demonstrates a critical flaw in the way that scientific news is reported, because many of the science aggregators and mainstream news organizations fail according to this standard. If the motivation behind publication is only to generate buzz or readership the result is a haphazard set of reports on whatever is hot and new, and not necessarily a reflection of the literature as a whole, a common theme we complain about here on scienceblogs. Good science has to age a little bit, and every new result, with some exceptions, shouldn’t hit the lay press without qualification because all that generates is confusion and resentment among the population. Science is not nearly so fickle as a the mainstream reporting of it would have you believe.

Maybe my attitude will change when I have more time to write. I think in about 2 more weeks I will be able to write a little bit more regularly and bring the pain on these denialist jackasses. However, in the meantime, I’m enjoying being able to just zip through my RSS feed, spotting the tactics, and just moving on…

February 18, 2008
Skeptics' Circle #80 up at Bug Girl's Blog

I’m late to the party sorry, but this week’s circle is up at Bug Girl’s Blog. Check it out. She’s one of my favorite bloggers and she’s done a great job with her Valentine’s day edition.

In particular I will point out Greta Christina’s review of “Mistakes Were Made (but not by me)”, and the new (to me) blog BPSDB (like BPR3 but with this snazzy new icon).

My brother Chris would also like Andrea Buzzing about Scientology’s claims about psychiatry.

February 17, 2008
Edyth London targeted again by animal rights terrorists

I’m very upset to see that following up on previous threats, animal rights terrorists have set fire to a scientist’s house.

I’ve been saying for a while that the real threat towards biological science isn’t the evolution denialists and other silly cranks’ rather laughable attempts at trying to convince people the earth is 6000 years old.The real threat is what we’ve seen in England and other countries of extremist violence against scientists for using animals in research. These actions are often justified based upon the absurd premise that research can be performed without the use of animals.

Let’s be clear, biological science and medicine are dependent on animals and animal products. From basic research to implantation of heart valves, the success of medicine and medical research is dependent on the use of animals and biological materials. While one can disagree with the ethics of using animals for research, one can not deny, without being dishonest, the absolute requirement of animals for the advancement of biological science, and for current therapeutic modalities used every day in medicine. And I think we can all agree that setting fire to Edyth London’s house has more than met the definition of domestic terrorism on the part of the animal rights extremists.

It’s fine if you think it’s immoral to use animals for medical research, I’m not upset by this. But realize that if ALF and PETA have their way there will be no biological research. It is not possible without animals, and if they’re going to be honest about their objectives they have to make it clear to their supporters that the agenda of animal liberationists (note not animal welfare) includes the cessation of progress in biomedical science. Further the groups behind this action have made it clear that they believe scientists may be killed to save animal lives.

Where do you stand? Should it be acceptable to terrorize people like London for using animals in research? Do you agree with Vlasak that people like me should be killed to save animals’ lives? Or are we going to be realistic about the role of animals in research and honestly explain to people that the ultimate objective of these terrorists will be the elimination of progress in multiple fields of research? If they still agree with these extremists based upon that information that’s one thing, but I don’t think that most people realize how extreme the objectives of animal liberationists really are.

February 11, 2008
Science Debate 2008

Having been busy and a bit out of the loop for the past month, I think it’s time I stop and point out what a great job Chris Mooney and other have done in generating a real movement behind making this happen. In particular note the supportive essay from the Editor-in-Chief of Science and the addition of the AAAS to the list of supporters that we’ve seen in the last week.

This is a gratifying turn of events because it shows me a few things. For one, I think it shows blogs like the Scienceblogs can make a huge difference in the real world. Second it shows that enough people care about science to make it a priority in this election.

So often in the last decade the reins of power have been in the hands of rank ideologues or outright denialists who reject science, rationality, and reason, and the results have been disastrous. The reason I have supported this effort from the start is that I believe that whatever the implementation of such a debate, the real victory is making people who value science a constituency that must be courted and respected. It’s about acknowledging the importance of science not just as a critical part of our country’s R&D and infrastructure, but as an enterprise that can inform and improve all aspects of government.

So, a big salute to Chris and the others for all their hard work. I’m impressed, and wish time had allowed me to do more (I’m still doing what I can).

February 4, 2008
A month into surgery – back to the books

I’ve just completed my first month of my surgical rotation and still find almost every day fascinating. I just finished a 4-week rotation in the hepatobiliary service (liver, biliary and pancreatic surgeries mostly) and now go on to thoracic for 2 weeks, and then trauma for 2 weeks to complete the core requirement. I’ll also be doing orthopedic trauma and neurosurgical rotations before I’m done in March and I’ll be sure to write about those as well.

Friday night we had the medical student pimp-off AKA surgical jeopardy. For the uninitiated, pimping refers to the practice of quizzing students on the wards to make sure they’ve been studying (or occasionally to show off one’s own knowledge of medical minutia). For surgical Jeopardy/the pimpoff the residents get all the medstudents on the general service rotations together and quiz them Jeopardy-style. It was a lot of fun, one team even had t-shirts made, everybody was getting pretty into it. I even won a book! Although I’m afraid the smack talk may have gotten out of hand. Oh well.

And speaking of books, I’ve just got to write about what it’s like constantly having your nose in one. Above is the ICU Book I won Friday, as well as the Essentials of General Surgery textbook which is more or less required reading for the rotation. Then there is Surgical Recall (my cat is investigating), a book born right here at UVA which consists of several thousands of questions and their answers. It’s kind of a survival guide for the rotation since the questions are the kinds of things you’re likely to be pimped on. Like, what is the gastrinoma triangle?

Books for me have almost become a form of self-medication. When you start medical school, often fresh out of college, you quickly are overwhelmed by the sheer volume of information you must assimilate. These are the basic science years and in a way the first year is the most difficult. It’s a little bit like trying to drink water out of a fire hydrant. The material isn’t even necessarily challenging, but the sheer overload of information becomes overwhelming.

Somewhere in the middle of second year though you wake up and realize you’ve adapted to the information flow and suddenly you can rapidly absorb absolutely huge amounts of knowledge. You’re all proud of yourself. It’s great, and studying doesn’t seem to be as much of a chore.

Now I’m in third year and it’s back to drinking out of the hydrant again. Not only is the sheer amount of material for any given rotation overwhelming, but in addition you’re learning to apply it practically – a very different beast – while trying learn about managing real patients. I think it’s something people seldom appreciate about medicine is just how immense it is, and every field within it you could devote an entire life of study to. For example, wandering around the library looking for the textbooks to prepare for my next rotation I found these two hefty fellas:

These are huge volumes, with very dense material. Each subspecialty is daunting. Say you want to study plastic surgery?

Or, God-forbid, opthalmology?

See what I mean? You really get the feelings as you go along the best you can do is dent the surface, and you really appreciate why specialization has become so extensive. Each of these multivolume books contains hundreds of chapters dealing with specific diseases and descriptions of medical therapy or surgical techniques. Each chapter represents the work of an expert in that field who essentially writes a review of the scientific literature and current practice applied to a single problem or family of disorders. And on top of that, since texts are constantly going out of date, they are just the starting point. You must always keep up with the current literature on any given problem as you are treating your patients.

The amount of information you don’t know becomes overwhelming. Although these days studying is oddly no longer a chore, but one of the few ways I can decrease my anxiety. You see day to day how critical thorough knowledge of medicine is. And when I get nervous about how little I know I compulsively go out buy a book. It’s an expensive habit, but it seems to be the only thing that decreases the stress of having such inadequate knowledge. Hence I’ve become the Amy Winehouse of textbook purchasing.

Then there is the most frightening thing of all – the realization that the feeling you don’t know enough will probably never go away.

February 4, 2008
Don't fall asleep during the Sarah Connor Chronicles

For the benefit of Teresa and her son, here’s a description of a day in the life. This may not be all medstudents on the surgical rotation, but at the moment it’s what I’m doing.

I wake up around 4AM, put on scrubs (usually, but on clinic day you dress nice), and go to work. I spend about an hour going over labs, checking vitals from overnight, in and outs as they say, and visiting with patients to ask them how their night was as well as performing a brief physical exam. I then round with my team for about half an hour, and for the patients I track, I try to present them to the residents without making a total hash of it. A historical note, several medical terms come from Johns Hopkins, including “rounding” and “residents”. Rounds came from the fact that their hospital was circular, so you literally did a round of each floor when you visited each patient. Resident came from the fact that the doctors-in-training were worked so hard they lived in the hospital during this period. Hooray for the new hours rules.

6AM – morning report, a hand-off from the night shift of the cases from the last evening. Usually a great learning experience as the residents’ presentation is an opportunity to see how experienced docs present cases, patient histories, and make diagnoses.

7AM – class, a clinician visits the medstudents and gives us a lecture on something they know a lot about. This is often my favorite part of the day since the professor teaching is usually describing their job, and since they tend to love their jobs, they love teaching us about their jobs. Also you can eat breakfast.

8AM – unless it’s a clinic day, you head to the OR for cases. You observe, help in any way you can, and see what surgery is all about.

3-7PM – usually I’ve been out by 7 at the latest, but it’s hard at first staying on your feet for so long. After about 10 days you’re acclimated though and don’t mind anymore. You find your team, see your patients again, prepare for the next day’s cases and then usually go home unless you’re on call. Any time you have to spare you read.

You can try to study when you get home but more often then not I just fall asleep immediately. I tried watching the Sarah Connor Chronicles this week. It was an error. I fell asleep during the first 15 minutes then had nightmares all night that I would never amount to anything because no one has bothered to send a robot back in time to kill me. How’s that for low self esteem?

January 28, 2008
Surgeons have cool tools

Surely no one can be pissed at me for pointing out that surgeons have some of the coolest tools, so I think I’ll describe a few of them that I’ve seen used a great deal in general surgery.

The one most frequently in use is referred to simply as “the Bovie” and it is used for electrocautery. Named for William Bovie it was first used by the famous surgeon Harvey Williams Cushing almost a century ago. The patient in the OR is laying on a large conductive pad that grounds them, and the Bovie device, which resembles a little plastic pencil with a flat, rounded metal tip, generates an electrical current which is transmitted directly to tissues to cut like a scalpel.

I can’t find a nice video of one in action, but it really is an interesting little device. By generating an alternating current at the tip it rapidly generates a great deal of heat in a very tightly-controlled location. Further, because you aren’t grounded, you can use it in close proximity to your fingers, or touch it to metallic surgical instruments to transmit the current to through the instrument to tissues without burning yourself. The effect of the device is dramatic. On one setting, the cut, a continuous waveform is generated that allows you to cut through tissue like a scalpel. The second setting, coagulation, turns the current on and off rapidly for a slower heat which coagulates while it cuts. The advantage of a Bovie over a scalpel is that a cut can be made that is clean and doesn’t bleed excessively thus maintaining hemostasis. One can also grasp a small vessel with a hemostat (or clamp) and touch the Bovie to the hemostat to rapidly coagulate the vessel to prevent bleeding.

More below…

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January 25, 2008
Only in California

Weed via vending machine.

No I’m not kidding.

January 24, 2008