I know that for the most part, if you read QDN, I’m the proverbial preacher and you’re part of the choir, but I figure I have to point out to those who peeking in the windows that the official Republican Party platform now calls for a ban on all embryonic stem cell research, public or private, derived from existing cell lines or not. This goes even further than Bush’s 2001 law that allows research on embryonic stem cells that weren’t created expressly for the purpose of research (e.g., unwanted IVF clinic embryos that are going to be discarded), and turns its back on an amazing amount of promise. It’s quite a stunning change; the scientist and cancer researcher in me is aghast that this alone might still not be enough to drive folks from the arms of the GOP in droves.

(As a related sidenote, how does this principled stand on the part of the GOP not mean that the party should also be strongly and firmly against in-vitro fertilization? The process generally involves creating more than one embryo, and likewise generally does not involve transferring all of them, meaning that there are left-over embryos that are put into liquid nitrogen tanks and saved. After some amount of time, a significant number of these remaining embryos never get used, and end up being discarded by the families and IVF clinics — how is this somehow better than doing research on their stem cells?)

Anytime an article contains the phrase “These are sweeping generalizations that are intended to provoke a heated debate, so try not to get too offended”, you can be sure that it’s a total piece of crap penned by an intellectually-dishonest author who’s too lazy to put a sufficient amount of coherent thought or reason into his article. Given that truism, Aaron Rowe’s “Top 5 Reasons to Dislike Pre-Med Students” doesn’t disappoint, and in fact, might delight those who discover that it’s an even more steaming pile of crap than you’d have guessed from its title!

Bill Simmons, ESPN’s Sports Guy and possibly the biggest Boston sports homer in the world, found himself at this year’s Super Bowl without his lucky Wes Welker jersey. He grabbed a Randy Moss jersey from the vendors inside the stadium, put it on, and proceeded to watch the Pats get stunningly upset by the Giants; after that, he went home, threw the jersey away, but then thought twice about it and decided to auction the jersey off for charity. So now, you can head over to eBay and bid, with all proceeds (literally, 100%) going to the Jimmy Fund! Having worked at the Jimmy Fund clinic for three years, I can dig the sentiment, and hope that the eventual winner of the auction follows through with the donation — I like how Simmons put it in the auction listing:

Note: A warning to anyone thinking of bidding this auction up without any intention of paying the final fee: This is for charity, we’re raising money for cancer research, and you would be guaranteeing yourself a lifetime of bad karma if you ruined this auction in any way. Go on the Jimmy Fund’s website, read about the kids they’re trying to help, and tell me how it would possibly be a good thing to sabotage this auction. Hopefully, we can raise some money for cancer research and reverse the bad karma that this jersey has wrought on the Patriots franchise. Once you get the jersey, I don’t care what you do with it - you can wear it, you can burn it, you can bury it in your backyard. I don’t care. I never want to see it again.

So, ummm… yeah, things have been a little quieter than normal around here, for a bunch of reasons.

First, I spent four straight weeks as the attending on the peds oncology service at work (rather than the customary two-week blocks we do), and while I thought that it’d be minimally harder to do, it ended up draining me quite a bit more than that. Between four straight weeks of earlier-than-normal mornings, later-than-normal evenings, weekend mornings at the hospital, and an unconscious fear of the pager going off, I found myself with a bit less time and energy to put into all the normal side stuff I do, meaning less time for blogging.

Second, even without the added clinical responsibilities at the hospital, my “regular” work (building bioinformatic systems for clinical research) has exploded a bit over the past two or three months. That’s awesome — I love what I do — but again, it means that I’m spending more time in meetings (and preparing for meetings), more time building specs and debugging apps, and more time on long-term strategy planning.. which again, means less time blogging.

And finally, Shannon and I have had a lot on our plate at home, what with a new project we’re working on. (For those of you who aren’t so much into knitting, scroll down on her post to see what I’m talking about.) Things are going well, but just like everything else, it all adds up to less time to just sit, chill, surf, and post! Pathetic of me, I know, and I hope to recover a bit now that my clinical responsibilities have diminished, I’ll be able to devote my full attention to my research, and things at home are in a groove of sorts…

(Of course, come mid-March, I make no promises!)

Wow — turns out that the D.C. drinking water probably isn’t all that safe. Looking at the actual Environmental Working Group report that triggered the Post story, the only solace we can take here on Capitol Hill is that the two places tested that are closest to us had “acceptable” levels of contaminants and chlorine in the water. In any event, it seemed like a no-brainer to order up a Brita filtering pitcher; the only downside is that we’ll have to keep up with replacing the filters, but I figure that’s an incredibly small price to pay for safe drinking water.

Apparently, there’s a pretty critical blood shortage throughout the Washington DC metropolitan region right now — according to this article, there are around 50 units of type O blood in stock from Virginia to Pennsylvania as of this past weekend. If you are able, you might want to think about taking some time to donate blood over the next few days — both the Red Cross and INOVA have information about donor centers in the area. (The Red Cross also has a good list of restrictions on donating blood, which you might want to peruse before making the trip!)

What a shocker — Richard Carmona, the Surgeon General from 2002 through 2006, now acknowledges that the Bush Administration continually muzzled him on issues like stem cell research and contraception. In Carmona’s words:

The problem with this approach is that in public health, as in a democracy, there is nothing worse than ignoring science, or marginalizing the voice of science for reasons driven by changing political winds. The job of surgeon general is to be the doctor of the nation, not the doctor of a political party.

I couldn’t have said it better myself.

Tonight brings a few short takes, since I’ve had a few tabs open in my browser for days now waiting for a chance to get ‘em posted.

  • The New York Times published an incredible article last week about the ways the Karitiana Indians feel they have been misled and abused by various medical research teams who have visited the tribe and made promises in return for participation in research. The Karitiana are a tribe from western Brazil and have historically remained relatively isolated and close-knit, and both in the 1970s and 1990s, both these traits led American medical teams to ask for blood in order to study how disease penetrates through generations of families, promising access to modern medicines and care in return. The tribe never received the promised returns on their participation, though, and recently learned that the collected blood and DNA are now being sold by private companies in the United States and France. Needless to say, they’re not pleased.
  • It seems that DirecTV is about to introduce a sorely-needed feature to their high-def DVRs — autocorrection after fast-forwarding, similar to what TiVos have had pretty much forever. This is, bar none, the biggest annoyance of using the HR20 DVR after having had a TiVo for the last seven years, so I’m certainly thrilled that the feature looks to be coming soon! (I’m also excited about next week’s scheduled launch of the DirecTV-10 satellite, which promises to bring a slew of new HD programming to DirecTV users as soon as they’re able to put it through it’s paces in orbit.)
  • A study was published in this month’s Archives of Internal Medicine looking at the effect of doctors talking about themselves during patient visits, and as I’ve come to expect, most of the news coverage misses the nuance and makes sweeping and indefensible conclusions. The study used fake patients and judged their subjective reactions to physicians talking about themselves during first visits; unsurprisingly, most of the “patients” didn’t feel that the physician’s personal chitchat added much value to that visit. Reuters more or less blew off the “first-time patient” detail in its coverage, implying that there wasn’t really ever a place for that kind of doctor-patient conversation during visits, but the study doesn’t say that, and my personal experience is that with longer-term, established patients who might see you once (or more!) a week, there’s certainly a place for occasional personal comments or observations, all of which can help keep the therapeutic team (doctor, patient, nurse, psychosocial providers, etc.) intact and functioning at its best.
  • Finally, I’m really getting excited about Movable Type 4, which is now in beta — damn, are there some great features lurking in there! If I didn’t have such a complicated setup, I’d migrate over this very second. As it is, though, I probably have an hour or two of work ahead of me before I can get my site into MT4 exactly as I want it to be, so I’ll probably wait a week or two, when I can carve a chunk of time out to make the move. I can’t wait!

There’s an interesting journal article in this week’s New England Journal of Medicine that reports the results of a recent survey of over 1,600 physicians in six different practice areas, results which found that 94% of the physicians reported some type of a relationship with the pharmaceutical industry. That’s a pretty shockingly high number; even when you look at the numbers for specific relationships, 78% of doctors report receiving free drug samples, and over a third report accepting reimbursement for academic meeting expenses. (On the flip side, merely meeting with a pharm rep is considered to be a “relationship” by the survey, something I feel pretty secure saying is as likely to be totally innocuous as it is to be suspect in nature.)

I consider myself pretty fortunate to be in what appears to be the very small minority of this survey — I trained in a residency which banned pharm reps from having any contact with the residents and in a fellowship which had a similar restriction, and I now work for an entity which has the same proscription in place across the entire organization (as well as a very strict ethics process which even requires me to divest myself of any stock holdings in any part of the health care industry). I can probably count on one hand the few things in my life that came from pharm money — and thinking it through, they were all provided by unrestricted educational grants that were given to national societies like the American Society of Hematology rather than as directed contributions to me or my program.

All that being said, it bears stressing that the NEJM article makes no conclusions about the outcome of the relationships; for example, while there are clearly some doctors whose prescribing practices are altered by the availability of pharm perks, there are others who use free samples (like vaccines) because it’s the only way their patients can afford any kind of treatment whatsoever, and that’s the kind of relationship that some would say might have a positive effect on at least a certain segment of healthcare. I fully expect that these survey results are going to make waves in the press in the coming days, but I also expect that most press coverage will do a piss poor job of making this distinction clear. (I also would love to see the same survey done of a few other industries, making the appropriate substitutions — like of elected Federal officials and the groups they regulate, or of financial services reps and the financial sectors they cover.)

Chains of affection

I’m not sure how I missed this when it came out, but two years ago, Peter Bearman (go Columbia!) and colleagues used extremely detailed data gathered as part of the Adolescent Health Project to map the romantic and sexual network of 832 of the 1,000 students at a large high school somewhere in the Midwest. The results of their research is the American Journal of Sociology article “Chains of Affection” (the full PDF of the article available here, from the home page of one of the other sociologists who was involved in the study), and it’s a hell of an interesting read. The relationship map was put together with the dual intents of getting a better sense of the disease transmission risks faced by high school students and of figuring out optimal strategies for implementing social policy changes, and there are a few things that came out of the study that are pretty amazing to me.

The most noticeable part of the map is that there is a huge, interconnected network containing more than half of the romantically-involved students in the school — all in all, there are 288 students who share common links in their relationships. Within this subgroup, students were separated by as many as 37 steps, and while some members of the subgroup only had one other partner, others had as many as nine. (Fascinating to me is that the 37-degree separation actually forms a completely circular core of this network — you can start with any of the 37 students, start tracking that individual’s relationships, and end up coming right back to that same individual.)

While those 288 students all formed a large, branching relationship network, 126 others formed 63 separate monogamous relationships, and 63 students formed 21 three-person networks. That’s interesting in and of itself, since it reflects nearly 200 students who were relatively isolated from sexual risks. There were also only two same-sex relationships identified in the network (one within the large network, and one within a much smaller grouping of relationships); that number is small enough to make me at least wonder whether the researchers identified every single relationship in the school. Due to the design of the study’s data-gathering methods, students weren’t asked about relationships that they had with non-students, so that’s probably another place where there are a couple unknown links in the network.

All in all, Bearman and his study group put together a pretty amazing look at the sexuality of students in an average high school, and effectively drive home the real risks that parents, educators, and public health officials need to acknowledge.

Holy crap — Dianne Odell, a 60 year old woman in Tennessee, contracted polio at the age of three and has spent the last 57 years living inside an iron lung. I had no idea any iron lungs were still in use, but according to that article, there are 30 to 40 of them still delivering breaths to people in the United States. Minnesotan Marilyn Rogers has spent nearly the same amount of time dependent on her iron lung, as has Dolores Thompson in California, both of which, like Odell, have tried more modern ventilators and been unable to tolerate the switch. Unfortunately, the only company which was able to repair iron lungs discontinued its service guarantees in the middle of 2004, leaving all these people on pretty thin ice.

I’m not sure there’s any stronger an argument for the importance of the polio vaccine than this whole story — polio is a nasty disease, and its eradication is one of the true miracles of 20th century medicine.

Scott LaFee wrote up a great little history of the petri dish in the San Diego Union-Tribune — it’s a fascinating piece about a piece of scientific equipment that’s so important and pervasive that pretty much every lay person out there knows its name and function. And in addition to the simple dish’s role driving science forward a million different times a day, it’s also been the palette for some pretty cool art, some mathematical theories about fractal development, and even the appearance of a major diety; there are literally a million derivatives of the petri dish, from three-dimensional ones to ones that fit on the head of a pin. Very cool indeed, especially given that it’s an invention by a scientist whose career was otherwise unremarkable.

(One note: while doing a few searches to write this post, I stumbled across this Flickr posting of a petri dish, and immediately recognized it as stolen from this scientist’s online gallery of his own petri dishes. The part of it that I find the most galling is that the Flickr user, Jack Mottram, assigned a Creative Commons license to the photo that demands that others attribute any reuse of the image back to him, as if he has any rights to the photo to begin with. That’s severely broken.) Update: he appears to have added a credit for the photo and removed the CC license… but I’d argue that it’s still not kosher to have the image in his Flickr photostream at all.

Seriously, how much do you have to hate having a medical license to take a call from someone having 105-degree fevers and hallucinations, offer up a diagnosis, and prescribe medicine all without asking the person to come in to be examined? What if the dude had meningitis? What if he was septic? How would you defend your choice to just prescribe and forget?

Lately, a little bit of press has been given to people who claim to be sensitive to wireless network or cellphone signals, some of whom have convinced school systems to remove wireless networking from entire buildings in order to protect themselves and their children. This has always been a little fishy to me (I posted about an Oak Park, Illinois debate back in October of 2003); these signals are pretty much omnipresent at this point (for example, microwaves put out quite a bit of energy at the same frequency as WiFi), so getting rid of a single WiFi access point or cellphone isn’t really making that big a dent in the total sum of non-ionizing radiation that surrounds any one person. Well, thankfully, there’s now some science to support that position: the British Medical Journal performed a double-blinded, randomized, placebo-controlled study and found that those who claimed to be sensitive to GSM cellphones were unable to identify the presence or absence of a phone with any reliability. Better still, when individuals with ostensible symptoms of sensitivity were told that the wireless signal had been discontinued, their symptoms improved whether or not a signal had been discontinued. The same study hasn’t been done with WiFi yet, but it’s just a matter of time. (Thanks to Glenn for the pointer.)

Jeff Gates made a good pickup in the DC Metro system, where he noticed an oddity in all the Blue Cross/Blue Shield ads on the train platforms: the pupils of all the people’s eyes in the ads have been Photoshopped to reflect the BC/BS logo. Now that I know what to look for, it seems that the same thing was done to the ad at the top of this page, the info about the new federal vision benefits program; I can’t find similar ads on any other BC/BS websites, so Jeff is probably right that the ads are related to the new vision offerings. It’s a bit freaky, and despite the fact that I go through Metro Center twice a day, I never caught this. Weird!

Am I really the only one who sees the irony in the fact that the company implicated in the bagged spinach E. coli outbreak is named Natural Selection? It feels like the sort of thing that, despite its seriousness, would have caused a bit of chuckling in the land o’ weblogs; in any event, it’s certainly an interesting Darwinian coincidence.

My favorite weblog du jour: Free Floyd Landis. I’m incredibly hopeful that this is yet another example of the interface between bad lab testing and overzealous enforcement of rules that only have the most tangential relationship to actual doping.

Fabulous: researchers reported this month that increasing obesity in America has caused a doubling in the number of radiologic studies that gave limited results. The limitations were most-often seen in ultrasound studies, which depend on a sound wave that has to penetrate through the skin and soft tissue and then bounce back to a detector; other times, the problem was something as simple as patients being unable to fit inside the CT or MRI scanner. The numbers are small — the increase is around a hundredth of a percent per year — but given the fact that we know obesity’s increasing at amazing rates, it’s a sign of the difficulties doctors and patients are going to face over the coming decades. (Nevermind the fact that you know a trend’s probably real when the biomedical marketers jump onto it…)

Just a quick public note to Dan Cederholm (the man behind SimpleBits), his wife Kerry, and his three-month-old Jack to say glad everything went well! Jack just underwent surgery at the fabulous Children’s Hospital Boston to correct two congenital heart defects, and is recovering quickly enough to be out of the intensive care unit. Go Jack!

Congrats to Columbia University, the ol’ triple-alma-mater, for the receipt of a $200 million gift to create a center devoted to the study of the brain. It’s the largest private gift ever for the creation of a single institution, and will be headed by the esteemed threesome of Richard Axel (Nobel Prize in Medicine in 2004), Eric Kandel (Nobel Prize in Medicine in 2000), and Thomas Jessell. I had the fortune of being taught, at various stages of my education and training, by all three men; it’s entirely unsurprising to me that they’d be the ones tapped at leading the effort to better understand the way we think and behave. (And the picture of Eric Kandel that graces his Nobel bio is the perfect representation of him — a happy, old-world guy with a passion for his work!)

Sorry about the complete silence from the Land of Cheese lately — Real Life™ intervened (a dying patient, a push to secure my post-fellowship future, a semi-urgent need to upgrade the lifeblood of the Queso network, and a baffling attempt to understand the world of home financing). Things are slowly returning to normal, though, and I hope to be as chatty as ever soon!

In the mean time, I have to say that one recommendation I got over the past week that’s served me incredibly well is Matt telling me to give reBlog a shot. It’s a website syndication aggregator, built on the codebase of one of my favorite (but increasingly neglected) apps, and it’s just frickin’ amazing. (Matt authored a review, complete with a screencast, over at Lifehacker today.) Because of the aforementioned system upgrade, I actually uncovered a wee little bug in reBlog, but the code was easy enough to read that I banged out a fix for it over the course of a night and I’m now pretty much sold on the app. If you’re in the market for a web-based aggregator, go set up an account on the online demo app and see what you think.

If you want to be a wee bit depressed, head over to the Anderson Cooper 360° weblog at CNN.com, specifically to the comments on Dan Simon’s post about the connections eleven women have made to each other after each underwent artificial insemination with the same donor’s sperm. In that comment thread, you’ll find such gems of wisdom as “these procedures rationalize polygamy,” “it totally ruins the very definition of a family,” “I guess these women have have little common sense or spiritual background,” “God designed marrige [sic] and families for a specific purpose,” and “how despising that humans have come to this” — all from a bunch of readers who can’t even lay claim to knowing how each of the eleven women came to her decision to undergo artificial insemination, but are damned sure that the decision was wrong. A bunch of the comments are enough to highlight what is, in my mind, a pretty big division in this country, a division between those who are willing to accept ways of living life that differ from their own, and those who feel not just that their beliefs are unquestionably correct, but feel the need to impose those beliefs on the rest of their communities.

How predictable — Cheney is going to break his “I-shot-someone-in-the-face-chest-and-heart” silence today by talking to the Fox News crew. Meanwhile, the White House spent most of yesterday either ignoring questions about how the public was informed of the shooting or making jokes about it, and doctors have spent most of today debunking the migrating-birdshot reports (honestly, none of us here at my hospital can quite figure out how a 5-millimeter 2.4-millimeter chunk of metal would be able to travel through blood vessels and end up in the heart without first having to find its way through some 5-micrometer pulmonary capillary). This gets stranger and stranger…

Pretty recently, most big pediatric hospitals began offering patients and their families the ability to set up websites that they can use to stay in touch with their friends and relatives. (The hospitals aren’t insane enough to become webhosts themselves — nearly all of the sites are offered through one of a number of services like CarePages, CaringBridge, or theStatus.) Due to the chronic nature of cancer, a lot of my patients’ families have set up and maintained websites for a while now, and I’ve found that the pages provide me with a completely different perspective on what the kids are going through. They can also be absolutely hysterical; this bit posted by the mother of one of my patients with childhood leukemia had me laughing so hard I was crying. (Of course, I’ve redacted my patient’s name.)

[H] has a new game that she plays, called, “I am Dr. Jason.” I should preface this by telling you that one of her chemo meds, Vincristine, has the lovely side effect of sometimes causing constipation. So before she could get Vincristine at the beginning of her cycle, Dr. Jason would ask if she was having any constipation issues. The conversation usually went like this:

Dr. Jason: Any mouth sores?
Me: Nope.
Dr. Jason: Eating okay?
Me: Yep.
Dr. Jason: Pooping okay?
Me: Yep.

We have had this conversation about a gazillion times since H was diagnosed. But in H’s little world, apparently the only interesting part of this exchange was the part about the poop. So she’s sitting on the couch next to me, being Dr. Jason. She’s got a pad and pen and is carefully recording my answers just as Dr. Jason does.

H: So, Mommy, are you pooping okay?
Me: Uh, yeah?
H: Is [H’s sister] pooping okay?
Me: Yes?
H: Is Daddy pooping okay?
Me: Yes?
H: Is [H’s other sister] pooping okay?
Me: Yes?
H: Is Grandma pooping okay?…

And it goes on… until she’s ascertained that everyone in her life is pooping okay. Makes me wonder what she thinks all those clinic visits were all about anyway. Cancer? What cancer? As long as you’re pooping okay, H!

Now here’s a great story about the positive side of karma: Kevin Stephan, a seventeen year-old young man in Lancaster, NY, saved Penny Brown from choking to death a week and a half ago… nearly seven years after Brown saved Stephan’s life when he suffered a freak cardiac arrest.

Back in 1999, while on the field during a little league game, Stephan was hit in the chest by a bat and went into cardiac arrest. Brown (an intensive care nurse) was in the stands, rushed onto the field to help, and was able to restart his heart with near-immediate CPR. Now, fast-forward to last week, when Brown began choking on her food in a diner in Lancaster. The staff and other patrons called for the help of a volunteer firefighter who was washing dishes in the kitchen — Kevin Stephan. He came out and successfully performed a Heimlich maneuver, repaying the debt. Amazing.

I can’t even begin to describe how angry it makes me that many states are considering sanctioning the idea that health care providers can deny people care based on religious beliefs. Forget about pharmacists who exercise their religion at work and refuse to fill prescriptions for birth control medication; the absolute truth — no exaggeration at all — is that “right of refusal” laws like these could grant a doctor the right to put you on a ventilator even if you have a perfectly valid, legal living will stating your preference otherwise, and could allow everyone from doctors to social workers and pharmacists to completely decline care for gay patients. Hell, they’d even let fundamentalist pediatricians and internists refuse to treat sexually-transmitted diseases in unmarried patients, and Jehovah’s Witness physicians could refuse to give patients blood transfusions.

This crap is the perfect illustration of the idiocy of mixing religion and government. With laws allowing medical providers to enforce their religious beliefs on patients, where do you draw the line? What religious beliefs are acceptably covered by these laws? Who determines if some provider’s religious beliefs are worthy of protection? Ultimately it comes down to this: why are a doctor’s religious beliefs more important than the will of the patient?

It’s been a bit of a busy week; I’m part of the faculty group that’s teaching the second-year medical school hematology course right now, meaning that I’ve been waking up about an hour and a half earlier than normal, teaching for most of the morning, starting all the other work I have to do around noon, and getting home feeling like I’ve been run through the ringer a little bit. That being said, teaching is a lot of fun, and it’s a hell of a reminder of how much I’ve learned since I was in the same class eight years ago back in New York.

Oddly, my respite from the world of medicine this week has been task-guided learning of a new programming language, Java. Towards the end of last week, Matt got the idea of starting up a Jabber server linked to his übersite MetaFilter, and really wanted people to be able to use their MetaFilter usernames and passwords to log into new service. He decided to try out a server that’s coded entirely in Java and has an open, extensible architecture, and asked me what I knew about getting it to talk to his user database. I started looking into the app, and quickly realized that Java is built from the same elements as are most of the other languages I know well, something that went a long way towards putting to rest my fears about delving whole-hog into the guts of the server. A few hours later, I had put together the code that Matt needed, and early this week, I wrote an plug-in from scratch which allows regular users to see a list of all the active users of the server. And while I wrote the first set of tools — the authentication modules — in response to Matt’s need, the goal of getting my feet wet in Java motivated my development of the plug-in as much as did the development of a useful tool for the MetaFilter community. For me, that’s the best way to start to learn a new technology: realize a need, discover that the technology is the best way to fulfill that need, and jump in.

Wow — after decades and decades of hunting, it looks like scientists at Penn State have identified at least one genetic mutation that accounts for the difference between black and white skin color. (Washington Post coverage of the paper is here.) Even at the very scientific medical school I went to, it was an oft-repeated statement that skin color had no genetic basis, but that always struck me as an odd thing to say; what the hell else but genes would account for that fundamental a heritable difference between two groups of people? It’s nice to know that, once again, the gene theory won out in the end!

If you’re curious about just how bad the American health insurance system has become, wander over to Blurbomat and read about Jon, Heather, and Leta being rejected because, you know, they actually have needed health care in the past. Fortunately, there are a lot of great suggestions in the ensuing comment thread about how people like them — and like a whole slew of others — can go about actually getting reasonable insurance.

I stopped off at a local drugstore today to pick up a supply of loratidine (the generic name of Claritin) for Shannon and myself, the allergy duo, and the labels on the shelves reminded me of the power of marketing and brand recognition. All the products had a label below them, on the front edge of the shelf, that had both the price of the product and the unit price; in the case of loratadine, the unit price was the price per 100 pills. And looking at all the different options, between the number of loratadine pills in a bottle (five, 10, 20, etc.) and the various brands (Claritin and Alavert being the two most well-known names, Nuprin and Dimetapp getting in on the mix with their own offering, and the ever-present store brand), the price per 100 pills ranged from $25 (the store brand, 120 tablets for $29.99) to $119.80 (Claritin brand, five tablets for $5.99). Even just looking at what I would pay for a bottle of 30 pills, the unit price ranged from $47 to $77 — making it nearly two-thirds more expensive to buy the brand-name than it is to buy the store-brand. In an age when a ten-percent gas price rise provokes fear that the end is nigh, people seem perfectly willing to spend 60 to a couple hundred percent more for the exact same product sold under a different name. That, to me, is interesting.

Yesterday, the GAO released the report from their investigation into how the Food and Drug Administration went about rejecting the application requesting over-the-counter status for the morning-after pill, and it’s even more damning than most thought it’d be. The GAO went through all 68 applications filed between 1994 and 2004 for conversion of a drug to over-the-counter status, and found that the FDA used entirely different criteria in its determinations on emergency contraception than it had on the other 67 applications. Likewise, the FDA had never before ignored the recommendations that came from its own internal scientific review committee, and top management had never before involved itself to the extent it did in the Plan B decision. And then, there’s my favorite part: there’s good evidence that the rejection decision was made by the same high-level management officials even before the scientific review committee concluded its work. It’s a shining example of politics getting in the way of healthcare; while the FDA has issued a statement questioning the integrity of the GAO’s investigative process, it’s pretty clear that that’s just the agency’s way of expressing its anger about being caught cheating. Sad.

A ruling came out of the Florida courts yesterday that’s managed to pique my interest a bit. In the case, a group of accused drunk drivers requested access to the program code for the breathalyzer that was used to document their blood alcohol levels; the court agreed with their request, and ordered the state to provide them with the code. The kicker is that the manufacturer of the breathalyzer claims the source code as a trade secret and is refusing to surrender it to the state, meaning that all of the drunk driving convictions obtained by using the device can now be called into question (and potentially overturned).

To me, this makes perfect sense. If a tool is going to be used to document some fact that’s used to make decisions about right and wrong — criminal and legal — then that tool better be as transparent as possible so that experts can be sure it works the way it’s advertised. In medicine, we would never make clinical decisions based on experimental or unverified test results; in fact, there’s an entire certification process through which new laboratory tests must be put before they can be used to make clinical decisions, and that process forces the people who develop and manufacture the tests to open their processes up to independent experts for verification. Why should the criminal justice system treat tools used to gather evidence in a different manner? (This is all the more important in the Florida case, as the breathalyzer in question has a questionable accuracy record (PDF), and was even subject to a recent software recall.) Conversely, why would a police department feel comfortable using a tool that operates in a completely hidden, unverifiable way?

It makes me happy when rigorous scientific standards find their way into places they logically belong.

If you’re like me, and cringe every time you notice a mainstream news article turn a meaningless observation into a scientific fact or elevate a hypothesis into a research finding (“red wine prevents cancer!”), then you’ll probably enjoy reading Ben Goldacre’s “Bad Science” column over at The Guardian. I only discovered it a few weeks ago, when his column “Don’t dumb me down” got a little bit of linky love across the world of weblogs; the piece did a good job of fleshing out how hard science gets edited out of most mainstream press articles, leaving unsupported claims and overstated “truths” in its place. And happily, all of Goldacre’s past columns (since 2003) are archived on his website, as well!

camden with the sox

Sorry about the radio silence this weekend; I took a trip down to Baltimore to catch yesterday’s Orioles/Red Sox game with a bunch of the teenage kids from my oncology clinic. The whole thing was awesome — we flew in Friday night, got a tour of Oriole Park at Camden Yards on Saturday, ate a quick lunch and hurried back in time to meet more than a half-dozen Red Sox players (Olerud, Timlin, Nixon, Ortiz, Myers, Wakefield, Youkilis, and Mueller), and then had a catered luxury party suite for what turned out to be one hell of a baseball game. Most of the kids had enough energy left over to put a few hours into ESPN Zone last night, and everyone filled their tanks back up with a huge brunch this morning before hopping onto a flight back to Boston. It was amazing to watch more than thirty kids with cancer — some on active chemotherapy (and one who was discharged from the hospital less than two hours before the trip started!) — get the chance to free themselves from their parents, spend a whole weekend running around with their friends, meet and talk with their idols, and overall get treated like royalty everywhere they went.

Things that make me want to pull my hair out:

Things that make me happy:

I could spend the next month delving into Science magazine’s “125 Questions”, a huge list of scientific questions to which we don’t yet have answers. From “How are memories stored and retrieved?” to Why do humans have so few genes?”, the people behind Science celebrated the 125th anniversary of their journal by coming up with a list of the big unanswered questions, and specifically, the questions to which science might finally be able to provide answers within the next 25 years. In the words of the editors, the list “is not a survey of the big societal challenges that science can help solve, nor is it a forecast of what science might achieve. Think of it instead as a survey of our scientific ignorance, a broad swath of questions that scientists themselves are asking.” Cool.

In the past two days, the New York Times has had two fantastic articles on the problems that face New York State’s Medicaid program. Yesterday’s piece detailed billions of dollars of fraud that have been committed by unscrupulous medical service providers, including a dentist that billed 991 procedures in a single day in 2003 (100 an hour!), a doctor that wrote 12% of the prescriptions for a $6,400 a month AIDS drug that went to helping bodybuilders bulk up, and a school administrator that rubber-stamped applications to enroll 60% of her special education students in speech therapy (twice the national average), thus netting the Medicaid payments for the school district. And in today’s followup piece, the Times looked into the program’s ability to investigate fraud and found it in equally poor shape. In the past 25 years, the staff tasked with finding abuse has been cut to 25% of its original size, and the amount of money recovered by investigations has gone down 70%, all of which has let the abuses found in yesterday’s article go unchecked. After today’s piece, NY Governor George Pataki ordered a complete overhaul of the program — but of course, he’s billing it as “an effort to further enhance the State’s successful efforts to control Medicaid costs” rather than “an obvious reaction to getting his ass handed to him in the pages of the paper of record.”

Today is all about bone marrow transplant.

First of all, right now, I’m sitting in the bone marrow transplant fellow’s on-call room; it’s my initial foray into a new call system wherein the transplant fellow stays in the hospital all night, taking care of the patients on the transplant unit (instead of the prior resident-level coverage) and handling any hematology- or oncology-related emergencies that might pop up. Looking at the eighteen total calls I have this year, I can see how spending the night in this tiny, overheated call room might become a bit tiresome — but the service is behaving itself, so that means that tonight is also about finishing off Harry Potter and the Half-Blood Price and catching up on some long-overdue email replies. No complaints there, really.

Second, I saw one of my bone marrow transplant patients in clinic today, and his family had a surprise for me: they brought the bone marrow donor along for the visit, with whom they had spent the weekend. When you’re a marrow donor, the whole thing is pretty much anonymous — if recipients wants to write letters to their donors, they have to do so via the National Marrow Donor Program, which redacts any identifying information before sending it along, and the same process holds true for any communication in the opposite direction. This is done to prevent ethical tragedies (like donors having to pull out of a commitment to donate and being harassed by their potential recipients), and is one of the few inviolable rules that both parties have to agree to up front. After a year, though, if both the donor and recipient agree to it, in some cases the NMDP helps both parties break the anonymity, and my patient and his donor agreed to that this past weekend. So while it was awesome to see my patient doing well (he’s a little over a year out from his transplant and is already back to playing hockey and baseball at the level he played pre-transplant), it was equally awesome to see the starstruck look in his (normally completely irreverent) eyes when he was in the presence of the person who donated his bone marrow to save a life. The donor had his two daughters with him, and the entire group was about as life-affirming as I’d imagine is possible. All in all, the visit was a fabulous reminder that as screwed up as the world seems sometimes, there are fundamentally good people out there who do the right thing and don’t think twice about it.

A study that’s being published in this week’s issue of BMJ (neé the British Medical Journal) yet again demonstrates that using cellphones while driving increases the likelihood of being in an accident. (The full PDF of the article is also available.) The specific conclusions of the study were that use of a cellphone increases the likelihood of an accident by four times, and the risk is the same whether the driver was using the phone normally or using a hands-free set with the phone. In addition, nearly all accidents were associated with at least one injury, and nearly half resulted in two or more injuries, injuries which required visits to hospitals for care.

Living in a town like Boston, where the rules of the road have been demoted into weak suggestions, this is all the more frightening. I walk more than a mile and a half each way to and from work, and I’d say that nearly a third of the time that I’m threatened (in a crosswalk, at a driveway) by a two-ton hunk of metal on wheels, the driver of said vehicle is obviously chatting away on a phone and even more oblivious to the world around the car than the average Masshole driver. Unfortunately for me, if a driver’s use of a cellphone ends up involving me in an accident, I’m likely to be the injured one — I’m on foot, and the driver’s wrapped up in a protective cocoon of steel and plastic. That just sucks.

At 8 AM tomorrow morning, I’ll be done with all my on-call time for my second year of fellowship. Wow, how time flies.

This is sad: the state of Texas has had to take custody of a 12 year-old girl with Hodgkin’s lymphoma after her parents refused to proceed with her radiation treatment. More details are provided in a series of articles from the local Corpus Christi, Texas newspaper; it appears that Katie Wernecke’s family believes that her Hodgkin’s is in remission, and thus that she doesn’t need any more treatment. Additionally, the family appears to have read enough to believe that treatment of Hodgkin’s lymphoma without radiation is possible, and is furthering this as justification for their decision to decline radiation. Given that this information is from the news reports I’ve been able to find, I’m sure that it’s somewhat of a simplification, but it does appear to form at least the core of the family’s argument with Katie’s oncologists.

Whatever their arguments turn out to be, as a pediatric oncologist, there are two truths that guide most of what I do in the clinic: first, the achievement of remission doesn’t mean that the treatment so far is enough to prevent relapse, and second, there is a stark difference between what we know to be true and what we suspect may be true.

In terms of the first truth, the best example is that of the most common malignancy in pediatrics, childhood acute lymphoblastic leukemia (ALL). With certain treatment regimens, we’re able to cure nearly nine of ten kids with ALL. With reasonably rare exceptions, every child with ALL is in remission after the first month of treatment; one of my favorite conversations with families is when I get to go in and tell them that their child has no evidence of residual leukemia. That being said, we know — with decades and decades of the best data that could possibly be gathered — that if we were to stop after that month, almost every single one of those children would relapse, and relapse soon. For that reason, we continue on with an additional one to two years of therapy, therapy which includes additional chemo, and in some cases radiation to their brain and spine. Again, this treatment isn’t us oncologists just making a random decision about what to do, but rather is supported by decades and decades of data that tell us that stopping treatment any sooner than that, or omitting parts of that therapy, lead to unacceptably higher risks of relapse and death. (An important adjunct body of data also informs us on the importance of completely dealing with the leukemia the first time — relapses that occur earlier are much, much more likely to be untreatable and lethal.) While this example involves childhood ALL, the same data exists for most every cancer we deal with, and certainly exists for Hodgkin’s lymphoma.

In terms of the second truth, one of the reasons I went into pediatric oncology is fact that most everything we do is guided by clinical data that supports its efficacy. Before adding chemo drugs to treatment regimens, we study them (first in cells, then in lab animals, and finally in patients); before taking parts of a treatment regimen away, we similarly study the alternative regimen to make sure it’s safe and doesn’t compromise our success rates. And here’s where there is a kernel of truth to what the Wernecke family is saying — there is currently a study being run by a national pediatric oncology consortium to examine whether there is a select group of Hodgkins lymphoma patients in whom radiation can be omitted from their therapy. But here’s why it’s just a kernel of truth, and not the whole truth: the hypothesis of the study contends that it’s only the truly lowest of the low-risk patients who could be cured without radiation, and in fact, an intermediate-risk arm of the study had to be closed because it was clear that the patients were doing worse (read: more early relapses). And thus, while pediatric oncologists believe to be true the fact that there’s a subset of lower-stage Hodgkin’s patients who don’t need radiation to cure them of their disease, we also know to be true that with the chemo medicines we have today, higher-stage patients require radiation in order to give them any chance of a cure.

Again, this is sad, mostly because the family and the oncologists weren’t able to come to a consensus that acknowledged the sometimes-bad side effects of treatment for a cancer that is certainly lethal without effective therapy. Hopefully, where the doctors haven’t been able to do their part to act in Wernecke’s best interest, the courts will, whatever the facts of her diagnosis are and whatever the outcome of the court hearing next week.

Every time I sit down and read SciAm’s “15 Answers to Creationist Nonsense”, I think the same thing — this should be required reading for anyone embarking on a career in science. Not only is it a terrific resource to have on hand, but it’s a reminder that the arguments creationism claims to refute are rarely the arguments being made by evolutionary biologists, but rather are Disney-like simplifications of incredibly complex observations.

my radiation monitoring badge

Today, I had a flashback moment that ended up connecting me to my parents in a way that I never would have expected.

Both my parents are physicians, and for most of my childhood, I remember being surrounded by the trappings of their work lives — white coats hanging on the backs of car seats, a stethoscope curled up on top of the cookbooks in the kitchen, otoscopes in the drawers of our buffet counter, beepers occasionally shrieking to life and prompting us all to run to see if we could catch the audio message (this was in the days before pagers displayed text messages). Nothing ever stood out as particularly representative of their work, but rather, all the stuff was as much a part of who my parents were as was their hair color or names. Since deciding to become a doctor, I’ve had a few moments that have triggered these memories, or made me better able to understand why there was so much of my parents’ physician lives intertwined in their home lives.

Today, I finally got around to taking my radiation research safety class at the hospital, and at the end of the class, the instructor handed out the monitoring badges that we have to wear whenever we’re in the lab. When he put mine down in front of me, I had a weird moment in which I flashed back to the same badge being on every single one of my parents’ white coats I had ever seen, a moment that was as much of a visceral connection as it was a visual memory. Thinking about it, both my parents had research labs in the hospital, and they’d both have had plenty of cause to wear monitoring badges in their daily lives, so that part makes total sense. What I can’t figure out is how, in my head, the badge became so emblematic of them being doctors — and how after it had, I then managed to completely forget about the association until today. In any event, the most interesting thing to me is how getting the badge made me identify more with my parents than anything else has prior, including them giving me my first stethoscope, and all the conversations I’ve had with them about patients in the past seven years. How powerful this little piece of plastic and film is!

On today, the day of Terri Schiavo’s death, it’s fitting that I came across “Live Everlasting,” a fantastic essay by Garret Keizer in Harpers. It’s one of the best statements I’ve read about the interplay of medical and social norms about the prolongation of life at all costs, and highlights a lot of the contradictions made by those who wish to take decisions of life from individuals and invest them in some higher authority. There are precious few pullquotes that do the length and depth of the essay justice, but perhaps this is enough to tempt you to dive in:

From that exalted vantage point, consider Dr. Thompson’s cavalier disregard for human life. He may have hastened his patient’s death by as much as five minutes. Let’s be as reckless as he was and say five hours. But should you perchance check a mortality table, you will discover that life expectancy at birth is roughly five years shorter for an African-American baby than for a white baby. This is true for both genders. In the interests of brevity we will not go into the life expectancies of Creoles born downstream from Louisiana power plants or Pacific Islanders born on former nuclear test sites or country kids born in the back hollows of Dr. Thompson’s practice.

Reading the dissent in today’s Eleventh Circuit Court of Appeals ruling on the Schiavo case, I think I found the words to explain what’s so offensive to me about the actions of Congress and Schiavo’s parents to date. The following quote, from the dissenting judge’s reasoning on why a preliminary injunction forcing the resumption of feeds would be approriate, is what gave me focus (emphasis mine):

In fact, I fail to see any harm in reinstating the feeding tube. On the other hand, a denial of the request for injunction will result in the death of Theresa Schiavo.

The Florida courts went through an excruciatingly detailed process to determine what Terri Schiavo herself would have felt was harmful, and ruled that there is clear and convincing evidence that she would feel it harmful to be artificallly supported in any manner. And as a result, replacing her feeding tube would be the very definition of harmful, for the very reason that it would prolong her life. I guess what I wonder is if the presence of a living will specifically forbidding the continuation of artificial sustenance would have changed the dissenting judge’s opinion on the harm of replacing the tube. Put another way: can the judge truly ignore what has been determined to be Schiavo’s ideas of benefit and harm and then substitute his own in order to decide how to proceed?

Extended more broadly, that’s exactly what all the supporters of the Congressional bill did — used their own views (or, says the skeptical side of me, the views of the various groups that support them) about good and bad, benefit and harm, moral and immoral, and then imposed those views on Terri Schiavo and the country. In the end, that idea that the views of someone other than me matter at all when I’m hooked up to life-sustaining equipment is what’s so frightening.

Two quick morning observations about the continuing Terri Schiavo abomination:

First, it’s at least a little heartening to me to see that this afternoon’s Federal court hearing is before James D. Whittemore, a Clinton appointee and someone who’s expressed an understanding of the difference between state and federal powers. We’ll see how it plays out, but at least I feel that much more secure that by putting the issue into the hands of the Federal judiciary, Congress actually has taken a lot of the politics out of the debacle.

Second, how has it not come up in the popular press that the same President who flew back to Washington to sign the Schiavo bill also put his signature on the Texas Futile Care Law while governor of that state in 1999, a law that allows hospitals to discontinue life-sustaining measures over the objections of parents? (It’s the law that led to Texas Children’s ending life support on a baby last month, after a protracted legal battle that wasn’t able to tug at the heartstrings of our elected Federal representatives.) It’s hard to reconcile the two acts on Bush’s part, other than to observe that both laws had strong support from the religious right.

Update: thanks go out to Rafe for the pointer to this great (but long) post at Obsidian Wings, which says it all much better than I could deign to.

Wow — I just found the text of the Terri Schiavo bills being considered by the House and Senate, and honestly can’t believe what I’m reading. To quote from the Senate Bill, S. 686 (emphasis mine):

Any parent of Theresa Marie Schiavo shall have standing to bring a suit under this Act…. In such a suit, the District Court shall determine de novo any claim of a violation of any right of Theresa Marie Schiavo within the scope of this Act, notwithstanding any prior State court determination and regardless of whether such a claim has previously been raised, considered, or decided in State court proceedings. The District Court shall entertain and determine the suit without any delay or abstention in favor of State court proceedings, and regardless of whether remedies available in the State courts have been exhausted.

So, to paraphrase, the Senate is demanding the following:

  1. that Schiavo’s parents can start another lawsuit;
  2. that the Federal District Court will then have to start anew in considering the new suit, without reliance on any prior state court hearings;
  3. and that the Federal District Court cannot decline or defer to the prior decisions of state courts.

Now, to quote from the House bill, H.R. 1332 (emphasis again mine):

In hearing and determining a claim or cause of action removed under this section, the court shall only consider whether authorizing or directing the withholding or withdrawal of food or fluids or medical treatment necessary to sustain the incapacitated person’s life constitutes a deprivation of any right, privilege, or immunity secured by the Constitution or laws of the United States. The United States district court shall determine de novo any claim or cause of action considered under subsection (c), and no bar or limitation based on abstention, res judicata, collateral estoppel, procedural default, or any other doctrine of issue or claim preclusion shall apply.

To paraphrase the House:

  1. the Federal courts must consider whether withholding life support deprives Schiavo of some right;
  2. the Federal courts must not consider whether continuing life support deprives her of her right to determine her own fate;
  3. the Federal courts again cannot rely on prior state hearings or decisions.

This is so much worse than I originally thought. Is there any doubt that this is a horrible violation of both separation of powers and states’ rights?

For those who are interested in a reasonable attempt to look at the reality of the Terri Schiavo case, Matt Conigliaro has an amazingly detailed information page, including a list of questions and answers that demonstrates how reductionist the media coverage (and Congressional “inquiry”) has become. Conigliaro is an appellate lawyer and has run a website for over two years focused on Florida law, and his coverage of the case over that time period has led to (relatively ridiculous) accusations of bias from both sides of the ostensible debate. Reading his numerous posts, it’s hard to see that bias; instead, he seems to be a good legal analyst, and very empathetic to both positions in what is fundamentally an emotionally wrenching debate however you look at it.

After reading Conigliaro’s chronology and Q&A section, I’m left with the understanding that every single court that has held a hearing has concluded that Schiavo is in a persistent vegetative state and that there is clear and convincing evidence — the strongest burden of proof available in civil cases — that she would have wished removal of life support measures. This determination was based on more than just evidence from reports of conversations with her husband, as well, something that’s not mentioned too much in media reports of the conflict. I’m also left with the realization that every attempt to subvert the ultimate court rulings have come from the realm of politics — initially, Terri’s Law, and now, a farcical consensus bill from the U.S. Congress, something that manages to be both unsurprising and terrifying at the same time.

What I’ve been confused about — and while slightly less so, remain confused about — is what the law being rushed through Congress right now aims to do. It seems from reports that it’s a case-specific law, allowing Federal judicial review of the state court rulings in Schiavo’s case; what I don’t understand is how there’s some idea that this will lead to a different outcome. As I understand it, the Eleventh Circuit Court of Appeals has denied every appeal and dismissed every case brought by those who have tried to overturn the rulings of the Florida courts, and the U.S. Supreme Court has twice declined to intervene, once in January and once yesterday. So we now seem to have have what might be well less than a majority of our Congressmen (since it only takes a majority of present legislators, not of all legislators, to pass a law) furiously posturing, and the President himself returning to Washington, D.C. early, all in the name of likely having no effect on the ultimate outcome whatsoever.

In the end, it seems that most everyone agrees on the right for people to create formal living wills that spell out how we wish to be treated in the case of tragedies like this. In Schiavo’s case, there isn’t a written living will, but every level of court available for recourse has determined her wishes in a manner that is as legally binding as a living will would have been. In spite of this, we now have the highest elected body of legislators in the country acting to force an entirely different set of wishes. What gives them the right? What would prevent Congress — or any elected body — from acting similarly even if a formal living will existed? Therein lies the real horror of the Schiavo case; apparently, it’s one more way that some seem willing to let the lawmakers of this country intrude on the private debates and decisions of its citizens.

Sorry about the silent week — it was a tough one at work. On Monday, I learned that two of my patients had relapsed, and that another patient’s tumor had begun growing in leaps and bounds. I spent most of the week scheduling tests, getting recommendations from more senior oncologists, and breaking bad news to the families, and every night I just collapsed from exhaustion. It’s a week I hope to never, ever repeat.

Sigh… Milo Dysplastic? Don’t the Associated Press and Reuters have, you know, editors around on New Year’s weekend?

To flesh out the info in the news reports, myelodysplastic syndrome — MDS — describes a group of conditions in which the precursor cells in the bone marrow (stem cells of sorts) gain mutations and stop producing the child cells that make up normal blood (white cells, red cells, and platelets). MDS is preleukemic, in that the mutated stem cells don’t crowd out the normal ones, but rather function alongside them. Once that crowding-out occurs, though, that signals the evolution to actual leukemia.

(And to highlight the biggest difference between the worlds of adult and pediatric cancer: according to this summary, there are about 13,000 new diagnoses of MDS each year, and every news report has mentioned that this makes it a pretty rare condition. Alas, that’s also a good estimate of the total number of new pediatric cancer diagnoses, of all types, that are made annually.)

I don’t know why, but it’s weird to see news from a talk at the conference I’m attending as one of the current top stories on CNN.com.

It’s always amazing to me when someone makes what might be a major medical advance merely by thinking outside the box, introducing a slight shift in their approach to a problem and ending up disproving the way that we physicians have tried to deal with that problem for decades. The latest example of this is the tale of Jeanna Giese, the rabies survivor in Wisconsin, only the sixth known person to survive rabies and the first person known to survive without having received antibody and vaccine shots prior to the onset of symptoms.

Rabies kills by rapidly proliferating in the brain, causing major central dysfunction and allowing the virus to spread to other vital organs like the heart. Most therapies to date have mirrored those we use for other infectious diseases — using medicines and antibodies that aim to limit the proliferation of the virus so that the body’s natural immune defenses can keep up with, and defeat, the infection. The medical team taking care of the Giese added a second approach to her treatment — they surmised that another way to reduce the replication of the virus might be by reducing the metabolic rate of the tissue in which it had set up shop, the central nervous system. Of course, there’s really only one reliable way to reduce the metabolic rate of the central nervous system: putting someone into a coma. Giese’s medical team did this with sedatives and anesthetics, and at least in her case, it appears to have allowed her immune system and the antivirals to catch up and clear the virus from her system.

It’s too early to say if this will work in all cases, but apparently the Centers for Disease Control has taken note and is interested in more formal testing of the method. And if it pans out, it will be the kind of major medical advance that leaves us all shaking our heads, wondering why we all were so blinded to the simpleness of it all.

Given how quickly the trend has taken off, I guess it was just a matter of time before counterfeit Lance Armstrong LIVESTRONG bracelets appeared on the scene. There are plenty of other eBay cheats hawking the fake bracelets; once those are all shut down, I’m sure about fifteen dozen others will spring right back up. There have even been a few news articles on the fakes, complete with local investigative journalism angles. You can be sure that not one cent of the money people spend on these goes anywhere but into the manufacturers’ pockets, which is the real shame.

If you’re not put off by the trendiness of it all, want a bracelet, and want to make sure that your money helps fund the cancer research foundation that started it all, remember that there are only three legitimate places to get them: the Lance Armstrong Foundation store and Nike sell the adult- and child-sized ones, and the Build-A-Bear Workshop sells the teddy bear-sized ones (that also conveniently fit toddlers!).

Something I learned overnight: in the world of pediatric oncology, it’s tough when patients die of their cancer, but it’s a whole world tougher when they die of the treatment.

I’m not a National Geographic subscriber, which means that I’m going to have to swing by the library over the next week or two — the feature article on creation vs. evolution this month looks like it’ll be a great read. (Of course, I can’t deny the added appeal in the issue’s cover text asking “Was Darwin wrong?”, and the pullquote on the first-page of the feature answering “NO. The evidence for evolution is overwhelming.”)

Two long pieces that are worth the time it’ll take you to read: Tim Golden’s New York Times article, “After Terror, a Secret Rewriting of Military Law”, and Malcolm Gladwell’s New Yorker article, “High Prices”. The former is an in-depth look at how, in the post-9/11 environment, the Bush Administration went about the secretive process of rewriting a slew of laws and rules to allow the unfettered detainment and civil abuse of anyone that it decided was a terrorist, and is one of the few written pieces that has made me understand just how unimportant civil rights have become under our current President’s leadership. The latter is a well-researched, impeccably-detailed trip through the problems that surround drug prices, pharmaceutical research, and physician behavior in this country; it’s really the piece that I wish I could have written nearly two years ago.

Wow — rofecoxib (Vioxx) was taken off the market today due to increased “cardiovascular events” (heart attacks and strokes, mainly). Chris Rangel has a good little ditty today on the deshelving, noting that it’s just part of a cycle that starts with overhyping, continues on to hemorrhaging health care dollars, and ends with multibillion dollar tort lawsuits. Makes doctors and lawyers happy to be part of their respective professional communities…

A patient of mine — an eleven year-old boy — came to our attention a few months ago when, after feeling more tired than normal, he was noted to have a markedly-elevated white blood cell count by his pediatrician. Soon thereafter, we diagnosed him with acute lymphoblastic leukemia and started him on therapy. Four weeks later, though, his leukemia hadn’t gone away, meaning that the therapy failed to induce a remission (a very rare event in pediatrics), and at that point, we let the family know that the only therapy which had any chance of curing him was a bone marrow transplant. The search for a suitable donor turned out to be quite difficult, though; finding a match involves finding someone with the exact same six antigens generated from part of the sixth chromosome, and the young man has a rare enough combination of antigens that the best we were able to find was five out of the six (with a mismatch at another, more minor, antigen location as well). Given the dismal prognosis without transplant, though, we were happy to have found the one donor, and when we found out that my patient was finally in remission two weeks ago, we made the official request to the National Marrow Donor Program to have the donor come in for the medical part of the pretransplant workup.

Today, we learned that the donor “deferred,” meaning that he or she decided not to participate in the donation process. That means that at this point, we are left with no suitable match for my patient. And therein lies the very reason that the marrow donation process is done with complete blinding between the institution caring for the potential recipient and the NMDP — it would be too easy for me to go completely nuts on the poor potential donor, screaming and yelling about how he or she is dooming my patient to a near certain fate, without having any clue about the potential donor’s reasons for not wanting to go through with the process. As disappointed as I am right now, that’s the mindset that I’m trying to maintain; for all I know, the person carries a lethal virus or condition but was pressured into participating in a marrow donor drive at work, or has some other such reasonable cause for deferring.

The one thread of hope that remains is a person who, at least crudely, has the potential to be a match, but who isn’t going to be worked up more precisely for another two weeks. In the mean time, we have to continue my patient on maintenance chemo with the hope that he remains in his fragile remission, hold tight to the chance that the new person will be a suitable molecular match, and pray that if that’s the case, he or she will be willing to go through with the donation posthaste.

Busy, busy week — I ascended to the glamorous life of a second-year fellow, was on call for four nights straight, trained all the new first-year fellows on the three dozen separate computer systems that (barely) allow us to provide efficient care at two of the biggest hospitals on the east coast, and had a great birthday (replete with a new drill from Shannon!). I only have two days left on service in the hospital, and then I move on to the research lab for a few years . It’s a little less hectic of a life, but it’s also a little less of the day-to-day patient contact that’s so much of a blast.

On call, Monday: eight year-old with newly-presenting leukemia.
On call, Tuesday: nine month-old with new 11 centimeter mass in his abdomen.
On call, tonight: three year-old with newly-presenting transient erythroblastopenia of childhood and 11 month-old with newly-presenting leukemia.

What could tomorrow night possibly have in store?

As a pediatrician, something about this strikes me as just plain wrong. I know, I know — when compared to slicing off a little kid’s foreskin, it’s not all that shocking — but still!

Today, for the first time in a long, long time, I did the ol’ accidentally-hit-reply-all thing… and ended up sending a profanity-filled rant to one of my best friends and the director of radiation oncology. Worse still, I had no idea I had done it until said director wrote back to me, pointing out my electronic error.

Lucky for me, the profanities weren’t directed towards the radiation oncologists. The original email just served as the launching point for my rant, and that may be the only thing that saves my bacon. I can’t say that that makes me feel all that much better about dropping the F-bomb — twice — to the woman who runs a dozen radiation protocols at my hospital and who mentors all my learning about the use of radiation in cancer care, though. I’m sure that she’s filed it away in her in-case-I-need-to-use-it folder; God knows I’d do that!

Tonight’s one of those nights where my pager keeps interrupting me with its shrill screams, so in an effort to feel like I’m a bit more in control, I’ve decided to log all the calls. My hope is that, by posting the pages, I can somehow exert cosmic influence in a way that calms things down a bit. 8:05 PM, from my resident: the surgery team spent a lot of time with us yesterday, explaining how important it was for them to be present when one of our patients received an interventional radiology study. Tonight, they weren’t there, and the surgery team claimed to have no idea why they would be there. We talked it through, and they’ll be there. 8:20 PM, from A’s father: A is a five year-old girl with neuroblastoma, who we sent home yesterday after the first of her two back-to-back bone marrow transplants. She wasn’t drinking so well when she went home; she’s doing equally poorly today, and her parents feel that they’re unable to push any harder without her totally shutting down. They also feel like they’re at their wit’s end, ignoring their jobs and their other daughter for the sake of getting A better. And in the end, they’re getting her better so that she can come back in for a second bone marrow transplant, to face the same issues again. We’ll work more tomorrow, but I told them to back off and let A be the boss for the next 12 hours. 9:12 PM, from my resident: this afternoon, we readmitted S, a 17 year old young woman some 100 days out of transplant, for low-grade fever and vomiting. Tonight, she can’t take any of her oral medicines, including the two that help suppress her immune system so it doesn’t reject her new bone marrow. We worked through converting the meds to intravenous doses. 9:32 PM, from my resident: it turns out that S’s kidney function isn’t so great, which definitely limits our ability to use intravenous contrast to do a CT scan of her belly. One of the best ways to prevent contrast-induced kidney failure is to use a drug named acetylcysteine, but you have to drink it, and as we know, S ain’t drinking anything. We decided to just use big-time intravenous hydration, instead. Wow — no calls after I posted all this. Maybe the voodoo works…
There are times when this job is hard, there are times when this job is really hard, and then there are times when it’s all worthwhile.
Yet another good day of fellowship — a well-received tumor board presentation this morning (on something I knew nothing about prior to preparing it), an interesting consult in the newborn nursery, a probable confirmation of a non-diagnosis of cancer in a teenager, and a great bone marrow biopsy specimen (that came along with a compliment from the hematopathologist!).
Fellowship has been just as time-consuming and emotionally taxing as I anticipated it would be (as, in part, is evidenced by the random gaps in posts here), but something else I anticipated is that I’d have some amazing experiences this year. Today, the day of my program’s annual Holiday Festival for our patients with cancer, would definitely qualify as amazing. The Festival is held in a local hotel ballroom, and patients’ families are encouraged to bring all of their kids along. This year, a national department store donated a ton of presents, and other companies donated food, drink, and goodies for the parents. One of the senior doctors in the department plays Santa every year (mostly because he already fits the role with his body habitus and perpetual cheer), and all of the first year fellows play Santa’s elves, complete with bloomers, stockings, and pointy shoes. Today, we stood up on stage with jolly Saint Nick, helping the kids through the line, getting them to smile for the pictures, and handing out age-appropriate presents. It was just awesome to see all of our patients in their holiday best, running around and excited to be out of the hospital. (And it was actually fun to be mocked by a few of my patients, and pose with them for pictures so they could keep a bit of evidence that their doctor is willing to make a fool of himself for a bit good cheer.) And despite the occasional Christmas buzz-kill — a parent or two who cut into line, a few more who asked to exchange the gifts that their kids received because they wanted something better — I was glad to be a part of it.
Day one of the Pediatrics Board exam down, and boy was that tough. Day two in ten hours…
After today, I can make one solid educational point: an inadvisable way to end your work day is to spend the last three hours of it explaining to a sixteen year-old and his family that, despite aggressive chemo and other supportive treatment, he probably only has one or two days left to live. Having a teenager push away an oxygen mask to ask you how long he has left is pretty much the worst thing possible; it was all I could do to not break down sobbing during my conversations with the family. By the time I got home, I felt dull all the way down to my very core, a feeling which is only now starting to subside. I know that we do a lot more good for kids than we do harm, and I also know that this is all going to get easier; right now, though, I’d trade both of those things for a chance at giving my patient a little more time.
The thing that depresses me the most about this is that the parents were taking their child to the Burzynski clinic, which is possibly the single most offensive affront to the practice of oncology. Worse than peddling useless therapy, Burzynski offers up false hope to a group of people who cling to whatever remnants of hope they can find, and offers it up for considerable personal profit.

Last night was my final 24-hour call in the hospital (a fact I didn’t realize until about 1 o’clock this morning). The milestones are just stacking up; next in line, my last class retreat (next weekend), my last clinic (two Tuesdays from now), and my last overnight call in any capacity (three Wednesdays from now). In the mean time, though, I’m off to Boston for one day of geekery before returning to marking the passage of time…

Another few milestones passed: my last overnight call as the senior resident in charge (last Saturday), and my graduation ceremony (today, although there are still two and a half weeks left). It feels totally strange to be finishing my association with an educational institution that has provided the last eleven years of my education, but it also feels liberating. In three weeks, I’ll be in a completely new hospital, with a completely new ethic, learning completely new medicine. I’ll have a new apartment, be driving my new car, and be further than three miles from my family for the first time in 10 years. From the start of college through now, I’ve rested on my New York haunches at every decision point, partly because it was the best thing to do in the context of each decision but also partly out of stasis. Now, I finally get the experience of totally uprooting my personal life just as I’m starting the next stage of my professional life, and once I get past the holy-shit aspect, it’s going to be a ton of fun.

Around here, things have been busy lately. As soon as I finished in the emergency room, I was thrown into the inpatient wards as the senior resident on service, meaning a return to early mornings and fourteen-hour days. And just after walking in the door at night, I’ve been heading straight for the laptop, getting down and dirty with code as I craft a content management system for one of my web projects in the hospital. With Shannon in the middle of her finals, we make quite a couple, tiredly collapsing into our respective ends of the sofa and communing with our computers until the wee hours of the morning. All in all, it’s enough to form the framework for a new reality video, “Overextended Dorks Gone Wild.”

That being said, I’m really enjoying my work. The web project is allowing me to finally pick up a language I’ve wanted to use for years, and get off of a CMS backend that I absolutely despise. It’s also letting me play with workflow design and systems architecture, which may not sound exciting, but which makes my brain feel right at home. And importantly, the project may actually earn me a little money — something that I welcome wholeheartedly, given that my looming move to Boston is already taking a bite out of my bank account.

In the hospital, as the only third-year resident on my inpatient team, I’m getting a great chance to see how much I’ve learned over the course of the last few years. What took me hours of reading and contemplation two years ago is now second-nature; a kid who could instantly drive me to panic as a first-year resident now drives me to start delegating tasks and taking action. (It’s even been enough to push me into starting a new pediatric arrest curriculum for the hospital, which has unquestionably been the most satisfying thing that I’ve been involved in thus far.) I now have only six and a half weeks left as a resident, and while I only feel like I’ve been a pediatrician for fifteen minutes, those fifteen minutes feel like they’ve been jam-packed with great learning, awesome kids, and more rich experiences than I would have ever believed possible.

I’ve never been one to handle idleness well, quickly finding something to fill any gaps in time or commitments. These last two months in New York promise to be busy as all hell, but I don’t think I would want it any other way.

I can’t believe I’ve neglected to mention up until now that I had my very last ER shift as a pediatrics resident ever this past Saturday. You cannot imagine how exciting this is for me; as much as I love the critical care stuff in the ER, the primary care stuff (and the overt abuse of the system) drives me up a wall. I had grown to dread going to work in the ER, and now, I can officially say that it’s all behind me.

In the intensive care unit last night, I did something I’ve never done before: replaced a patients entire blood volume with fresh, new blood. It’s called an exchange transfusion — literally, your goal is to exchange as much of a patient’s blood volume as you can with new blood. And when I say that I did it, I mean that on every day of the week but Saturday, my hospital has machines to do this procedure, but on Saturdays, it’s the resident who has the privilege of moving all that blood into and out of the patient. For four and a half hours, it was my job to draw off 165 milliliters of blood from my patient’s arterial line every 10 minutes, as bag after bag of fresh blood dripped into a intravenous line in his other arm.

By the end of the first hour, I had it down to an exact science; I could get the 165 ml off in four minutes, leaving me with a luxurious six more minutes to rush around the ICU taking care of my other patients before I had to be back at his bedside to repeat the cycle. By the end of the second hour, the novelty had long worn off, and I was cursing my hospital for not having the mechanized exchange machine available. (I was also growing curious about the three or four plastic urinals full of discarded blood that had already accumulated at the foot of the bed.) By the end of the full four and a half hours, I was just amazed at what we had done — taken over four liters of blood out of a fifteen year-old boy, and replaced it with blood that had been donated by over a dozen people, none of whom could know that they were helping this young man avoid going onto a ventilator. This morning, the patient was saying that he felt a lot better; given how much manual labor went into the procedure, that made me feel a lot better, too.

Anthony Sebok has written an interesting column for Writ looking at a recent decision making an HMO equally liable for coverage decisions as a doctor would be for therapy decisions. It’s a big finding, because in the past, HMOs have shielded themselves from malpractice claims by stating that coverage decisions aren’t the same as active medical care; as such, they aren’t stopping someone from getting specific care, but rather, just saying that their insurance won’t pay for that care. In Cicio v. Vytra Healthcare, however, the Second Circuit disagreed with this, holding that there are times when a coverage decision is indistinguishable from the choice and implementation of a specific treatment — in effect, coverage determines treatment. And while the decision isn’t perfectly generalizable, Cicio seems to potentially open up the door for further HMO liability when care is denied based solely on cost. It’s an acknowledgement that medical care has changed a lot since malpractice law was drafted. In the words of Sebok:

It may be time for the foundations of medical malpractice to shift. Once, this area of law was based on the special relationship between doctor and patient. Now perhaps it should be based on the fraught economic relationship between the patient, the doctor, and the insurance company.

The Step 3 is now complete, and I couldn’t be more relieved; for some reason, studying for them was way more annoying to me than it should have been.

The last segment of the exam today consisted of nine individual clinical vignettes, and my job was to work from presentation through diagnosis and treatment. The exam is administered via an application that let me write orders, perform procedures, studies, and tests, call consults, and generally do what I’d do if I were actually caring for a patient. An artificial intelligence engine interpreted my requests, and asked for verification when it needed it; the system also enforced a virtual timeline, with results coming back in the same time period that they would have in the real world, and complications unexpectedly popping up as the workup and treatment took place. Aside from a pretty terrible interface and painfully slow responses at times, the application was cool, and I’m excited to see that medical testing is moving to the next level.

Now, for the Massachusetts licensing application…

One day of the USMLE Step 3s down, one more day to go…

(And, for the record, one of the big reasons I decided to go into pediatrics was that I much prefer patients whose presentations don’t start with drug or alcohol abuse and then devolve into a list of a dozen prior medical problems and an even longer list of current medications. Keeping track of the threads of illness in the adult medicine questions is getting tough on my pediatrician brain!)

Just in case you were wondering, Dan Chaon’s story on McSweeney’s, “The Bees,” is a near-perfect description of night terrors. I only hope that Frankie’s pediatrician told his parents this…

There’s an interesting report of neurologic damage in two children of women who adhered to vegan or vegetarian diets in this week’s Morbidity and Mortality Weekly Report. The link between the cases was a deficiency in vitamin B12 (cobalamin) in the womens’ diets; whereas there is much known about adult B12 deficiency, its rarity in infants means that it takes random case reports like these to see the sheer extent of damage that can be caused. And while it’d be easy to pass judgment on people who eat vegan diets, there’s an even easier lesson here — if you’re pregnant or breastfeeding, take your vitamin B12.

Since Monday, I’ve been on the overnight shift in the emergency room, taking care of the kids who make it in despite weather so cold I haven’t felt my earlobes in days. As you’d expect, the freezing temperatures keeps a lot of the less acutely-ill children at home, so while we’re still busy, it’s with patients who need relatively urgent intervention — tight asthmatics, kids with acute abdominal pain, teenagers with serious injuries — rather than those who are probably best served by a visit to their local pediatrician.

Last night, I took care of a 16 year-old girl who was horsing around outside and tripped on a curb, whacking her head against a stone pole. Her left eye was a mess, with a huge bruise around it and the lid so swollen that she had to make a serious effort in order to open it. I felt a depression in the bone above her eye and told her that she probably had a skull fracture, and she began to cry; it was clear that she was pretty much at her limit with the bruising and swelling, and the idea of a broken bone shattered through her resolve. Luckily, we were able to help her even with that — one of the attendings showed her the scar above his right eye and recollected the time he was hit in the head with a golf driver, causing not only a fracture of the bone but a laceration deep enough to make his doctors worried about an open communication to his brain. Once she was done laughing, she seemed better, got a dose of IV antibiotics, and went for her CT scan.

Two days ago, I had my dream: two sets of twins, in adjacent beds, who arrived within ten minutes of each other. Both sets were premature, and both sets were within the first three weeks of life; with all of the playing and oohing and aahing, it was hard to tear myself away from their beds in order to care for my other patients. I ended up sending one set home (they were in for jaundice, but their bloodwork made me feel that they were doing well), and admitting one of the other set of twins (she had an apneic spell serious enough to make me worry about a repeat episode happening at home, unobserved).

The hardest patient this week, though, was the one that we did the absolute least for. We got a call on our notification phone telling us that EMS was inbound with a 17 year-old boy who was discovered not breathing by his family. About 2 minutes later, paramedics rolled in with the boy, one bagging him, another doing chest compressions, and a third guiding the entire group into our crash room. They said that he was completely unresponsive when they got to his home, and that they only got the most minimal of cardiac rhythms; they had already shocked him twice and given him epinephrine four times. By the time he got to us, his pupils were fixed and wide open, and he had a good deal of morbid lividity, and about a minute later, we called the arrest. As a death within 24 hours of admission to the hospital, the medical examiner will perform an autopsy to try to determine what happened, but realistically, we may never know what happened.

Nights in the ER are long and tiring; I can’t wait to go back to my day schedule.

Some may remember Zac Unger’s weeklong diary about his 27-week preemie, Percy, and all the difficulties the baby was facing in her first week of life; I was sad that the diary only lasted a week, after which we all lost touch with how the little one was doing. Well, Percy is now 92 days old and still in the neonatal intensive care unit; Zac provided an update on Slate yesterday. I wish them the best — they’re right, the NICU will be a memory soon enough.

Apropos of nothing, it turns out that the information we all learned in high school about eye color inheritance — brown dominant over blue, work it all out with a one-gene Punnett Square — turns out to be not all that accurate. To date, three genes have been discovered which involve determination of eye color, EYCL1 (also known as gey), EYCL2 (bey1), and EYCL3 (bey2). The ways that these genes interact can’t explain all of the known inheritance patterns of eye color (like blue-eyed parents with brown-eyed children), though, so there are at least a few other undiscovered genes out there.

In a rare move, the New England Journal of Medicine released six fascinating articles about smallpox today from an issue that isn’t to be printed for more than a month. Most interestingly, there’s an article modeling the best vaccination model (health care workers first, but the public only if there’s a valid threat of an outbreak or biowarfare), an unsurprising study demonstrating a need for better public education about smallpox, and a great retrospective by Thomas Mack looking at the time he spent studying the spread of the disease in Pakistan. Print the articles and put ‘em into a folder alongside those from the Journal’s April 2002 series, and you’ve got yourself a pretty comprehensive review of smallpox.

There’s been a little bit of news today about the newly-approved vaccine that combines protection against diptheria, pertussis, tetanus, hepatitis B, and polio. Much of the news revolves around the promise of less shots for kids in the first six months of life (in one report, “up to six fewer injections”), but by my calculations, Pediarix (the new vaccine) will generally lead to only two less shots in the first six months. Right now, infants get four shots at each of their first two visits — DTaP (diptheria, tetanus, and pertussis), Comvax (hepatitis B and H. influenzae), Prevnar (pneumococcus), and IPV (polio). At six months, kids get three more shots — another DTaP, another Prevnar, and another IPV, totalling out at 11 vaccines in the first six months. Under the new scheme, the little ones will get three shots at each of the first three visits — Pediarix, Prevnar, and IPV — adding up to nine total vaccines. Add to that number the fact that Pediarix causes a statistically-significant increase in fever after vaccination, and I’m not sure that the new preparation is worth it.

It looks like McSweeney’s is starting off a series on wintertime in a pediatric ER, written by JB Orenstein. (Orenstein is a Virginia ER doc who’s provided quite a few inside glimpses into the world of medicine.) Of course, I’m currently working the overnight shift in our ER, so I don’t know that I exactly need more information on what the cold weather does to kids, but it’s pretty entertaining.

Today, I had the kind of day that justifies each and every bad day I’ve had in the hospital. And because I feel like sharing my glowing mood, I’m going to do just that.

I’m currently on an outpatient rotation, which means that I spend most of my time in my clinic, seeing well children and walk-in, nonemergent sorts of things. Another thing that we do during outpatient is spend a day with one of the nurses from the Visiting Nurse Service of New York, and today was that day for me.

Now, I had been warned by some of the other residents that there aren’t pediatrics-only VNS nurses, so part of my day would also include adults (bleah); our first visit (a fortyish diabetic woman who was pregnant) bore this out, and afterwards, the nurse I was with told me that our second visit would also be an adult. This woman had recently delivered her baby via C-section, and VNS was involved only because mom’s abdominal wound was having problems fully healing. Our trip to the family took us into one of the poorest neighborhoods in New York, and likewise, into one of the more dilapidated buildings I have seen in my life. Up four flights in a tiny urine-drenched elevator, and we were there.

When we got into the apartment, mom immediately told us that she was doing very well, but that she was pretty worried about her new (16 day-old) baby. The nurse told mom that today was her “lucky day”; I, a pediatrician, happened to be along for the ride. I asked mom what she was worried about, and she told me that her son wasn’t eating very well, that he was less active than normal, and that he had a pale color — all of which can serve as red flags in a newborn. She then told me that he had been delivered at 36 weeks and that the early C-section was because mom had had preeclampsia (also red flags), and I asked to see the boy.

That’s when she handed me her newborn son, and also when I began to worry.

He was not just “less active,” he was lethargic. (Anyone in the medical field can tell you that we reserve that word — lethargic — for a very select and special class of patients. You have to be pretty sick for that particular adjective to enter the conversation.) He was mottled, yellowish-purple, didn’t seem to have all that great a respiratory effort, and his arms and legs were completely limp. I tried to stimulate him, and it didn’t do much… no crying, no major movement or increase in muscle tone, not even much eye-opening.

I quickly grabbed my stethoscope and put it on his chest, and his heart rate seemed to be pretty good — 150s to 160s (normal range for a newborn). Just as I was taking the stethoscope off, though, I heard it start to dip, and after listening for another ten seconds or so, I heard his rate go as low as 60. During this, he had no respiratory effort, but after the ten seconds, he started to breathe deeply again, and his heart rate came right back up. Over the next two minutes, he did this a few more times, and when we took the temperature, it was 95.2.

This is about when it hit me fully that this had ceased to be a visit for mom, and turned into an emergent visit for her son — he needed to get to an emergency room, quickly.

I pulled out my cellphone and called 911, and explained that I was a pediatrician with a patient who needed an ambulance immediately. I told them short form of the story (16-day old, lethargy with apnea and bradycardia, guarded condition), and they patched me directly through to the precinct dispatcher; he reassured me that someone would be there very shortly.

Again, I remembered — we were supposed to have been visiting mom.

After hanging up, I briefly called my hospital’s pediatric ER, got the attending for the acute side on the phone, and told him what was going on, warning him that we would be coming in in a hurry. Then I asked mom how long her son had been like this, and she said that it had been since yesterday morning. That begged asking her why she had waited to say something about it, she said that she had. She had called her pediatrician when she noticed the change, and after having her take the baby’s temperature (99), he said that the baby didn’t have a fever, but that she should go to the ER if she was concerned. She did go to the ER (not at my hospital), where they examined her son, decided that “he had a cold,” and sent them home. Mom remained concerned, though, and said that she had been waiting for VNS to come so that she could talk to her about it.

This whole conversation with the ER and with mom took about two and a half minutes; I know because that’s how long the police took to arrive at the door. They told me that the ambulance was less than three minutes away, but that if I felt that we couldn’t wait, they would take me in the police car — my fear of needing oxygen or advanced resuscitation equipment prevented me from accepting that offer, though. Once the EMS paramedics got there, we put an oxygen mask on the boy and started helping him breathe with the manual ventilation bag, and he perked up a bit. Next, it was down four flights in the tiny urine-drenched elevator (this time packed with the paramedics, me, the baby, and a policeman) and into the ambulance. I spent the duration of this concentrating on (a) not dropping the baby, (b) continuing to ventilate the baby, and (c) maintaining a good seal between the baby’s face and the oxygen mask, and because of that, the paramedic literally had to sit me down in the jumpseat and harness me in. He took over the manual ventilation while I held onto the baby and the mask, and we roared off, sirens blaring.

We were supposed to have been visiting mom.

About four minutes (and two hit curbs) later, we pulled into the ambulance bay, and the attending met us at the door. There were about six other people gloved, gowned, and ready in one of the trauma bays, and the baby got swallowed into their mass. IVs were put in, EKG leads and oxygen sensors were attached, blood was drawn and urine was obtained. The baby was still markedly hypothermic (95-96 degrees), he wasn’t managing to maintain his own blood oxygenation (88-89% on room air), and he was in moderate respiratory distress. The senior resident pushed antibiotics immediately, and with that, the oxygen, and the constant stimulation, the infant looked to be improving. While waiting for some results to come back, I grabbed the parents and explained to them everything that had gone on. And while speaking with them, I realized that, for the first moment in my residency, I had the real, undeniable, concrete understanding that I had been the difference between life and death for a child.

The first labwork to come back was the arterial blood gas, telling us that the baby was acidotic (he couldn’t breathe fast enough to keep up with and expire the acid that his body was producing). A stat portable chest X-ray told us why — it looked like our little boy had pretty sizable right upper-lobe pneumonia. At the least, he was suffering solely from the respiratory symptoms of the pneumonia, but much more likely, he was septic from whatever was going on in there. I called the respiratory therapist to have him come down to set up CPAP (it’s a relatively non-invasive form of positive-pressure ventilation), and then went back to talk to the parents, updating them on what was going on.

Finally, the senior resident secured the baby a spot in the peds ICU, and I told the parents that they would be going upstairs in a few minutes. I reassured mom that she had done everything right, shook their hands, and said goodbye, but just as I was turning the corner to leave the ER, mom called me back. She seemed to be nervous, looking at her shoes and tentatively rustling a packet of papers in her hands; she finally asked if I would consider becoming their baby’s primary pediatrician.

And I was pretty much the happiest person alive.