Grand Rounds V. 5, No. 27

Now that I'm posting with a little more frequency, I submitted one of my recent entries to the bloggers' grand rounds. They're up to Vol. 5, No. 27 over at Code Blog, and since I was linked, I'm glad to be able to send some readers in that direction. Enjoy this week's best in medical blogging.

The Open Laboratory 2008

As you may recall, one of my posts from last year was selected for the Open Laboratory 2008 compilation, which gathered 50 posts from the science blogoverse for a print edition that you can buy. It may seem backwards to take internet material and print it on paper, but there's a good reason for it. The collection's proceeds go toward supporting ScienceOnline'10, a science blogging conference next January. The book is also a nice way to see how bloggers make legitimate literary and journalistic contributions to whatever conversations are being held on matters relevant to science, society and beyond. I've had only a few sciencey things published thus far, so will probably permit vanity to reach into my wallet to buy a print version. It's also available in .pdf. And if you wish to read each post in its original context, each one is linked at A Blog Around the Clock. If you do buy it, do so from lulu.com. The conference organizers get more funding that way.

I Blog, Therefore I Am

Instead of attending the ScienceOnline'09 conference, I was working on sorting out where my life's next stage would be set. But that didn't keep me from following some of the discussions about web publishing. One really interesting conversation worth your attention is the argument over the dichotomy between writers' lives online and in the real world. Dr. Free-Ride makes an insightful statement about the topic.

We may think of ourselves as being a particular kind of person on the inside, but from the point of view of the world we share, it's hard for me to believe that we aren't largely constituted by the stuff be bring out of ourselves. And I don't think that there's a principled difference between the stuff we bring out of ourselves in a three-dimensional conversation transmitted by sound waves and the stuff we bring out of ourselves in a blog post. Both are instances of communication that give others at least circumstantial evidence about what kind of person we are.

This supports my own approach to blogging. I blog because the internet affords a potentially interested audience for expressions that it is logistically difficult to find interest in off-line. And the people I meet on- or off-line will hear the same story, whether the word are printed or spoken. In the end both forms of communication end up shaping our futures, whether by design or accidental. Dr. Free-Ride continues,

Our past is out there on the internets. But testimony about our past would be available even in the absence of the internet (unless, once the recommendations are signed and sent, you've arranged for the speedy demise of all those who mentored you -- something against which I recommend in no uncertain terms). Opting out of leaving an online footprint is not going to give you full authority to tell the story of who it is you are and how it is you came to be that way. Your "authorial intent" in living your life matters, but the lives your life touches give their own testimony, and sometimes the story takes a turn you neither expected nor intended.

Right on! Would I be involved at Virtual Mentor or at WebMD or as an ethics teacher if I hadn't tried out this blogging thing a few years ago?

No Way!

Vote for The Differential

The Differential, a blog written by medical students for medical students (and others) has been nominated for a 2008 Weblog award. (I write articles over there.) If you read that blog or are inclined to vote for it, visit this site before January 13, 2009. You can vote every 24 hours.

The Open Laboratory 2008

Remember when I used to blog about science?

Lately I've been defending a position that scientists and engineers ARE needed in emergency rooms. But these arguments have been confined to physicians' offices in Boston, Chicago and San Francisco. I've neglected (or spared) you my vision (or opinion). So too have posts at my other blogs trailed off, the correction of which would be on my list of resolutions, if I made them.

But here's some good news to jump start my 2009 blogging efforts: Hope for Pandora has been included in The Open Laboratory 2008 for contributing one of the top 50 science blog posts of the year.

Those of you who've been with me the longest may remember my "Dear Reviewer" post from about a year ago. It's a lovelorn account of the complex relationship between author and peer reviewer.

I've read several of the other posts (over the year and this morning) and am honored to be in such good company. Head over to A Blog Around the Clock for the full list, and stay tuned for how you can get your hands on a hard copy or .pdf.

Hello. I'm Thomas. And I'm a Blogaholic.

Okay.  It's time to dive head-first into the medical blogging controversy.  One of my colleagues at the University of Washington is interacting with administration there to possibly set guidelines and recommendations for medical blogging.  He's got me thinking again about this issue.  As you recall, I thought a lot (and still do) about the line between sharing a patient's story (anonymized) and respecting her rights.  I settle with asking patients or masking identifying facts so much that the patient would not recognize the account as his own.  You can imagine there are a lot of people who have things to say about this.  I respond to my professional society's position in this week's article for The Differential.  Check it out if you have the chance.

Regarding blogaholism, I actually do score positively on the CAGE screen for blogging (A and E).

Carnivals!!!

My fellow bloggers,

Are you looking for some carnivals to showcase your best writing? Listen up!

Like so many of my extra-curricular interests, blogging has fallen a bit behind in the face of licensing board exams, finals, and long hospital work hours. It doesn't help that my current bus lines do not have wireless... But you've seen an increase here and at The Differential of late. I am really excited about what is going down over at Clashing Culture in the next two weeks. Thanks to the strong work one of my co-bloggers there (Mike, also known as Tangled Up In Blue Guy), Clashing Culture will be hosting not one, not two, but three carnivals in the next two weeks.

On deck over there is:

• October 8: Carnival of the Liberals ... Liberal politics hosted by Mike
• October 8: Four Stone Hearth ... Anthropology hosted by me
• October 15: Carnival of Evolution ... Evolution hosted by Mike
  

If you want to submit to any of these, click on the links above to either connect to a web form or to email the host.

500 Coyotes

Earlier this week around 6 AM, we caught a glimpse of a bushy black-tipped tail. And this evening, there was the familiar refrain of yip yaweeee. What a great way to celebrate my 500th post! The introspective coyote, searching for his reflection in pavement puddles is not a bad representation of the recent self examination I've been doing in the residency application process.

I'm guessing this season will have more rain and introspection. Hopefully, more coyotes too!

Happy 500 to me!

The HIPAA in the Room

I've been a little gun-shy of my posts on Hope for Pandora recently. It seems as though a Seattle medical version of big brother may be watching... watching blogs. One of my friends - a blogging friend and real-life friend - was asked to remove material or shut his blog down because a compliance officer at a hospital where we train was concerned that certain of his posts violated patient confidentiality. Check out Noel's blog, aptly named, Constructive Procrastination.

I have sought to maintain the integrity of my writing by anonymizing my stories or asking permission of my patients to write about them or folding several patients into one pseudo-fictional account in the interest of telling a good story. Each of these techniques fall within the guidelines of the Healthcare Blogger Code of Ethics. What bothers me is that my friend had also observed these behaviors in his writing.

What bothers him is the manner in which he was approached. I'll let him tell the story in his own words, which started a couple of weeks ago. It seems as though our hospital wants to have more control over what gets into the public domain from experiences inside the hospital. Since I have vague aspiration to publish some of my own expereinces in a format more commercial than a blog, this got my ears up. After all, I already write for lunch money over at The Differential. I contacted folks in the community relations department before starting that gig - I wonder if someone else is trying to enforce some element of control or oversight on writers like me.

I think that my hospital administration is a little out of its league right now. One in ten Americans have tried their hand at blogging or something like it. I'm betting that health professionals are no exemption to that. I'm a little worried about an Orwellian move here. Why isn't the Health Care Blogger Code of Ethics or something like it good enough?

The compliance office may be full of friendly faces and good intentions, but do they really know what they are trying to do? Fortunately, my friend has volunteered to provide a voice for us bloggers.

Facebook Pages

Here's a little entry to bring the blogosphere and the facebookosphere (?) a little closer together.


I've recently joined some Facebook groups that some of my readers may be interested in:

1. The American College of Emergency Physicians (ACEP), where I've started a little thread about ethics in emergency medicine.
2. The American Scientific Affiliation - a group of Scientists who are Christians... all perspectives are welcome - even extreme ones - but most of us seek paths that makes the two fully compatible.
   
3. The Student and Early Career Network of the ASA... there isn't a lot of support for younger Christians who are scientists. Perhaps this group could help with that.
4. Science Bloggers. Yeah, I think I am one of those.

Oh, and if you want to be my Facebook friend, drop me a note.

Podcast From the ASA Meeting

The talk I gave last weekend at the annual meeting of the American Scientific Affiliation about blogging as a useful tool for talking about ethics, science and religion in the classroom and in the public sphere is online. Listen to it here. It features my motivations for blogging, my experience here and at Clashing Culture, and some ideas about how blogs could play a larger role in dialogue about science and society in the public and within the mission of the ASA.

Man, is it painful to listen to yourself. Follow the link to the audio file at your own risk. I'll figure out how to post my slides, too.

I did talk a little about PZ Myers and Pharyngula as an example of discussions about religion that are more one-sided than I like. What did not come across until late in the discussion was how PZ linking my page once was a great boost to my activities on the web. For his notice and the associated traffic it brought I am thankful.

I did meet some other bloggers at the conference. One of whom lives about two miles from me.

Don't worry! There will be plenty of responses to the meeting coming up, mostly at Clashing Culture. See you there!

Blogging My Needle Stick

Taking my lead from ScienceBloggers Abel, who blogged his vasectomy, Dr. Free-Ride, who blogged her mammogram, or Zuska, who blogged her dilation and curettage, I decided to blog a recent personal medical experience of my own: a dirty needle stick.

Working in the Harborview emergency room is a unique experience. Medical students have the unique opportunity to be 'doctor' for a large number of patients. Yes, we have supervision... but if a case is straight-forward, we are permitted, correction, expected to manage the patients' care from start to finish. Students also see a large number of complex cases. Typical large hospitals may see 4 or 5 traumas roll through the door in a day. Regional trauma centers like Harborview commonly receive 50 medivac, airlift or medic arrivals each day. Medical students only manage the most simple of these cases, and even then, it's under the close eye of two residents and an attending physician.

It was in one of these cases that I incurred my first dirty needle stick.

Before this time, I'd never actually stuck myself with a needle. Five hundred rodent thoracotomies and a year in medical school, and never once had I punctured my skin with a suture or injection needle. My clean streak ended in the Harborview ER.

We received a morning transfer from a hospital in Montana. The announcement had come in over intercom that an intubated young man with a gunshot wound to the face was in transit. Only the basics are conveyed in these announcements, the dispatch only relays information critical to receiving the patient and supporting him. Often, GSWs (as they are referred to on the patient board) come with no warning. Rooms are already equipped to handle victims' emergent needs. By the time that "Airlift is through the door" was announced, I was in the room ready to help with the case.

My extensive (for a medical student) experience with delicate surgeries comes in handy in the trauma bays. I am happy to suture head and hand lacerations for the busy residents, and I take pride in my skillful artistry. (Although, I am careful not to tell patients where I got all of my experience.) By some miracle, the large gage bullet missed the jugular vein and carotid artery. It had destroyed most of the right half of the jaw and torn open the neck below where the angle of the jaw had been. Without major vessel damage, it was clear that some temporary repair would be performed before the patient went to the operating room; I made sure I was in the right place to help. By the time the ear nose and throat (ENT) surgeon came down to the ER, I had washed the wound with five liters of warm sterile saline. The surgeon was a young resident. At the time, I made no notice - owing to my extra-medical education, most of the residents are younger than I am. But this guy might fly in the face of a previous argument I made in the debate over whether it's more dangerous to get sick in July than any other month.

In the hierarchy of medicine, there is one way to make suggestions to superiors that helps get around the delicacy of status. It's the "would you like me to" question. Medical students and residents should always pay attention to the friendly nurse who asks, "would you like me to send this blood for lactate and enzymes, too?" or the physician's assistant who asks "would you like me to sign an order for labetasol? I've had good success turning this into a nice approach to suggest we do something with minimal toe steppage. In this case, I asked:

• Would you like me to make a sterile field around the wound?
• What size gloves do you wear?
• What do you think about clamping this small artery? and
• Would you like me to move the sharps off your field?

I'm pretty sure I asked that last question immediately before I felt a sharp twinge in my left ring finger. The resident had put down an old needle in a rather precarious spot, and I thought, "he's going to stick himself with that when he reaches for his forceps." I grabbed the remaining stub of thread from the field, careful not to let the dangling hook catch my glove while he took a sweeping pull at the current suture on his first knot. Ouch! Quick inspection showed the cutting needle had caused a rent in my glove and that my blood was mingling with the patient's. I immediately left the sterile field, washed my hand with soap, all the while milking the wound like a blood drive phlebotomist checking your hemoglobin. My hand was in the wrong place at the wrong time.

At my hospital, one employee per day experiences a needle stick. It is so common among health care providers that there are highly standardized approaches to dealing with the experience. The first steps occur in the ER. Fortunately for me, I was already there and everyone I came in contact with worked in an efficient manner. Along with the compassionate first year surgery resident who later that day asked if I wanted to talk about my experience, or the attending who checked in by email several days later, the efficiency of the process counter-balance my building worry with a sense of support. None of them knew that my wife was on vacation out of the country and that I might not have anyone at home to talk about this with. They were just there.

So what is the risk of needle stick injuries in contracting blood-borne diseases? My reading suggests the average risk for HIV transmission after percutaneous exposure to infected blood is low - about 3 per 1,000 injuries. And that is with exposure to infected blood. The other killers to worry about are the hepatitis B and C injuries, and they have much greater transmission rates. Transmission in needle sticks with exposure to the hepatitis B virus is 30% and could be as high as 10% for the hepatitis C virus. Like all health care workers, I am immunized against Hep B. There are a host of other diseases transmissible by blood (see this nice Canadian site for more info), but I was most worried about Hep C and HIV. There are no cures or vaccines for these diseases, but there are decent treatments for them. In particular, immediate use of anti-retroviral drugs have good evidence of reducing transmission from needle sticks. But did I want to take them? This returns me to the specifics of my situation. Much of medicine is paying attention to the history; this case's history is obscured because the patient was intubated and communicating via hand squeezes, and that his family was still en route.

The patient was a young man from rural Montana. Epidemiologically, that cuts his risk of having HIV or Hep C. But why was he shot? The story at the time was that he was snooping around a hermit's shack at 2:00 in the morning. My hunch was that illegal behavior was involved. Fair or not, at the time, this element increased my perceived risk of his being seropositive. In my head, I quickly came to the conclusion that my chances of catching one of the big three were very small, but not non-existent. I made the quick decision to take a dose of Truvada.

Whenever there is a dirty needle stick, the potential donor's and the stuck person's blood are sent for testing. This information is used both to treat or reassure the stuck employee and to establish a record of serotype. Usually the patient who's blood contaminated the needle must give consent for the tests, but in the case of an unaccompanied unresponsive patient, this makes matters more difficult. So my blood was sent, and eventually his was. (By the way, this information is divorced from the patient's or my medical record, for both confidentiality and billing purposes.) When the rapid antibody-based HIV test returned negative, I was comforted, but not quite enough to stop taking the anti-retrovirals. Anyone who's taken or given an HIV test should know about the "window period." This is the time it takes for the immune system to seroconvert: it's the interval between infection and a measurable level of antibodies in the blood. For HIV, this is about 6 weeks, but many still use 3 months as a fallback number. The antibody test can therefore only tell you the HIV status of a person three months ago. There's another, more expensive test that measures the virus rather than the human antibody to the virus. It uses genetic amplification to look for viral genetic markers. This can both reveal virus before antibodies are formed and tell physicians how much virus is in the blood (and therefore, more about the patient's symptoms and disease progression). I decided to request this test. After all, if this young man recently took to exploring hermits' shacks, what's to say he hasn't experimented with new drugs or sexual practices?

This argument was barely enough to convince the employee health director to proceed with the genetic test on the patient's blood and required me to take two more days of the one-a-day emtricitabine/tenofovir combo drug. After several conversations opening with my telling her my mother's maiden name, I learned that my serologies and the patient's were all consistent with no infections or infectivity. By then the stress of this experience had faded into just another experience in the Harborview ER. I'll probably be stuck again, and next time, probably won't seek the viral PCR test. But will I take the anti-retroviral immediately after the exposure? You betcha! With no side effects and once a day treatment, the only reservation is cost. I don't know how much one Truvada pill costs because my hospital paid for it. By the time the next stick occurs, the state of diagnosis and prophylaxis for HIV and Hep C may have changed. Perhaps there will even be vaccines.

Perhaps.

Market Research

Hi there,

Every so often it's nice to hear from regular readers. Toward that end, DrugMonkey threw out a meme that I thought was worth a try. But instead of posting something on your own blog, all you have to do is post an anonymous (or nominous, I guess) comment. If you read regularly and I don't know about it, it would be nice to hear a little bit about who you are. These days, I think most of my readers come in via google searches because I am not putting much content out, what with my insane schedule. Anyway, here's your charge dear reader:

Tell me about you. Who are you? Do you have a background in science or medicine? If so, what draws you here as opposed to meatier, more academic fare? And if not, what brought you here and why have you stayed?

Have a nice day.

The Internets

The internets are back at my house!

After almost 3 weeks without the line, we now have connectivity.

You'll see a few more posts from me here and elsewhere, but not many, owing to the insane schedule I've been keeping.

Later!

On Blogging in Medical School

Nick Genes, an MD/PhD emergency medicine resident, was recently asked the question, "What is your advice for medical students?" It was part of a feature of him in the Student British Medical Journal. He answered:

Start a blog. As I wrote in a column for Medscape, medical school is a transformative but isolating time. A public journal can update friends and family who might otherwise not hear as much from a preoccupied student. Blogging also prompts reflection and records intellectual and emotional growth. Medical student bloggers also make connections with other students who are considering the same specialties or places to train.

I'd say this is spot on. Whoa - an MD/PhD blogger who went into emergency medicine... Cool!

Google Me!

Just to be clear: I, Thomas Robey am neither a senior vice president of investor relations for Time Warner nor an otolaryngologist in Milwaukee, WI. Nor am I a Khoros computer language programmer or a Rotten Tomatoes film reviewer. As fun as those things all sound, I'm happy with who I am and what I'm doing now.

The Liability of Academic Blogging

It's been almost 8 years since I've had to sell myself. I'm again at that stage in life. It's coming time for me to shape up my curriculum vitae and personal statement for residency applications. And here's the dilemma: do I talk about blogging in my essay?

First, a step back for context: I'm fortunate in that I have some friends at hospitals where I hope to match. Some of them are even in the programs I'm applying for. One friend, in particular, has volunteered to be my insider agent at that school. I'm quite happy about this, because she is a very good student and will be an excellent ER doc - probably a professor - someday. It's nice to have folks who believe in you, but sometimes I worry about favoritism. Where is the line between the good-old-boy cronyism and networking? Anyway, she's already connected me with folks who will be helpful in my application process. My interest and dedication to the ethics and policy of science and medicine is one thing that makes me unique compared to other applicants, so this is part of her description of me. A description which often includes 'blogger.'

Ethics and policy is the way my commitment and passion for improving 'the system' takes form. In graduate school, the main way that I did this was by organizing events and bringing people together under the umbrella of the Forum on Science Ethics and Policy. Now that I'm busy with medical school, I work in ways that allow me to contribute to and learn about the contextual issues of science and medicine on my own time. Reading and writing, mostly. And this is where blogging comes in. I write other things - like the review article about urgent care clinics' impact on the ER safety net I've been working on for a couple of months, or the syllabus for a med student clinical ethics course, or those pesky responses to reviewers for my work in graduate school, but blogging is where I transcribe a majority of my ideas.

My blog does not have a lot of readers. At first, my main goal was to increase readership. Readership does grow slowly with quality content, but it grows much more quickly via self-promotion, links from big bloggers and writing on oft-searched topics. I even wanted to be assimilated by the ScienceBorg at one point. Getting this attention is no longer my priority. When I started blogging, it was primarily to find a voice. These days, I use my blog as a laboratory where I experiment with writing. I had no idea how cathartic the activity would be, and my interest in writing has since spilled over into two other (much more widely read) blogs and a (sorry, no public access) personal diary. Dare I say that 'blogger' is now a key part of my identity?

So how does this all fare in the world of residency applications? Despite efforts on the part of a philosophy professor in the bay area, the notion of blogging is still taboo in academia. (Note to said philosophy professor: is there any way you could seed this trend of legitimate academic blogging in some of the institutions just to the north of you? :-) --> j/k) I believe that in the right format, blogging is a legitimate academic activity. Even so, I still tend to de-emphasize blogging and use words like columnist and writer to describe what I do. Blogging is just a means to ends activity anyway: the end could be as broad as 'increased understanding' or 'better writer,' or as specific as 'a book' or 'drafts of opinion pieces in journals and newspapers.' And all of these ends should help me be a better academic, right? So why am I afraid to present the means in my personal statement?

Clashing Culture

I'm in the process of starting a new group blog called Clashing Culture. It's meant to be a place where atheists, agnostics and Christians can contribute and discuss posts that deal with the intersection of science and religion. So far, Mike Haubrich (Tangled Up in Blue Guy) has signed up. We're looking for more authors. If you are interested, drop me a line.

Looking For Medical Student Blogs

Has anyone out there encountered a medical student blog written by a first or second year, or by a recently accepted student? Perhaps you read it, perhaps you write it. Either way, I'd like to add good ones to my blog reader...

Thanks for your help.

Asked To Be Super, But Not Up To The Task

This one goes out to ScienceBlogs readers.

Last month, I received emails from two different science bloggers inviting me to be a ScienceBlogs "Super Reader." Since I read several of Seed's ScienceBlogs and think that blogging is a good way to diversify the conversation about science, I agreed to be a reader. So what does a Super Reader do? Basically, Seed wanted to present a more qualitative metric by which a 'best of' list could be compiled. In the large ScienceBlogs venue, some of the most thoughtful writing may not be the most emailed or the most commented on; the former often are funny or cleverly sarcastic, while the latter are usually posts by PZ Meyers.

In a nutshell, Super Readers are tasked to post at most 3 entries a week to a del.icio.us account that the Seed blog editors have access to. This information is fed into a sidebar that indicates the readers' picks. This way, when I only have 15 minutes to surf the net, I can rely on well-informed readers to clue me into the most interesting posts. I imagine each blogger is allowed 2 super readers so that every blog is given a fair shot at making the hot list. While the "Most Active" feature is like the populist House of Representatives, the "Readers Choice" list is like the Senate - equal representation from each blog.

Some bloggers posted invitations for their readers to apply. I was solicited by folks who know I am a regular reader and commenter. The funny thing is, after I received the invitations and replied that I was willing to do a little bit of Seed's legwork for them (see the comment in this post), I haven't heard a thing.

Now comes the part of the post that presents fanciful theories. I am surely in the minority of folks who have been critical of how, well, overtly atheist the ScienceBlog community is. Often, I wish that folks like Rob Knop were still around to stir the pot. Perhaps knowledge of my minority view is why the Seed editors have not replied to my emails 'accepting' the role of SuperReader, but I doubt it. I bet there are some bloggers over there with religious beliefs from the East or West, old and new who see the conflict between science and religion as either constructed or impertinent to their mission as writer bloggers. Maybe I got the wrong email address in my response accepting the invitation. Or maybe, the Borg (a lovingly pejorative term for the ScienceBlog community) somehow knows that I only read 15 of the blogs over there. But in the end, there are already too many crackpot conspiracy theories out there about the blog collective than are reasonable. I have the sense that good things make for big targets, and rather than continue to assail, I'd rather contribute. My emails were probably and simply lost. (Update: this last theory is the correct one!)

I'm still happy to participate - It's not very hard to click a button when something you read is interesting! And I do think that participating in a community of commentators such as exists at ScienceBlogs is important. And if I don't fit into the Borg's demographic as an enthusiastic unpaid volunteer, that's fine. It would have been nice to have been told as such.

After sending another email and posting this mini-rant, I'm ready to move on.

Thanks for listening.