SC And NV As Measures Of The Southern Electorate

It looks like Hilary Clinton has won the Nevada Democratic caucuses. Romney took the Republican vote there, and at this time, South Carolina is still up for grabs. Let me try to break down the implications of this for you by consulting my clairvoyant test tube wonder-rack.

It appears that the blue marbles at right (proper name: Elaeocarpis grandis) have developed a white scaly monospecies growth. The effect is quite striking, a simple, raised white scale with well demarcated borders in 0.5 mm to 8 mm diameter colonies involves the surface of each fruit without altering the underlying azure pigmentation. The next development since New Hampshire is a localized proliferation of filamentous grey mold on select snow berries. Colonization is limited to berries that have undergone chromatic denigration (white to brown). Numerous unaltered berries persist. The other specimens remain grossly intact, but with minor signs of degradation and dehydration.

What does this all mean? I invite you to consider these berries' initial presentation and put forth your own opinion. Rarely is one person's political commentary enough. Since this is my blog, I'll start us off.

My read of the blue marble phenomenon has troublesome implications for the Democratic party. To have such a large contingent of the blue tubes' representation contaminated with mold suggests either that the principles or approach of the party is failing. An alternative interpretation is that one tube (one candidate, perhaps?) is off to a quick start but that the direction is fallible. What about the lack of change in the red tubes? We must consider that the red tubes do represent the conservative party. Conservatives tend to resist change, after all. The small amount of dehydration (indicated by shriveled skin) demonstrates some initial signs of fatigue early in the race. We might expect some of the specimens to endure the race differently. It will be interesting to seewhat happens by the next primary. Super-Duper Test Tubesday appears to be the next contest of note. Check back then for more completely serious analysis.

I hope by this point that you realize my method as no more rotten than the analysis techniques favored by the talking heads on the news networks.

Surviving Overnight Call

There are probably numerous anecdotal reports out there about how to survive a post-call afternoon. I am too delirious to do the work of finding and/or categorizing them right now. Anyone have any tips?

For those outside of medicine, post-call is the afternoon after you were up most of the night caring for hospital patients. My two previous rotations only required me to stay at the hospital until midnight. Inpatient medicine is another story. I am at the hospital for 30 hour shifts twice a week.

While I am in the hospital, I'm pretty sure my cognition is around my baseline. I cannot however say that I am used to being post-call yet.

The first time I pushed through the afternoon with caffeine, went to bed early and woke up groggy at 3 AM. The next experiment involved cutting the caffeine at 10 AM (I am on until 1:00), taking a brief nap when I got home, exercising somewhere in there and then going to bed at a normal hour. In those cases, I got 4-5 hours in the hospital sleep room. Last night, I only got 2-3 hours. I promptly crashed for 3 hours when I got home, completed a rather lame attempt at a workout and now am still awake...

I have tried to eat my regular 3 balanced meals, but when you are up for strange hours, I think another meal or snack needs to be thrown into the mix. We must also consider the regularity and balance offered by hospital cafeteria cuisine.

Anyone out there have any tips? You should know that I have a celebrated history (as an undergraduate) of conducting all-nighters without much difficulty or consequence. I haven't decided if my difficulty these days is that I'm 1) out of practice or 2) old.

A Case For Obama

Brain. Quivers. Like. Jello. I'm post-call today. Yesterday I admitted one patient to the intensive care unit, and unfortunately, another coded and needed to move down there. Needless to say, I did not have much time for sleeping.

It's times like these that I can rely on my friends to say thoughtful things about stuff. The rest of this post is an email to me from one of my MD/PhD colleagues when I revealed just how undecided I am about the upcoming Democratic primary. He also happens to write a column for Seattle's alternative newspaper The Stranger called Dear Science. Each point has a link to a longer, wittier post over at Slog, The Stranger's blog.

I'm leaning heavily towards Obama, for three disparate reasons.

1. His favorite TV shows are M.A.S.H. and The Wire. (Ok. I'm being somewhat serious here.) The wire perks my ears up. It's a seriously dark-minded exploration of the decay of US cities and communities. Most intriguingly, a central theme is the limited ability of those in power and institutions to deal with the problems faced. Any president (or presidential candidate) who starts from this attitude gets some respect from me just for self honesty.

2. Obama, when he was a State senator, initially supported a bill to require universal influenza vaccination during the last big shortage. Public health advocates visited him and explained that during a shortage it is way better to limit the vaccine to those who really need it--the infirm and health care workers predominantly. He argued back, asked tough questions, but eventually was convinced. He publicly supported the less politically tractable but empirically "correct" policy, even though it wasn't his initial judgment. To my mind, this demonstrates why Obama the most "scientific" candidate--willing to critique, accept and change with data.

3. His rhetorical strength is well suited to the presidency. Hillary and he essentially support the same policies. Hillary claims she knows how to best maneuver in the existing political environment. Obama claims that he can *change* the political reality to make dramatic policy changes. I find Obama's read to be the more compelling. In other words, Hillary has made and excellent case for herself--as senate majority leader.

Pair up an Obama presidency with a Hillary Clinton led senate? Wow. I get shivers.

Me too. Oh yeah - that's because it's 17 degrees in Spokane...

Metastatic Prostate Cancer

This one is heavy.

"You and I talked yesterday about the blood prostate test that came back with a very high value. That combined with your low blood counts is why we did the bone scan this morning. It looks like some prostate cancer has spread to your pelvis and tailbone."

It's taken a while for me to work this first experience delivering a cancer diagnosis into a cogent journal entry. When it comes to this blog, I have the most success transcribing ideas and feelings immediately. This one required more drafts; a whole folder of entries spanning several days sits tucked away on my hard drive. What I keep coming back to is that through my entire experience with this patient, I never felt uneasy.

Sitting on his bed, without my white coat, without my clipboard, and without a rehearsed statement, I was simply present with him. I still can't find the words to describe my feelings in that moment. Why can I not pin down my emotions? Was it confidence about a puzzle solved? Relief that the patient was finally given an answer? Surprise at how much the patient already knew (even without symptoms or knowledge of lab results)? Was I feeling an adrenaline rush due to an awareness that I was participating in an important point in this man's life?

In the end, the question I need guidance about is: Is it wrong to be comfortable delivering bad news?

This patient gave me permission to write about these experiences but asked me not to use his name.

Are you SAD?

If you've heard of SAD, you've also heard about light therapy. If you pass off light boxes as voodoo, you've overlooked a body of scientific literature indicating otherwise.

Head over to The Differential for my latest article about seasonal affective disorder (SAD) in medical school. While you are there, check out the good posts by Ben and Kendra about medical marijuana and successful presentations on the wards. (Those are two different posts.)

Oh - and SharpBrains has the lastest installment of Grand Rounds. The gracious host accepted all 38 entries (so I got in!) and formulated each into a question for the next US President.

Washington Precinct Caucuses 2008

It is less than four weeks until Washington State begins the process of nominating candidates for president. Unlike many states, Washington has both party caucuses and a primary. If you are a Democrat, the primary doesn't count for anything. It's more complex if you are a Republican. (Washington Republicans pick 49 percent of their delegates at Feb. 9 caucuses, and 51 percent in a Feb. 19 primary. Washington Democrats pick all their delegates at Feb. 9 caucuses.)

Caucusing is a little complex, and this post is meant to remove some of the mystery of it for you. Pay attention, because Washington State could actually make a difference this year. (Especially if what seems to be the Obama-Clinton race is not settled by February 5th's Super-Duper Tuesday.)

My experience with this phenomenon includes caucusing for Howard Dean in 2004; I was a delegate to the 46th Congressional District Convention several weeks after the precinct caucus. By then, Kerry had clinched the nomination, so all of the delegates (even if their initial choice was out) lined up for him. He eventually carried Washington's primary (and later the general election).

Caucuses are a way to bring communities together to argue the merits and demerits of presidential candidates. In Seattle, they mostly occur in churches, schools and libraries. Those in attendance from each precinct gather for a more-or-less structured debate about the candidates. After eye-to-eye conversation (and sometimes conversion), several polls are taken. Any candidate with more than 15% of the vote is then entitled to delegates to the total reported in newspapers the next day. These delegates move on to the district, county and state conventions, with the final outcome of the selection of Washington's delegates to the parties' national nominating conventions. Caucuses and conventions are ways to begin the party mobilization process - essentially organizing get-out-the-vote efforts 9 months before the general election. (Somewhere in there is a really good gestation metaphor.) It's not just the presidential race that is considered, though. Die-hards can offer resolutions at the precinct level that have the opportunity to contribute to district, county and state party platforms. A basic explanation of the Democrats' system is available here.

In the end, what happens February 9 mostly just provides bragging rights for whichever candidates remain in the hunt.

The first tier in the caucus-convention cycle consists of the precinct caucuses which will be held on Saturday, February 9, 2008 at 1:00 pm at a location in or near your neighborhood. Because you have to be present in person to participate, it's important to know your precinct number. In King County, visit this web page to look up that information. That page will tell you your polling place, BUT NOT YOUR CAUCUS SITE! That is because the state runs the primary and the parties run the caucuses. To find your caucus site, you need to go to your state's or county's party website. The best is the caucus finder on the Washington State Democrats' web page. To help my one King County Republican reader find his caucus information, here is the website you will need. Where you caucus really matters which party you are in. For example, if I were a Republican, I'd be heading to the Nathan Hale High School cafeteria. Since I'm a Democrat, I'll be heading to Sand Point Methodist Church.

The only qualifications permitting a vote by proxy are religious observations, military service or disability. If these apply to you, fill out this form. For me to participate, I'll need to drive to Seattle from Spokane. Fortunately, I have other business in the Emerald City, so the trip will be worth it. Furthermore, I have voted in every election since moving to Washington, and I intend to keep it that way!

By the way, if you are looking for a prognostication of the outcome of these 2008 races, look no further than this blog's predictive installation.

SMFPNIS For Two Days In A Row!

Science is big news in Spokane! This picture of molecular anthropologist Dr. Brian Kemp made a splash above the fold on the front page of today's Spokesman Review. Using molecular techniques he devised as a graduate student at UC Davis, he has established the age of native peoples in the Western Hemisphere to exceed 15,000 years. Check out the Discover Magazine story, or the original report in the American Journal of Physical Anthropology. The story in Spokane's paper was to feature how prominent Washington State University is becoming on the national research scene. He actually did the work as a post-doc at Vanderbilt. It seems as though he is setting up a new lab at Wazzu.

If Seattle's papers would stop trying to pick apart the University of Washington for animal research policy, human subject trials and medical mistakes and focus on the positives of having a world class university in the backyard, maybe it would be easier to fund higher education in this state.

Wondering about the acronym in this post's title? Go here.

Science Makes Front Page News In Spokane

Someone once pointed out to me that Seattle is the most educated city in the country. This may be true, but when is the last time you saw SCIENCE on the front page of Seattle's major newspaper? You must look to the other side of the state - where cougars live and snow sticks around for weeks... I've already found a way to be proud of my temporary hometown of Spokane.


Not only did SCIENCE make it to the vaulted pages of the Spokesman Review, it came with the hottest accessory for the lab these days: colored safety goggles. Someone should remind Dr. Pink that the pencil she is absent-mindedly about to put in her mouth could be contaminated with liquid C. The photo accompanied an article about the impending showdown about the No Child Left Behind legislation that President Bush wants to carve into stone tablets. All I have to say is, "Hooray SCIENCE!"

I am not kidding: this was 8 inches wide and above the fold on Friday's paper.

High On The List Of Conversations Not To Have When You're Post Call Is...

...a discussion of the differential diagnosis for elevated liver enzymes.

Let's back up, shall we!

Post call is the day/ medical-legal term/ state of consciousness that occurs after an overnight shift at the hospital. "Call" has varied meanings in different health systems. For medicine residents, it usually means:

• Coming to work at the normal time of 6:00.
• Working all day.
• Taking care of the hospital service patients at night.
  
• Staying at the hospital overnight to admit new patients.
• Sleeping from 0-4 hours in a special call sleep room.
• Being available to answer pages from the floor or the ER and responding to codes, if needed.
  
• Presenting the patients (new and old) the next morning to the regular day team.
• Leaving the hospital no later than 30 hours after arriving.

In Spokane, things are a little different. They run the residency program like a hospitalist service. This means that one team of residents signs in at 6 AM and they hand off their patients to the night team at 6 PM. This is what is called (pejoratively by some) shift work. These transfers are called sign-outs. While the residents work 12 hour shifts, medical students in Spokane take the more standard 30 hour shift. But we are not limited to 30 hours. No legal recourse exists if we work more than 30 hours in a row or more than 80 hours in a week. That protection only applies to residents. Something to look forward to, I guess.

Well, tonight was my very first overnight call. My two previous rotations set medical student call as morning sign-out until midnight. Since my current hospital has a call room for medical students, I get to stay all night. I admitted one patient, and then checked up on my other three, one of whom had a new finding of elevated liver enzymes. Which brings us to the original point of this post: It is difficult to access information (even the basic stuff) when you are not used to staying up all night. There are a number of reasons liver enzymes could be elevated. And because I'm a nice guy, I'll tell you what they are.

• Drug Toxicity
• Acute Viral Hepatitis
• Steatohepatitis (Alcoholic and Non Alcoholic)
• Biliary Obstruction
• Infarcted Liver
• Traumatic Injury
  

Actually I made this list in a (probably futile) effort to cement them into my drowsy brain. But there you go. Good night Irene, good night Irene...

Evidence Based Obstetrics

One of the great things about blogs is how a post about one topic can quickly morph into a good discussion about another. I bet early meetings of Ben Franklin's Junto (or later the American Philosophical Society) were similar to what happens when a good discussion gets hijacked by a barely related intriguing idea.

Anyway, Drugmonkey posted an informative update about the current presidential candidates' positions on science. If there is one topic that has been wrongly overlooked by candidates this election season, it is a proper airing of their perceptions about science and health research funding, the role that science should play in public policy decisions and how science education can be improved. Head over to this DM post for a digest of Science magazine's handling of the candidates' positions on science. Within the comments thread, is a sub-discussion about the lack of scientific evidence for the choices obstetricians make during delivery. The specific question that I argue has no scientific answer to is: Do fetal cardiac decelerations necessitate Caesarian section? I admit: the left turn was kind-of my fault,but my appeal to you, dear reader, is to find your way to this thread and chime in about the role of evidence in Western obstetrical care. (Read about the candidates' views, too!)

I have a love-hate relationship with the current emphasis on 'evidence based medicine.' It is certainly indicated, even needed in many cases. Enough of the studies are poorly designed or in conflict of interest, that it is hard to change a policy because some perspective made it through peer review. I suppose I would advocate a slow transition to evidence-based practice. Meta-analysis means more to me as a mode for medical decision making.

But bringing this full circle, what does it say about the role of science in society that one of the areas of life that is perceived of as being influenced the most by science (medicine), is actually not very scientific? If science cannot be practically applied to medicine, or more specifically birth, can it really be applied to policy decisions? It's not like there's any shortage of research material.

Impersonating an MD

Here's an important quiz for you:

Which of the women below is a doctor? Which is a medical student?

Try not to pay attention to the body language in making your decision... If you're stumped, consult this introductory review.

Sometimes I wonder how much of medicine is just show. Good luck not being stopped by a nurse between the stairwell and the patient's room if your wearing just a shirt and tie. (Actually, I prefer an evidence based wardrobe: tie free and proud.) The appearance of physicianship causes people to hold doors for you, gives you wide berth in the cafeteria, and leads toward more held elevators than I care to list. I almost feel bad making those passengers wait for me as I turn in to the stairwell.

Get to the point, Robey!

Today I left the key to my hospital locker at home. This forced me to make a temporary wardrobe change. Not many med students serve at this hospital, and few of the staff are as large as me. There is a rack of clean guest coats in the residents' locker room; I was lucky to snag one labeled 2XLT. So until the program assistant was able to lend me an extra key, I wore the mantle of a resident. Not only did this coat fit better, it looked good. (Please apply your best girlfriend language to that last phrase.) If you think medical students' white coats look funny down to the hips, consider what it would look like down to the belt. Yes, it is that bad.

Anyway, by 8:00, the administrator had returned so I was able to slip back into my short white cloak of vulnerability. I'll just have to savor my 2 hours of power.

Here's what I will not savor:

• Wearing white coats on the bus. Talk about a power trip. Come on people, get over it already. Yes you are a doctor. You are also one of us. (Speaking as a non-doctor.)
• Wearing coats in the cafeteria. Who knows what other substances rhyming with cafeteria are on that coat. It's worse than Mr. Yuk - It's Dr. Yuk.
• Brown sleeve cuffs and clear signs of dirt. How does the jingle go? A-L-L: the stain lifter!
• White coats at noon conference. At least take the jacket off while you munch on your sandwich.
  
• Doctors coming out of bathrooms with white coats on. Gross!

Those who know me, feel free to call me out on any of these should you note hypocracy...

First in the Nation

What this primary season needs is more science built into the decision making process. To satisfy all of the political empiricists out there, I have adapted my art installation test tube series for the conduction of a long-running experiment. This piece is meant to gage the reactions of the electorate. I-a-want to measure the extent to which politics can be evaluated in the test tube. After all, it seems as though the activation energy has reached a critical mass, especially for the newer reagents on the scene. Let's face it, there are a few catalysts out there fomenting for fermentation. Some of us are already degrading the drawn out run times for this current cycle of American politics. Red or blue, there are many who seek a phase change. More than a sampling would offer that anything could yield relief from the current entropic change we find ourselves in today. What I have for you is:

"These Colors Don't Run (they grow mold, ferment, degrade, are infested with insects, turn to slime and just plain smell bad):
A Long Term Study Of The Forces Of Nature On Assorted Fruits From The Western United States"
Wood, Glass, Found Berries
Thomas Robey
January 8, 2008

For those of you keeping track, this is the third version of this living installation. (First & Second) In keeping with the tradition of scientific classification, from left to right we have:

Wild Rose Hips (large, shriveled by frost): Spokane, WA
Wild Rose Hips (small, firm): Spokane, WA
Snowberry: Seattle, WA
Wild Rose Hips (medium, blanched white): Spokane, WA
Wild Grape: Lafayette, CA
Blue Marble Tree Fruit: Honolulu, HI

Yes, Yes, I know - Three different rose hips! I would invite you to find red and white berries in Spokane. In the dark. Beneath several inches of snow. After working in a hospital for 12 hours... What I lack in diversity of species, I hope I make up for in geographic diversity.

Check back for periodic updates on the developments of this piece. Frankly, my expectations are about the same as for the current primary races: decay and destruction with the hope that something great comes of the mess.

Props to DrugMonkey for planting the seed for this experiment.

Too Legit To Quit?

How long can a newly minted PhD last without having a first author paper to his name?

Evidently, about 3 months...

Robey TE, Murry CE. Absence of regeneration in the MRL/MpJ mouse heart following infarction or cryoinjury. Cardiovasc Pathol. 2008;17:6– 13.

The text is available with subscription here. Email me or post a comment if you would like a .pdf.

This is the lead article in the first issue of the 2008 volume of Cardiovascular Pathology. Who says you can't publish negative results? If you recall, there was a bit of a splash earlier this decade about a funny mouse that could (amazingly!) regenerate its heart after injury. To catch up about how this over-hyped story has played out in the last 7 years, read this nice review.

It took a year for this to go to press after it was accepted, hence the lag between earning the PhD and being published. There are more on the way, hopefully including a pair I polished up for submission last Friday. But none will receive the fanfare I afforded this one. There is just something special about the first time.

As far as the post's title, what's up with PhD students slaving in the lab for years and then deciding not to pursue a career in academic science after all? I don't know. Check back with me in a couple of years.

The Differential

And now for something completely different(ial):

I now have the privilege of posting weekly over at The Differential. I'll continue to write here at Hope for Pandora, but The Differential affords me a new audience, new colleagues and a venue to more formally explore my experiences and ideas concerning medicine, health policy and graduate medical education. You are welcome to read (and comment on) my entries over there, but if you are a med student, prospective medic or just interested in what the real-life 'Scrubs' is like, I encourage you to read my colleagues' daily posts.

I'll be sure to link each of my articles here whenever they are posted. Here is my introduction. I'll use one of these logos to alert you to a new post:
By the way, The Differential is part of MedScape, which is itself a branch of WebMD. I'll see you there.

Darwin Trounces HIV

This just in: Charles Darwin has won the 2007 Spring Science Showdown. For those unclear of this event, it is a parallel (yet protracted) version of college basketball's March Madness. 65 themes, subjects, ideas and personalities from all corners of science converge for a grand battle of wit. Each match-up consists of a science blogger's play-by-play (sort of) commentary on the relative merits of the two entities facing off. The final match was between Darwin and HIV, and in a curious twist was decided by readers' comments. As you can see from this post, Darwin won. Some interesting past match-ups featured internal medicine (my current clerkship), Thomas Kuhn, invertebrates and fossil fuels.

I hope that I can be part of Spring Science Showdown in 2008. With my real-life basketball team (Pitt) missing two of its starters to injuries, I think I am going to need some more abstract objects to root for. As for credentials, I offer this commentary.

Looking Forward by Reflecting Back

Dr. Free-Ride alerted me to a year-end tradition of referencing a sample of 12 posts from the previous year. Drugmonkey did it, too. Since it's already the new year, this will be a reflective exercise for me - and since I'm late as usual for these sorts of things, I've mixed it up to include the first sentence of the last post in each month. If you click on the month's name, you can read the whole entry (and those from the preceding of the month). Here's to blogging 2007!

• January: Consider this entry the second in a series of accounts detailing the peril of trusting journalists to relay scientific findings to the public.
• February: What? Another bogus study?
• March: Those of you out there who have published scientific papers, have you ever seen this?
  
• April: Is not driving to work going to affect my carbon footprint?
• May: Have you seen a large, difficult to describe hominid wandering the shores of Puget Sound recently?
• June: It's a Saturday night - June's final day.
• July: Lately, my walks to and from bus stops or around campus have included a little foraging for berries, flowers, coyote scat and other cool stuff.
• August: Evidently, today is BlogDay.
• September: The game is tied in the bottom of the 10th.
• October: A good cartoon tells it the best sometimes.
  
• November: This is the third part in a series of posts describing a recent visit to two of northern Kentucky's attractions: the Creation Museum and the Ordovician fossil beds.
• December: So continues documentation of my eclectic vacation...

This is a good representation of teaser lines. If I don't start with a question, I tend to insert a brief context update in each entry. If nothing else, this little exercise has made me aware of the importance of a good first sentence.

Carry on...

10 Days Past Christmas...

• The days are getting longer (hopefully diminishing SAD).
• A forest of pine trees have commenced a slow march to the curb (hopefully to be composted).
• Wrapping paper has been purged from living rooms (hopefully to be recycled).
• Gifts have migrated from piles into their new homes (hopefully to be used).
• And Christmas is in decay (hopefully to be bleached).

As a reminder, the original colors were:
Snowberry, Laurel, Hawthorn, Salal Blossom, Fir Twig, Sumac Berry

But more specifically, Christmas is moldy...

Happy New Year.

Stay tuned for "Experimental Elections". Or perhaps I'll call it "Electoral Reactions." Or "A Test Tube Electorate." Or...

Joseph Cornell vs. Mr. Wilson

So continues documentation of my eclectic vacation...

Today I finished reading a most intriguing book: Mr. Wilson's Cabinet of Wonder. This fantastic non-fiction narrative is a pseudo-biographical account of David Wilson and his Museum of Jurassic Technology written by Lawrence Weschler. It is an excellent window into the subculture of museum quality pseudo-science similar to the kind forwarded by the Athanasius Kircher Society.

The other thing I accomplished today was a visit to the San Francisco Museum of Modern Art. There I made a beeline for the Joseph Cornell exhibit (in the last stop of a traveling exhibition). In many ways, he is the chief influence for my Wunderkammern creations (albeit via David Francis). I spent about 2 hours in the 1000 square foot exhibit, and was thoroughly impressed. This show only lasts until January 6 and SFMOMA is the last stop.

In summary, my New Year's Eve can be summarized as Joseph Cornell vs. Mr. Wilson. To those of you familiar with this art and work (or with the interest in following up on them): which do you prefer?

Christmas Lights

Do you live in the Bay Area? Have you not yet had your fill of Christmas Lights?  Do you have a tank full of $3.50-a-gallon 87 octane anxious to be incinerated?  If your answer to these questions is yes, consider driving to 2724 Ascot Drive; San Ramon, CA.  This writer (known to some in my family as "Mr. Cynical Christmas") drove there twice.  Add hypocritical to that moniker.  Anyway, once you are there, tune in to 100.7 FM.  If you want to surprise yourself, read no further.  If you are actually thinking of going, don't worry - it's much cooler in person!  If you only want to take a virtual trip to this fantastic display, please enjoy the following videos from YouTube.

First, you will need to check your processor speed.

Act One: 34th Street Overture

Act Two: Carol of the Bells

Act Three: Illuminations

If you want to do something like this using a commercially available controller unit, look no further than the Light-O-Rama.  And since you will be able to afford the extravagance of the several thousand dollar computer, the lights and the energy bill, consider offsetting some of your carbon.  Two companies that will take you money to invest in methane and wind projects are terrapass and NativeEnergy.   I have a gut feeling that planting trees is a better idea; the Carbon Trust devotes much of its donations to tree planting and conservation (and it's a non-profit).  Check out this Grist post for more of the gory details of carbon trading.

In the end, I was just as happy with a failed attempt to find the two western screech owls hooting in the trees above my parents' house.  In the process, I only scared one of their neighbors. 

I hope this post was random enough for you.  

Goodnight.

Book Review: Saturday

Today I read an excellent novel and feel like transcribing a response before I retire for the night. This is a mini-review that includes two quotations and a few comments. My intent is to reveal only whether this would appeal to you: a prospective reader. Attention to the diverse tags at the footer of this piece should clue you to this story's complexity.

The review and summary of Ian McEwan's Saturday you'll find at your favorite online bookseller calls this book "post-911 fiction." While I am uneasy about this label, I suppose it is appropriate. The story wraps itself around the events undertaken by one man in a single day in London. The man happens to be a neurosurgeon and the day happens to be Saturday, February 15, 2003 - the day 2 million Brits marched in Hyde Park against the impending Iraq war.

The protagonist - Henry Perowne - continually analyzes his own emotions and his own perspectives. Reflective and introspective are not common descriptors of neurosurgeons. They have a reputation (an unfair caricature, to be sure) as cocky brutes who see the entire hospital as an enterprise to support their masterful handiwork. I suspended belief for this element of plot, but needed not forgive other shortcomings. McEwan accurately (by this med student's appraisal) incorporated both the complexities of numerous neurosurgeries and the uncertainties of neurodegenerative disease.

The contemplative neurosurgeon is hardly unbelievable. His two children are artists: his son a blues musician; his daughter a poet. His pensive musings frequent upon his inability to understand them. By the time I reached this passage on page 54, I had committed to finishing the novel today.

Once, on a walk by a river - Eskdale in low reddish sunlight, with a dusting of snow - his daughter quoted to him an opening verse by her favourite poet. Apparently not many young women loved Philip Larkin the way she did. "If I were called in / To construct a religion / I should make use of water." She said she liked that laconic "called in" - as if he would be, as if anyone ever is. They stopped to drink coffee from a flask, and Perowne, tracing a line of lichen with a finger, said that if he ever got the call, he'd make use of evolution. What better creation myth? An unimaginable sweep of time, numberless generati0ns spawning by infintesimal steps complex living beauty out of inert matter, driven on by the blind furies of random mutation, natural selection and environmental change, with the tragedy of forms continually dying, and lately the wonder of minds emerging with them morality, love, art, cities - and the unprecedented bonus of this story happening to be demonstrably true.

This prose is just my style, the modernist presentation suits my taste in literature and the subject matter is not too far from my everyday life to disorient me on this simple restful vacation I find myself on. A lot of other people said good things about this book, so now I've put my hat into the mix.

I leave you now with verse selected from the climax of the story:

Ah, love, let us be true
To one another! for the world, which seems
To lie before us like a land of dreams,
So various, so beautiful, so new,
Hath really neither joy, nor love, nor light,
Nor certitude, nor peace, nor help for pain;
And we are here as on a darkling plain
Swept with confused alarms of struggle and flight,
Where ignorant armies clash by night.

Bonus points will be awarded to my readers who recall the author of these words.

Mele Kalikimaka

Merry Christmas from the windward side of Oahu!

I am taking some much needed rest from the toils related to finishing graduate school and transitioning into medical school. My comments and entries (if you haven't already noticed) will come a little more slowly in favor of boogie boarding and sunrises on the beach.

By the way, I highly recommend having in-laws that live in Hawaii.

End of Days

Okay, so final day (as in day of the final) doesn't exactly count as 'end of days.' None-the-less, it is nice to be almost finished for the year. In about 15 minutes I log on to a web exam for my family medicine clerkship. All over the Pacific Northwest, nervous little medical students (or big ones) will be holed up for three hours in some corner of a hospital or doctor's office answering questions about blood pressure, diabetes, earaches and depression.

At least this exam is a pass-fail test. You have to pass the first time to get 'honors,' but as I understand it, the score is not fed into an algorithm. This is good for me, because as I get older, I do less and less well on standardized exams... More on that later. I have to go complete an academic integrity statement!

Movie Review: I am Legend

I'm no film connoisseur, but I am a scientist and physician. Well, almost a physician. So it is from a biomedical perspective that I present my review of I am Legend, starring Will Smith. This is the first film I have seen on opening weekend in as long as I can remember, and the first I've seen in a theater since Arctic Tale. This article won't be a true spoiler, but I will address several critical plot elements. Stop reading if you don't want to ruin the surprises. First, it was nice to see the movie without knowing any of the story. (Will Smith got me in the theater.) Other reviews point out Smith's excellent acting, the weak CGI monsters and how much the story strays from the original novel by Richard Matheson. And Popular Mechanics assesses the verity of the 'junk science' built into the plot. I take a broader view. In sum, I was pleasantly surprised that not only was science important to this film, but it was the co-star. Enough with the preamble! Here's the review:

How many times have you seen a cocky scientist on TV extolling the unlimited cures science has to offer society? If you lived in California a few years ago, you probably met professor Irv Weissman and others promising that stem cells will cure diseases. (They were actually just hinting at it, but does that really matter now that CA is well on its way to funding $3 billion of stem cell science?) I am Legend opens with a smug blond scientist admitting on local TV that yes, she has cured cancer. Note #1: Scientists, if you want to get visibility for science, you need to get on the local news! Evidently, this scientist has built a virus that prevents either tumorgenesis or malignancy. Fortunately, the film did not get into that detail, because I would have something significant to critique! What is notable is that the plot plays on the public's lingering fear of gene therapy. And of course, the worst nightmare comes true. The virus mutates into a lethal strain that results in symptoms part rabies, part ebola, part bird flu. The virus first requires physical contact for transmission, but soon aerosolizes and crosses species boundaries. I am skeptical that viral evolution could actually occur as quickly as in the film, but perhaps such a trait is what enabled one virus to cure every type of cancer in the first place.

Speaking of curing cancer, our mad scientist (who had a vaguely European accent), indicated that of 10,009 clinical trials, 10,009 people were cancer free. This is likely a consistency flaw instigated by the script writers, since later, Will Smith's character tests his "compound 6" and calls one experiment a clinical trial. Note #2: A clinical trial includes hundreds, if not thousands of patients. This was a little mistake, but could misrepresent the process of evaluating safety and efficacy to the millions of people in the theater this weekend. By the way, this flaw was my infectious disease researcher wife's biggest beef with the film.

Speaking of infectious disease, we need to talk about immunity. If 1% or the world's population was immune to the film's virus, Manhattan should have been left with 15,000 people. It took 70 minutes or so for an explanation of why Will Smith's character was the only human remaining. It turns out that 30% of those who survived turned into zombies. These (poorly animated) zombies ended up killing the rest of the people. How likely is it that a virus could cause a devolution (or evolution) of humans into zombies? Greg Bear offers a pretty believable mechanism in Darwin's Radio. If this little viral beastie was a certain type of retrovirus, aggressive zombies could be the next step in evolution, and this could even occur in one generation. I am guessing that this is the part of the film that the audience is supposed to suspend its belief about...

What about the basement laboratory? Smith's character used a fancy eyeglass-mounted video camera to record his experiments on various compounds to reverse the virus's symptoms in sewer rats. The writers got some things right here. Only "compound #6" worked; this was one of twenty he tried in this series, in what we assume was a long string of trials. This brings us to Note #3: Only a small fraction of science experiments 'work.' Of note is that only one rat was tested with #6 before moving to human trials! I guess this paucity of pre-clinical data can be excused when civilization is at stake. While we are on the topic of animal experiments, the presentation of animal research in this film was well done. The rabid rats were clearly animated, so no beef could be made about living conditions for real rats (and the fact that they were injuring themselves on the cages). The cages, by the way, were appropriate for animal size and were not overcrowded. Smith's character didn't need to get IACUC approval for his work, but he was mostly in compliance for many rules about animal care. Some notable lapses: no dedicated facility, interventions that were terminal, minimal personal protective equipment.

The treatment of the bench science was appropriate. There were no unneeded CSI-styled eye-candy closeups of pipetting or tube shaking. (You know the shot: when one of the attractive lab techs flicks an Eppendorf tube up in front of his/her face instead of using the vortexer.) This workshop looked like a well stocked lab crossed with an intensive care unit. There were QPCR machines, vital signs monitors (just like those at the UW hospital!), and med supply carts along with an appropriate amount of clutter. Conveniently for the plot, there were also bullet-proof glass doors. Except for the dim lighting, this looked like a great place to do science.

In my opinion, the ethical land mine in this film was not the fact that some crazy scientist unleashed a deadly virus - that occurred off screen. I worried about the ethical use of human subjects. Smith's character has a wall packed with photos of zombies that he unsuccessfully cured of their zombieism. The viewer is asked to overlook the fact that these zombies have the potential to be fully human. At one point in the film, Smith's character reports that these creatures have lost all semblance of human nature. This is a fine trick to make it okay for experimenting on them. (That is how some scientists justify animal research.) However, the observant audience member will note that the zombies have clear emotional responses to stimuli, exhibit abstract planning and operate in a social manner. One (the chief zombie) even seems to show an attachment to the zombie subject Smith's character is trying to cure. Note #4: If a cure occurs only after sacrificing hundreds of zombie-humans, is the research ethical? Is exterminating the zombie way of life genocide?

Finally, over the course of the film, the protagonist shifts from a Christian to an atheist to an agnostic. First, he prays with his family before all Hell breaks loose. Later, he reasons that God would never permit such a catastrophe, therefore does not exist. The final resolution depends on a near-death and perhaps spiritual experience in which Smith's character adopts a perspective that things 'happen for a reason.' I did not appreciate (nor would my atheist readers) how his suicidal ideation occurred in the post-religion period, while the noble savior surfaced after reconsidering a religious perspective. Apart from that flaw, I was pleased that this portrayal of a scientist encompassed religious, agnostic and atheist perspectives, therefore illuminating Note #5: Science can be done by individuals from diverse belief spectra.

In the end, my wife and I agreed that this was an entertaining movie and worth the $8 after a day of studying. The plot was creative enough to get me thinking about some interesting research ethics and science in society issues. Hopefully it got some others thinking as well.

A Very Test Tube Christmas

Seattle's Colors have transformed into something a little more festive than their previous incarnation. This is a living installation, in that each tube may be cleaned and refilled with specimens found near my home. These items were all collected from Magnuson Park on a Saturday stroll with my wife. 'Tis the season for red and white berries. The previous incarnation grew a variety of mold in the months between Seattle Colors V1 and V2, further emphasizing the living nature of this piece.

Here are the same berries - red, orange, yellow, green, blue, and violet - after growing mold and being submerged in dilute bleach. I wonder what the next phase of Seattle's Colors will be? If you have any ideas for me, here's a fun craft: Download the image below, color it in and emailit to me. (Or just post a comment below.)

Merry Christmas! And please don't go out and buy stuff just for the sake of it. Consider crafting something personal, giving a gift of an experience or assembling a creative alternative to a store-bought item.

So Blue

(or why I'm a Democrat)

The world is globalizing, nuclear weapons are proliferating, the Middle East is seething, but Republicans are still arguing the Scopes trial.

-Maureen Dowd

Keeping Track

What a Day. Today in the ER, I diagnosed the following:

• New onset temporomandibular joint (TMJ) syndrome in a 29 year old woman.
• Phimosis and otitis externa in a 10 month old boy.
• Hip bursitis in a 72 year old man.

I participated in the care of:

• Man vs. table saw: the loser was a finger (unless the hand surgeons at Harborview can work a miracle).
• A young man with periodic familial hypokalemic paralysis.
• 51 year old man with suicide ideation and a plan. (See photo below.)

The currents are deadly enough without having to deal with the impact. I have first hand experience (with the current, not the impact). Let me tell you: going through at slack tide is a much better idea than trying any other time. The current gets up to 8+ knots at flood and ebb. My wife once diagnosed me with suicidal ideation for trying to take this tidal rapid in my now deceased aluminum Grumman canoe.

We admitted the the man with severe depression. Things are looking good for him. I am glad he came in today and decided to stay; he's also been an excellent teacher so far.

R(eee)view

It's been a month since I first unpacked my ASUS Eee laptop computer, and folks are clamoring for my review. I did promise you a breakdown of my experiences.

If you are thinking of buying an Eee, I would recommend NewEgg.com. They now have several models in addition to the white 4G model I purchased. Either they or UPS screwed up my shipping, but they were quick to admit their error and refunded my shipping costs. Here's me on the airplane last month writing my epic entry about evolution and creationism in Kentucky.

I'll spare you (and me) the specifications. If you are serious about buying one, you probably already know these details. I'm not in the business of sales.

• Size Matters: I love that it is less than 2 pounds! It can go anywhere. The keyboard is small, but my size 9 1/2 hands do just fine. I do have trouble using the touchpad, so I bought a mini-USB mouse with a retractable cord (no RF devices on airplanes) that does the trick.

• Battery Life: Don't expect the batt to last more than your other laptop. The longest I had it run was 4 hours, but the wireless card was disabled. The mini-mouse drains the power faster, too. On average, I'd say the battery lasts 3 hours between charges.

• Screen: For espn.com, the narrow screen makes navigation tough. But for authoring and reading blogs, word processing, and general web use, it's just fine.

• Start-Up: It's more like 25 seconds to start. And if you connect to wireless networks, it will be about 90 seconds.

• Connectivity: I've had some frustration with connecting to my current wireless network, but have had trouble with my PC on the same network. I use the hardwire cord to avoid that problem. I've been able to connect to every (other) wireless access point I've encountered in the hospital, the local library and the pub.
  

• Social Aspects: I get soooo many comments about how cute my computer is. The Eee has serious potential as a nerd/chick magnet. Seriously. No, really. I mean, I don't (ab)use the Eee that way, but maybe you could...

• Disk Space: It's pretty amazing to use a compy that has the operating system, all the needed programs and space for your files in 4 GB. I keep everything on an 8 GB thumb anyway, and have interfaced with my 1 TB mother drive. Anything I do on this little guy is small potatoes anyway.

• Operating System: I can hardly tell it's LINUX. Except that it's faster, doesn't have stupid update messages and has yet to crash. There are some things I wish I could customize, but I am a little afraid of that. Now that medicine is beating the engineer out of me.

• Name: Eee is hard to explain to people. The name is pretty lame.

• Role: For my life, this little machine can do almost everything I need in a computer. Honestly, this is not much. I have yet to try and print from it (no printer at my current residence). When my HP PC crashes for good, I will probably buy a desktop and use the Eee as my mobile terminal. Whether that terminal runs LINUX or not, I am not sure. I guess it depends how much of a geek I will need to be to install & maintain it. Because I am getting less geeky by the month.

• Applications: All OpenOffice applications are installed along with other programs like LTris, pdf Reader, Firefox and a sundry of others I haven't yet used.

Here I am a month later. These pics were taken using the built in webcam. (The direct connect via Skype might come in handy sometime.) For now, it simply offers evidence that I really like this hoody sweater. FYI, the words out of frame say "the unthinkable."

FAMILY Medicine

This is family medicine:

In the ER on Monday night, I injected a steroid/marcaine cocktail into a man's biceps tendon and referred him to an orthopedic surgeon. On Thursday, I saw his wife to renew her Vicodin prescriptions for rheumatoid arthritis. This afternoon, we deliver their 4th grandchild by C-section.

Socialized Mormons

So, Mitt Romney's a Mormon... This we knew. And he “will serve no one religion, no one group, no one cause, and no one interest. A president must serve only the common cause of the people of the United States.” Okay... That's inclusive (patronizing?) enough for me. And he does "not insist on a single strain of religion—rather, he welcomes our nation’s symphony of faith." Wait a minute... does this assume that all have faith? What about my atheist friends and colleagues? Will they have chairs in Mitt Romney's orchestra?

In the end, I think it is really too bad that Romney is not interested in being a spokesman for his faith. After all, the current President of the Mormon Church, Gordon B. Hinckley "hates war with all its mocking panoply... War is Earth’s greatest cause of human misery. It is the destroyer of life, the promoter of hate, the waster of treasure. It is man’s costliest folly, his most tragic misadventure.” The candidate willing to say this whose name is not Ron Paul, will get my vote. Even if he's from Ohio.

A look at Mitt Romney’s vision for America’s foreign policy reveals little, however, that resembles any of these most basic and central Mormon values. In contrast to Gordon Hinckley’s hatred of war, Romney’s central foreign policy concern, in fact, is a deepening of American militarism and war making. Specifically, Romney advocates drastically increasing American military expenditures, escalating the Iraq war, continuing operations against transnational Islamic militant groups, and preparing for a military assault on Iran.

That's the analysis offered by a little publication a friend recently alerted me of called The Mormon Worker. This was penned a few months ago; perhaps Romney will soon change his mind about Iran.

The Mormon Worker is a strange collection of ideas conflating anarchism, Mormonism, and socialism that highlights some central disparities between the teachings of Mormonism and the way most Mormons vote. Many of the arguments are the same made by Dorothy Day and the Catholic Worker movement. See also the Christians who in the voting booth or policy forum seem to always forget the teachings from the Sermon on the Mount.

Due to the agreements forged by church fathers and the state in the wake of the controversies surrounding polygamy,

Mormons find themselves supporting capitalism and government, and therefore exploitation, imperialism, jingoism, and militarism, considering these things inherent to their religion, despite the many resources within Mormon scripture advocating the contrary. One significant reason Mormons should seek to abolish government and capitalism is the fact that States continually wage war in foreign lands for the sake of economic gain.

To William Van Wagenen (the man behind the Worker) and the other Mormon workers (I wonder if all Mormon workers are stock brokers like Van Wagenan...) out there, I tip my hat. I challenge you to vote your conscience in 2008, even if there's no chance of Utah being a blue state.

Peds Grand Rounds is Coming to Town

This edition (Volume 2, Edition 12) of Pediatric Grand Rounds is presented in the context of that familiar ode to the jolly fat man. Some readers may bristle at the extent to which I conformed to the hegemony that Christmas has over the month of December, but the truth is that kids love Christmas. What I didn’t realize before compiling these entries is the extent that Santa Claus prescribes prevention in this instructive carol.

Before we strike up the band, Pediatrics Grand Rounds needs a new home. Clark Bartram did a great job initiating the tradition of collecting interesting pediatrics articles, but PGR is now in search of a new administrator. Please consider whether you could host or coordinate future editions. If you are interested, please comment on this post or send an email to Clark or me. Do the same if you would like to host January’s issue. With thanks to Thomas Nast and without further ado...


You better watch out for the greatest threat to kids’ health. Steven Parker brings home a topic that is close to my heart and flies under the radar too often in this country.

You better not cry, or is it actually okay to cry sometimes? Kristen Heinan at The Differential offers a connection between the difficult experiences in the PICU and the world outside.

You better not pout, I'm telling you why: the person responsible for your care, protection and nutrition might forsake you.

Santa Claus is coming to town and he’s bringing a new puppy. Curious about whether new puppies and new babies combine to produce pediatric allergies? Med Journal Watch digests the answer for you...

He's making a list of effective parenting techniques; or at least Dave Munger and his readers at Cognitive Daily are. Scientific studies of parenting are common, but studies linking parenting to morality are scarce. That’s why you should check this post out.

Checking it twice, just like you need to do with those pediatric liquid medicines. Mexico Medical Student helps you out with the not-so-simple math.

Gonna find out who's naughty - I bet you thought internet trolls were just bad for your blog. Sandy at Junkfood Science explains how trolls can turn into killers.

or nice. The Thinking Mother knows who is naughty and nice at home and in the classroom. She also offers ideas about how to facilitate more nice behavior.

Santa Claus is coming to town, and he’s got great gifts for kids of all ages. And Dr. Gwenn compiled them all into this handy compendium for your holiday shopping.

He knows you when you are sleeping, and Michael Breus thinks we all should be paying more attention to how much our teenagers sleep.

He knows when you're awake, and if you’re in between being awake and asleep, chances are you have yawned recently. Now is that because you’re tired? Dr. Deb thinks not.

He knows if you've been bad or good, but can dear old Santa resolve the dilemma about the 14-year-old Jehovah’s Witness who refused blood transfusion in Seattle and as a result died last month? Several bloggers have offered their perspectives critical of this situation including Beast at Atheist Haven and Orac at Respectful Insolence. Not happy with unbalanced perspectives, I offer my own assessment.

So be good for goodness sake! Sometimes, however a 3-year-old’s conception of good is a little different than yours or mine.

Santa Claus is coming to town! Be sure to email him before it’s too late. That's it for this month. Keep track of the next PGR at this site.

Witnessing Evil?

On November 28 a young man named Dennis Lindberg died in Seattle's Children's hospital. He died because he refused treatment for leukemia. I have personally met many individuals close to this case. I work in Skagit County, WA - the same county where Judge John Meyer made his well publicized ruling. Last week, A Jehovah's Witness who happened to have a deep vein thrombosis taught me about the Winesses' perspectives about blood. His wife shared that she was in the same congregation as this young man. The attending hematologist for this procedure gave lectures about leukemia when I was a medical student at Children's Hospital in Seattle. My wife worked with him for a new diagnosis of leukemia that presented in a kid that came to the Children's ER. I have taken courses with and from some of the professional ethicists on staff at Children's. I would not choose the same path for myself of a child in the same situation, but when you see the story from so many angles, it's harder to be so critical of the outcome.

On top of the complexity already inherent in this case, there are a few distortions, inaccuracies and partial truths about this story gaining traction in the blogosphere - particularly in the atheist community. This post is meant to bring to light some of those lapses in intellectual honesty. We all complain about how science is too-often misused by politicians; when dealing with an issue as controversial at this one, the least we can do is present all of the facts.

Here are some points that if you rely on blogger news, you may not have encountered:

(1) Jehovah's Witnesses were founded in 1872. Any reference to the faith being founded on Bronze Age or Dark Ages thinking is inaccurate hyperbole. The religion is based on 19th Century pre-modern medical thinking.

(2) The treatment denied by the judge was not the stem cell transplant. It was a blood transfusion. Why is this distinction important? Stem cell transplants are the single most expensive procedure in medicine (hundreds of thousands of dollars just to do the procedure). We do them (and many health insurers cover them) because they work, but not all patients facing leukemia choose to be transplanted. Some cannot afford it. Some do not want to go through the pain of the procedure. Others (like this patient) have different reasons. If after providing all of the information, the patient does not consent to a procedure, the medical establishment usually respects this decision. Keep in mind that the legal decision here was related to the blood transfusion which could keep the patient alive for several days, not the stem cell transplant, which has 70% survival at 5 years as reported in the media. It's not as simple as a 750 word article would have you believe. (The Seattle PI printed a good story overall.) The Cheerful Oncologist offers a refreshing perspective on this issue.

(3) There has been some criticism of the words "mature minor." Some say it is a contradiction. The terminology comes directly from Washington State law. Health care providers are very familiar with the term; mature minor is most often applied to pregnant teenagers and to teens who need psychiatric services. The right to make autonomous, confidential (parent-free) medical decisions about reproduction (including abortion) and mental health issues is routinely conferred to 14-year-olds. It has not been previously applied to patients with blood diseases. Joana Ramos outlines some of the issues in a white paper she authored:

Doctrine of the Mature Minor
In most states of the US, 16 is the minimum age for donating blood with parental consent. In a variety of instances, teens are able to consent to, or refuse, medical treatments including surgery. It is customary that 14 is the age of consent for confidential reproductive health services, including elective abortions; substance abuse treatment and counseling; and for consent or refusal of mental health services, even when parents feel that a child’s life may be in danger(1).

The legal concept of the mature minor is well established in case law nationwide(2). It governs such topics the age of consent to engage in sexual activity, to marry, and to make independent and confidential decisions about medical care. The following list of rights extended to teens serves as a good illustration of this concept. Many of these rights involve activities that carry varying amounts of risk, may have both psychological and physical health consequences, and may be neither beneficial nor life-saving. While the laws vary in each state, teens commonly have the right to:

• make decisions as to one’s own guardian or custodial parent at 12
• travel and to purchase a ticket to travel by public conveyance anywhere in the US at age 13 without parental permission
• be employed at 16, but to engage in agricultural work at age 12, in other occupations at 14, with certain jobs being exempt from any age limits
• obtain a license and drive a motor vehicle at age 16
• have one’s body pierced at age 16 without parental consent
• enlist in the military at age 17, with parental consent
• petition the court to become an emancipated minor with cause
• make decisions on behalf of a child parented by one’s self at any age

References:
1. Stenger, RL. ( 1999-2001) “Exclusive or Concurrent Competence to Make Medical Decisions for Adolescents in the United States and United Kingdom”, Journal of Law and Health, 14(2):209-41.
2. Forman, DL. (1998) Every Parent’s Guide to the Law. (pp. 87-154) New York: Harcourt Brace.

The legal precedent in this case is that the 14-year-old was conferred mature minor status for a condition that was not reproductive or psychiatric. In his criticisms of this case, Orac makes the right concession to adult Jehovah's Witnesses regarding decisions about transfusion. He believes a grey area to apply between age 15 and 17. Based on the above examples, I think the range should be 14-17.

(4) Some have written this to be an ignorant backwards, if not abusive decision. To those who think this, I would invite you to seek out a Jehovah's Witness. Ask him about blood. If you don't learn from that individual, every congregation has several experts and health advisers. I bet you will learn things about bloodless surgeries (a few of which are at least as successful as traditional approaches) and artificial blood that you had know idea about.

(5) The newspapers included a fact about this case that most bloggers have left out. The patient's biological parents (who filed the injunction to force the blood transfusion) had a long history of drug abuse. They were in and out of jail, but had been in recovery only recently. They flew to Seattle days before the court hearing and the patient's death. If their son was dying of leukemia, why were they not in Seattle in the weeks and months before this incident?

The bottom line here is that this case is complex. At its center is a 14-year-old's autonomy. Closely related to that is the freedom of religion. The same individuals who value the separation of church and state have called for that wall's dismantling via a court of law. In the end, the judge looked at this young man's ability to make life and death decisions. My suspicion is that Dennis Lindberg was better prepared to make this decision than you or I.

Continuity

Today is the midpoint of my family medicine clerkship. For the past three weeks, I have seen kids with coughs, guys who want Cialis, dislocated joints, pregnant mommies, runny noses, depressed senior citizens, strep throats, Caesarian sections, annual physicals, lots of funny skin spots, uncontrolled diabetes... the list could go on.

You know what I have liked the most out of my experiences so far?

Continuity. It is rewarding to see a women who formerly had oxygen saturations of 85% on O2 nasal cannula walk into clinic (from her home) and have no problem finishing a sentence. It is nice to be able to pick up a skin color change from mild jaundice to something to be concerned about. It is heart-wrenching to see an 80 year old man deteriorate from a compassionate caretaker for his demented wife and palsied son to a fetal position writhing in pain from a pelvic bone infection. (I hope and pray he recovers.)

These are all aspects of medical care I would miss out on by pursuing the top two specialties I've been considering recently: emergency medicine and hospitalist.

We shall see about this!