Grand Rounds 5:11 – Death and Transfiguration

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Welcome to Grand Rounds! I am privileged to be your host for this week’s edition of the best posts of the medical blogosphere. As in the previous two times I’ve hosted, I will integrate music into this edition, but unlike before, I will focus on one piece of music: Tod und Verkl√§rung (Death and Transfiguration) by the German composer Richard Strauss. I said when asking for contributions that adherence to a theme was not necessary; moreover no single theme could really encompass the excellent variety the medblogosphere has to offer. Since this musical selection is quite long–over 20 minutes at least–I have decided to present only excerpts so as to tell the basic story as we go along, placing musical interludes in the list of posts. Hopefully I still keep to the spirit of the piece while not detracting too much from the excellent contributions.

Death and Transfiguration is a “tone poem,” literally, a musical literary depiction. In this case, it is of a dying artist on his deathbed in his last moments, and what is experienced up to, including and after death. A patient in a bed knowing it can be the end is certainly scared, and perhaps even confused. Mother Jones of Nurse Ratched’s Place learned how to comfort a confused, hospitalized elderly woman in a very significant way in the early years of her career. In another mental health story of an elderly lady, Sara at My Sad Alter Ego appropriately rails against a fellow clinician pointing out that depression does not equal lack of competence.

The patient lies in his bed, breathing heavily, his heartbeat marked by syncopated triplet rhythms in both the strings and timpani. Falling sighs contrast against a flute and clarinet asking a wordless question in unison. There is not yet struggle, but there is certainly no peace.

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The near-code-blue status of primary care has received so much press recently, but in the end what has been done? What needs to be done? DrRich of The Covert Rationing Blog has some excellent insights and advice.

Dr. Val shares her insights at the dubious practice of Fecal Transplants (yes, you read that correctly) at her site, Getting Better with Dr. Val.

Mike Cadogan of The 28 Hour Diet shares his feelings on the general trend towards open peer review in scientific and medical publishing. I think he’s spot on.

Another spot-on editorial, and a shocking discovery for me, was Ramona Bates of Suture for a Living on the subject of medical method patents and the dubious practice of legally patenting something as ephemeral as a surgical technique. Is, say, a left-handed version of one safe from infringement?

Medical costs are skyrocketing, and since many of us are involved on the patient-end of healthcare, it’s sometimes alarming to read and be reminded that not all providers may act in the best interest of the patient, as a sobering post by InsureBlog indicates.

Violence in the ED is a disturbing and increasing problem, particularly in urban settings, as Marjan Siadat of Detroit Receiving writes.

Giving addicts sterile needles and a safe place to inject may seem like enabling on the surface, but Sam Solomon of Canadian Medicine shares there are quite a few good reasons to do so.

Suddenly he is startled awake with agony, struggling. The low strings groan with his pain. Driving rhythms, piercing brass motifs indicate his torment. The timpani, once quietly beating a halting rhythm, now pounds forcefully as though his heart will leap out of his chest. Relief is temporarily granted as he sighs back, exhausted.

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Jolie Bookspan of The Fitness Fixer in her post 14,000 Miles On a Bike reminds us that most intervertebral disc problems happen over time, and so too over time, they can also be repaired sensibly without invasive intervention.

How to Cope With Pain gives tips on how to be a “Computer Athlete” by showing sensible ergonomic suggestions.

Medicine for the Outdoors’ Paul Auerbach with a post entitled Sawyer Water Filter shows how a simple micron filter attachment to an ordinary bucket allows a pure gravity-enabled water filtration system that makes water from almost any source potable. It’s truly amazing, elegant technology.

Walter Jessen of Highlight Health shares remarkable new research indicating we might be closer to unraveling the genetic basis of autism. Not surprisingly, vaccines are not mentioned in the article. ;)

Ves Dimov at Clinical Cases and Images Blog is one of the pioneering physicians using Twitter to share conference proceedings in real-time, as he did at the Annual Meeting of American College of Allergy, Asthma & Immunology. Likewise, Twitter can also be used for USMLE Step 1 board preparation. Med students, this is an invaluable resource, since now First Aid can quiz you!

Nancy Brown of Teen Health 411 shares tips on teen oral health that may not be obvious.

Robin from Survive the Journey shares some new research that indicates Cushing’s Disease has a higher prevalence than common wisdom indicates.

At Sharp Brains, Dr. Rabiner talks about a quantitative EEG method for screening ADHD as opposed to observational/behavioral methods. The improvement of this new method is astounding and shows great promise.


Dinah from Shrink Rap talks about how simple medical jargon can be taken the wrong way by patients who don’t have the context clinicians do.

Christine at Corn Allergic shares a story where a conscientious nurse made a simple blood draw less of an anxiety-producing event (and not for the needle, either) by both being resourceful and non-judgmental.

Our patient begins a reverie, remembering his youth. theme. The strings’ rhythms drive forward, so full of exuberance they’re practically tripping over themselves. He must be thinking of a past love, unable to contain the rush of his passion, emotionally climbing higher and higher — until the brass for the first time fully states the “Ideal” theme in the piece (1:44). This represents his soul, the totality of his being, his essence. He has found himself through this 6 note theme, and having done so, can finally move on, secure in himself and who he is, ready to face whatever fate is to come with pride and dignity.

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Cris Cuthbertson from Scalpel’s Edge shares a personal letter spelling out her point of view on the differences between non-MD researchers and physician-scientists. (she also has great tips on preparing medical presentations)

Doctor Anonymous shares his thoughts as part of yesterday’s official observance of World AIDS Day. It is, as he pointed out, the 20th anniversary of the event, and we have made incredible strides in that time.

Bongi at Other Things Amanzi shares a story from his past about not looking down at people on your way up–they just might do the same to you when it’s their turn!


Barbara Kivowitz In Sickness and In Health shares how Gratitude Can Change You. Read how there is transformational power in giving thanks in a tangible way.

ADHD isn’t a disorder, it’s a personality type. That’s what Dr. Rob of Musings of a Distractible Mind writes in “The Doctor is Distracted.” ADD/ADHD confers its own strengths and weaknesses, and just like everyone else, each individual has their own unique aptitudes. The key is adapting and transforming “liability” into leverage.

In Reflections in a Head Mirror, Bruce Campbell shares a beautiful story about how love transforms perceptions, making the previously impossible possible.

Jacqueline at Laika’s MedLibLog really took off with the theme, so I’m saving this for last. She writes a very thorough review of a symposium on fear focusing mainly on a speech by an Israeli lecturer showing many neurological elements in fear processing and response. Post-traumatic stress disorder is featured prominently as an example of how extreme fear eventually can transform a person into someone else. She offers another German composer, J.S. Bach, to accompany her piece as well.

Finally we arrive at the end of our patient’s mortal journey: a pause, another short, violent struggle, and after his last agonal breaths, death arrives (0:52). However, no sooner than the tam-tam signals this event than the harp, low strings, brass, and winds indicate the soul’s release, loosed from his mortal coil, floating finally free. Sumptuous, almost agonizing pedal points stretch out like harmonic taffy as the “Ideal” theme transforms, grows and is passed around the entire orchestra. A final victorious flourish at our triumphant final key of C major (6:06) and our fully transfigured soul now rests quietly in peace.

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One may be wondering why I chose this rather heavy musical topic. For one, it fits in with a healthcare theme. Death and end-of-life issues are ever-present challenges in healthcare. Paul Levy just spearheaded a blog cause on this very issue. Facing our mortality isn’t easy for anyone. However, the main reason I chose it is because, metaphorically, it represents what I’ve gone through this last year. I decided not to tie in my own story along the way so as not to detract further from the contributors, but regular readers and friends know about the limbo status of my scholastic endeavors, unforeseeable health issues that took me out of commission for 9 months, and a divorce forced upon me in the middle of it all. One can allow dreams, relationships, etc. to simply die, or be transformed in the crucible of experience into something new. I hear Strauss and it reminds me I must do the latter. I have to believe this–like the musically idealized portrayal–is how things will turn out eventually. I invite those not already readers to join me in searching for my “C major chord,” speed bumps and all, and I’ll be there to share yours.

Finally, I do want to offer a small dedication to those that lost their lives in the tragedy in Mumbai last week. I think this post is an appropriate place to offer that, even though the topic was already conceived when the horror of those events unfolded. May the souls of the departed as well as the families and friends that mourn them find peace.

Thank you for reading! I hope that beauty and catharsis was found in spite of a weighty topic. I also want to thank Dr. Val and Colin Son for their work on keeping Grand Rounds what is is and giving me the honor to host once again. One of the things that makes Grand Rounds special is the variety of hosting topics and personalities one gets each week. So with that, I pass the baton to next week’s host, Sharp Brains. I look forward to their edition. Cheers and good health to all!

  • By doctoranonymous, December 2, 2008 @ 6:15 am

    Great Job Enrico! I enjoyed the GR theme this week. I’m liking the new WordPress theme. And, of course, the music files. A multimedia extravaganza! Cheers!

  • By rlbates, December 2, 2008 @ 6:47 am

    Really nice edition, Enrico!!!

  • By hgstern, December 2, 2008 @ 7:38 am

    Outstanding job!

    Thank you for hosting, and for including our post.

  • By motherjonesrn, December 2, 2008 @ 8:18 am

    Bravo, Enrico. Great job! Thank you for including my post.

  • By Dr. Val, December 2, 2008 @ 8:35 am

    Great edition, Enrico. I was interested to note that my “fecal transplant” post was categorized as “health policy.” I certainly hope it doesn’t become a policy… :)

  • By Barbara K., December 2, 2008 @ 8:45 am

    Excellent! The theme is timely and the music very special. Thank you for including my post.

  • By CT, December 2, 2008 @ 10:39 am

    Enrico, thanks so much for hosting. Great job.

  • By Clinical Cases and Images - Blog, December 2, 2008 @ 10:47 am

    Thank you for hosting Grand Rounds and featuring Richard Strauss’ music.

  • By purplesque, December 2, 2008 @ 1:55 pm

    Outstanding! (Confession- this is one of the few grand rounds where I read the whole thing instead of skimming. You write really well.)

  • By Kim, December 2, 2008 @ 3:50 pm

    Wow – what an edition! And what a gorgeous theme!!!

    The blog looks fantastic, too, btw! I’m a sucker for blue….

  • By Fat Doctor, December 2, 2008 @ 4:55 pm

    I remember your first grand rounds and am glad you stuck with a musical theme…so very YOU. Great GR, and I love the new template.

  • By Doug, December 2, 2008 @ 8:47 pm

    Wow. I read about your blog on Medscape, and as a graduate of the UAG (can I say that without upsetting you?), I came here and just spent the last 2+ hours reading about your life from 2005 until the present. Your observations brought smiles, affirmative nods, laughs and almost tears as I sat here reading away. I’ve told my wife that she needs to spend some time reading over all this great material. She accompanied me all through my Mexico years The memories you have stirred up hopefully don’t give me nightmares tonight. I still have those dreams where I am back in GDL, at the UAG, just starting a semester and I skip a class, then skip it again, until I realize it’s the end of the semester and I have to take a final exam in that course having never been to a class, read any material, and having not found any old exams to study….

    I’ve found a new internet site to spend my free time…

  • By Robin, December 2, 2008 @ 9:17 pm

    Love, love, love the music. And enjoyed reading, too. Now to visit some links….

  • By enrico, December 4, 2008 @ 1:45 am

    Thanks for all the positive comments so far! I really appreciate the feedback and that you enjoyed the edition.

  • By MaxJerz, December 4, 2008 @ 12:05 pm

    I’m with purplesque – this is one of a few editions of Grand Rounds where I’ve read the entire post and didn’t just skim. Excellent job!

Other Links to this Post

  1. Grand Rounds at Mexico Medical Student | From Medskool — December 2, 2008 @ 11:00 am

  2. Grand Round 5.11 at Mexico Medical Student « Laika’s MedLibLog — December 2, 2008 @ 5:57 pm

  3. » Blog Archive » Shrink Rap: Grand Rounds is up at Mexico Medical Student — December 5, 2008 @ 4:37 pm

  4. Mexico Medical Student » Welcome Medscape Readers! — December 10, 2008 @ 3:10 am

  5. Scalpel’s Edge » Blog Archive » Welcome Back and Merry Christmas! — December 14, 2008 @ 8:36 pm

  6. Welcome Back and Merry Christmas! — December 14, 2008 @ 8:37 pm

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