Hello! Above is the video post I did as a wrap-up for last night’s Doctor Anonymous Show in true Dr.A. fashion, except Dr. A. did his before I got to do mine! However, I still did it, because, as Wilford Brimley would say: “It’s the right thing to do.” haha

Thanks again to my star-studded panel: Ramona Bates of Suture for a Living, Mother Jones, RN of Nurse Ratched’s Place, Val Jones of Getting Better with Dr. Val, and Bongi of Other Things Amanzi. I am still in awe that these A-list bloggers all took 90+ minutes out of their Thursday to spend with me.  Awesome.

Also thanks to Vijay of Scanman’s Notes for calling in all the way from India; you made it a cross-contiental event x2!

Whether  you were there or missed the show, go the link above so you can listen to the archive, download it to your computer/music player, whatever you like.

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 Verklärung (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.

HEALTH POLICY AND BUSINESS:

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.

DISCOVERY AND LEARNING:

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.

PERSONAL STORIES:

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.

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!

And finally–TRANSFORMATION:

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.

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!

Links:
The Dr. Anonymous Show on BlogTalkRadio (this Thursday at 9pmEST)
Grand Rounds 5:11 – Death and Transfiguration

Update 03December: Confirmed panelists are Ramona Bates, Mother Jones, Val Jones, and Bongi (schedule permitting). It’s a star-studded event, ladies and gentlemen! Even Dr. A. is jealous! hehe

Before I continue, make sure you go see the excellent current edition at Canadian Medicine, featuring last week’s content.  If you submitted a piece that wasn’t included in Dr. Solomon’s edition, re-send to me for consideration.

Please have all articles submitted to me no later than 18:00CST/17:00EST Sunday, November 30th (00:00UTC Monday December 1st) for inclusion by sending an email to enrico -[at]- mexicomedstudent.com. Please put “Grand Rounds” in the subject, and in the body text include the URL and a sentence or two of summary. That summary is important because not everyone’s URL is descriptive, and when I have a table of URLs, etc. when planning the edition, a blurb really helps. 

I do have a tentative theme in mind but don’t want to reveal too much (and want some flexibility to change it ) but these words should be applicable: renewal, metamorphosis, change, transformation. That should be enigmatic enough for everyone.  Do not feel constrained by these, however. There is no judgment about whether to include or not based on any theme; each article is reviewed on its own merit. 

Thank you for your cooperation, and I look forward to reading everyone’s entries!  Good health to all, and for those traveling here in the US this holiday season, be safe.

Go check it out! Oh and happy ‘Diez y seis de septiembre‘, Mexican indepdendence day.  Unlike cinco de mayo which is all but ignored unless you live in Puebla, this holiday is the most important for the nation–their 4th of July, if you will. But it’s hard to make a beer/liquor campaign here in the US with such a long name.  Still, some people try like this group in Austin try to do it anyway and keep the true tradition alive.  I’m going to go do my part to celebrate *cough* *cough* later this afternoon on the other side of the border and hope Dept. of Homeland Security is gullible kind enough to let me back in.

Congrats from a fellow proud Texan!

(and I’m doing better but was offline for too long–the nerve of various places and family members not to have WiFi!! Can you imagine?! Updates soon once I get re-situated)

Prelude:
Thanksgiving is two days away in the USA. This will mark the 3rd Thanksgiving in a row that I am not home to spend with the rest of my family. Perhaps I’m just a little nostalgic for home right now, but I really wanted to incorporate the holiday here in a way besides references to turkey, pie, and football (Go Packers!). Victor Hugo said (translated), “Music expresses that which cannot be put into words and that which cannot remain silent,” and like the last time I hosted, it is to music I turn once again to express myself.

In the Thanksgiving spirit, all of today’s selections will highlight American composers. Since all links here are set to open in new windows (or tabs), you can read articles while leaving this window playing in the background. In all but one shorter case, the selections are about 8 minutes each; I hope you indulge my desire to share. Enjoy!

When Aaron Copland burst onto the musical scene in the 1920s, American music would never be the same. While there were several important composers before him–McDowell, Herbert, Sousa–Copland was arguably the first to truly musical codify what it was to be “American,” by drawing from folk songs, cowboy music and other “popular” sources. Everyone knows Rodeo (the last part used in the “Beef: It’s What’s For Dinner” campaign in the States), but there was far more to Copland than catchy tunes. Here is the 2nd movement of his third symphony. The expansive, colorful harmonies and driving rhythms are so distinctly American, one just feels it.

Editor’s Choice:
Sid Schwab at Surgeonsblog has a great piece about people’s need for magical thinking, particularly as it relates to “alternative medicine” and new discoveries. The post builds up steam (both momentum and ire) and finally culminates in a challenge bordering on the ridiculous (the whole point) to those who want to cherry-pick common sense. In a similar vein, Dr. Val comments on an infuriating decision by Medicare to no longer cover expensive, necessary treatments to lymphoma patients while at the same time, government dollars are wasted trying to legitimize the spurious benefits of homeopathy with more research studies. Craziness.

Coming back from the Twilight Zone to the ER (some would say that’s just a few steps away ), the truth always comes out eventually, as Bongi at Other things Amazni shares. It may not come via the patient nor the patient’s family or friends–it may require surveillance cameras to finally shed light on what’s going on. The delay, however, could be deadly.

And on the lighter side, Zac at Agraphia has a story about a particularly reptilian surgeon which had me belly laughing from a similar experience.

Mark O’Connor is of a newer breed of contemporary American composers. O’Connor draws his inspiration from the country and bluegrass aural traditions (handed down through playing, not written) and brings his formal training to transform it into something completely unique. O’Connor’s most famous piece is Appalachia Waltz, and O’Connor has arranged several versions, this one for solo cello. This is a slow, easy waltz, just like sitting on a porch looking at the mountains…

Clinical Perspectives:
Here are two selections about burnout and emotional balance. Keith at Digital Doorway talks about having been all compassioned out. Third-year medical student Nick Gavin at NY Emergency Medicine has a post entitled Traumatic Disconnect where he explores the fact that empathy and connecting with patients don’t come automatically with the white coat.

Straight Talk from the Stanford ER’s Sean Donahue writes a good summary of how an ideal stroke response plays out, from EMS to thrombolytic treatment.

Nancy Brown at Teen Health 411 writes with suggestions on how to ensure an inclusive, positive holiday season for the whole family. With so many families being “go-go-go,” just pausing long enough to communicate openly is probably more than half the solution.

Ever wonder why your psychiatrist doesn’t take your insurance assignment (especially if talk therapy is involved)? Dinah from Shrink Rap explains why.

Terry from Counting Sheep tells a touching story about how a frail, blind nonagenarian had the power to halt activity in a busy OR staging area–in a good way.

Clinical Cases and Images Blog comments on the Perioperative Ischemic Evaluation (POISE) trial and how it might affect perioperative beta-blocker usage.

Some patients just “get to you,” and some do so without you realizing it before they’re gone. About a Nurse talks about one such patient and her struggle to find balance when you can’t even grieve because there’s still work to be done.

In Emergiblog’s first-ever guest blogger post, an anonymous Army nurse writes a letter of thanks to her fellow military nurses who serve our country by helping manage the healthcare of detainees. It’s another world entirely when one is faced with a potential moral dilemma for every medication/intervention, every patient, every day.

Tara Gidus at The Diet Dish shares why she’s especially thankful this year.

How can one talk about American music and not include jazz? Well, 1) Ken Burns already covered that history at length, and 2) I am focusing on classical music. Nevertheless, jazz’ universal appeal influenced many composers from around the world, none more so than American composers. George Gershwin is probably most recognized for this, evidenced most popularly with his Rhapsody in Blue. However, the work I’m featuring is the Piano Concerto in F, an unmistakably American work but rooted in a more traditional form. In spite of feeling a distinct “swing” at times, it’s completely written out and is very strictly timed (as evidenced by the orchestra’s accompaniment–there are no free-form solos as in Rhapsody) Here is about 1/3 into the first movement to the end:

Patient Perspectives:
November is Diabetes Awareness Month. In a special feature, Amy Tenderich at Diabetes Mine interviews musician Elliot Yamin, former American Idol finalist and Type I diabetic, on World Diabetes Day. Stories such as Elliot’s are clearly inspiring for any diabetic feeling imprisoned by their illness. However, this can have an unintended counter-effect, as Kerry Morrone shares at Six Until Me. Just because a person appears healthy doesn’t mean they are disease-free.

In The Power of the Flower, Own Your Own Health talks about how physicians who tailor their communications individually to their patients win them over in more ways than one.

In Sickness and in Health, a chronic pain sufferer, has a nice, short post about appreciating the small moments of being pain free.

Of all the many incredible pieces Samuel Barber wrote, his “Adagio” is far and away the most known. The “Adagio” was first penned as the slow movement for his first string quartet, but was arranged by Barber once for string orchestra (which is most played by far), and again for a capella 8-part choir. It is this infrequently performed second arrangement that I present here. The music is set to the words of Agnus Dei:

Agnus Dei, qui tollis peccata mundi, miserere nobis.
Agnus Dei, qui tollis peccata mundi, dona nobis pacem.

Lamb of God, who taketh away the sins of the world, have mercy upon us.
Lamb of God, who taketh away the sins of the world, grant us peace.

The seemingly endless, ever reaching melody passes among all the vocal parts, finally culminating in a climactic chord and sighing quietly to the end. The tonality is never really settled until the final major chord, making one feel that after all of the yearning, peace is found at last.

Healthcare Business and Policy:
The Executive Physician gives his thoughts and concerns on the concept of “cultural competence” as mandated by Washington and New Jersey and offers a more generalized solution.

Regarding hospitals and their attempt to maintain an edge–or at least financial viability–two stories are presented here. ER Murse talks about interhospital turf wars over a trauma level designation. When things get really bad, as HealthBlawg describes, sometimes it may be best to just pull the plug.

David Williams from Health Business Blog interviews the founder of DoubleCheckMD, a free, public web-based medication service that checks interactions and utilizes natural language technology to correlate patients’ symptoms, in their own words, against drug data. I was skeptical given the marketingspeak from the interviewee, but I checked it out before including it here, and it is worth a look.

Toni Brayer at Everything Health laments the whole SCHIP fiasco. I never understood the argument that because certain adults and/or families above a certain income level might be newly eligible (and improperly so, say opponents) if passed, why that would be reason enough to deny coverage (a non-partisan fact) to so many children.

To send this edition off on an uplifting note, here is the finale of Howard Hanson’s, second symphony. Hanson is practically synonymous with the Eastman School of Music in Rochester, NY. He also wrote this symphony at a time when most composers of his day saw romantic, melodic music as an anachronism, preferring instead to embrace the atonality that was emerging from Europe. Hanson, a consummate melodist, unapologetically subtitled this symphony “The Romantic.” While Hanson is not as universally known as Copland, his legacy also lives through all of the Eastman students who have carried some of his spirit with them.

Culture and Media:
Christian at MedJournalWatch presents a absolutely fascinating case study in Africa about body image issues (!?!) and a surprising trend in the perception and desirability of body fat.

Jolie Bookspan at The Fitness Fixer shows how she performed martial arts movement analysis “old school” with high speed film years ago. Later, she returned to this area, except she was the model FOR a computer and even had her moves included in a video game. Cool stuff!

In the spirit of both Thanksgiving and the upcoming holiday season, Paul Levy of Running a Hospital shares his daughter’s essay on Salon.com about fruitcake and family tradition. It’s an extra click from his post, but the Salon article is an excellent read and well worth the extra navigation.

Canadian Medicine talks about how Canada’s health department warned against using a Chinese preparation of caterpillar fungus. Gee, ya think? I wonder how those meetings went. “There’s a fungus among us!”

Postlude:
I hope you enjoyed this edition of Grand Rounds! I hope everyone has a safe and happy Thanksgiving. Regardless what country you’re reading from, I know there’s something to celebrate and be thankful for–after all, you’re alive and reading this, aren’t you?

Grand Rounds leaves Mexico from Puerto Vallarta a few hours away and sails for the Philippines, home of next next week’s host, Prudence, MD. ¡Adios y buen viaje!

El plazo para mandarme sus obras para Grand Rounds ha terminado.

(Translation: Like MC Hammer, it’s too late for a comeback.)

Some relevant info:

• Send your submissions via email to enrico-[at]-mexicomedstudent.com with the subject “Grand Rounds” and the URL of the post for inclusion in body of the email, along with just a sentence or two of a summary. The summary helps when I look back through my mailbox and I can match the post in my mind with the URL.
• Most importantly, all posts must reach me by Sunday, November 18th at 5:00pm CST (6:00pm EST). Sorry for the Sunday, but I’ll need a little extra time this year because I’ll be starting a house move that week. I’m sure all of you can sympathize what that’s like. Any submissions received later than the above will automatically be forwarded to the next host.
• I may not include all the submissions I receive; I just wanted to say that up front. I will always strive to be inclusive, but I reserve my editorial prerogative to do what’s best for the edition.
• As soon as you’ve posted something and feel it should be included in next week’s edition, send it to me then. It’s a great help to get at least some posts before the weekend.

I hope to deliver a solid edition on the heels of such great presentations as of late. Let’s have some fun!