25 February 2011

Two Weeks to St Baldricks!

Two weeks from today I'll need to be wearing a hat (which is a sobering thought, since it's 22 degrees fahrenheit here today) because I'll have gone totally bald to raise money for kids with cancer. 
If you haven't taken a moment to sponsor my scalp, please do so: whatever you can afford. Baldrick's is a great cause, and the need for funding to support the research towards more effective treatments for pediatric cancers is a real one. Even gifts of $25 or $50 are appreciated. I'm over $10,000 raised so far -- tantalizingly close to my goal of $15,000 -- so if you can get me just a little closer to the finish line, I'll be very grateful.
You can donate on line at my personal St Baldricks page -- just click! Or if you prefer you can call toll-free 888-899-2253.
Thanks for considering!

15 February 2011

Going with the theme



Okay, technically it's not Jethro Tull, but it's Ian Anderson, the creative force behind Tull, and this song is in my standard bedtime playlist.

14 February 2011

More Tull



No interesting headgear on this one, but hella heavy metal flute.

The Cause of My Life

When my wife was diagnosed with breast cancer eight weeks ago, at the age of 36 and with four kids, the youngest of whom was 4 months old, it was what one might call a shock, the like of which you don't get too many times in a lifetime. It was a life-altering moment. As we walked out of the hospital, numb, one thing was clear, above all else:

This Changes Everything
There were so many decisions to be made. What would we do about the kids? About my work? Karate? PTA? The kids' music classes? Nothing could be taken for granted. Every little detail in our lives was about to be radically altered in the service of working up and treating Liza's cancer. Nothing would be spared. No detail was too trivial not to be affected by the monolith of living with cancer. I played out the game in my head, and I ran the calendar ahead and ran into a roadblock in March.
What was I going to do about St Baldrick's?
For those who do not know, I have participated in the St Baldrick's head-shaving event for the last three years (see here, here, and here). We raise money for pediatric cancer research. I do it in memory of my friend Nathan Gentry and a friend I never met, Henry Scheck. These kids died of cancer before they ever got to enjoy life. Their lives and their struggles changed me forever. But now we were embroiled in a struggle of our own, for the life of my wife, Liza.
So, am I on a "new team" now? Am I morally obligated to join the Susan G Komen foundation and wear a pink ribbon? It reminded me of an old Onion headline:
Rare Disease Nabs Big-Time Celebrity Spokesman
BALTIMORE–Flehner-Lathrop Syndrome Foundation officials excitedly announced Monday that actor Ted Danson has been diagnosed with the rare, deadly degenerative disease, bringing much-needed star power to their cause.
I was a fan of pediatric cancer, but I got drafted by breast cancer. (So that's what it feels like to become a Chicago Cub!) Is that how it works?
We've decided not. Note that I say "we," because this is as much Liza's position as mine. We do kids' cancer because it is important and because there is a gap there that needs to be filled. Just because some other disease has the temerity to come in and affect our lives directly does not mean that we will drop our priorities and put our provincial concerns in the top position. I knew about breast cancer (and colon cancer and heart disease and HIV and a host of other valuable causes) long before I decided to get involved in St Baldrick's. I chose pediatric cancer as the cause that I was going to dedicate my philanthropic efforts towards, not because it has directly affected me or mine, but because it's a critically important niche where I can make a difference, and because there is a real need for resources, in a way that is not true for other cancers, and also because the victims of pediatric cancers are vulnerable in a way that is unique. And that has not changed.
Please, understand that nothing I say or do here is intended to disparage those whose choices are other than mine. In fact, I suspect that for some, Liza's experience with breast cancer will inspire them to make breast cancer the cause of their lives -- and good for them! More people involved, more people fighting the fight is a good thing, and I welcome it strongly. Nor would I ever hint that "my cause is better than some others." That would be wrong and offensive in the extreme. All I am doing is explaining how I came to my own decisions.
Breast cancer is a useful comparison, because is has struck so close to home for me. For perspective, the Susan Komen Foundation is a $1.5 billion organization, with $337 million in annual revenues. The NIH spends some $900 million every year in research related to breast cancer. Which is as it should be: breast cancer will affect one out of every eight women. This is a lethal and common disease. It's absolutely great that there are people doing incredible work towards a cure for this disease, and I thank each and every one of you who has ever donated towards or worked for such a worthy goal.
In contrast, the funding towards all the cancers which affect children is a small fraction of that which is dedicated to breast cancer alone. The St Baldrick's Foundation had $22 million in revenue in 2010, and is the largest organization dedicated to pediatric cancer. St Jude's is another great organization, in the $100 million range, though they focus on all childhood catastrophic diseases, not just cancer. But the theme is clear: funding for kids' cancers lags an order of magnitude behind that of breast cancer, and other common adult malignancies. While this does make some sense, given their relative incidence, the fact that many kids' cancers have had such shocking decreases in mortality highlights the fact that dollars given to pediatric cancer research have a fairly high bang for the buck, so to speak.
So I'm still on "Team Baldricks" for 2011 and going forward. This is what I care about, and this is where I hope to make a difference. Because there are kids who need our help. And I'd like to ask for your support. Please take a moment and click through to my St Baldrick's page and make a secure, on-line donation. I've set an audacious goal for myself this year: $10,000. Whatever you can donate: $25 or $50 is the average donation, and it's greatly appreciated. If you can afford $500 or even $1,000, an angel will get its wings. Donations greater than $1,000 are rewarded with total consciousness, which is nice.
If it brings you more joy, click on Baldy the Leprechaun to donate:

Or, if it's more your thing, go on over to Susan Komen's place and make a donation in honor of Liza or the woman of your choice. It's all good.
Bonus: the top donor, if he or she is motivated to come to Seattle's Fado Irish Pub on March 10, 2011, will be awarded first swipe at my head with the razor! Any donors who show up, regardless of the level of support will be rewarded with a Guiness on me!

13 February 2011

A New Day



This song is an extended metaphor about the process of dying and passing into the "new day" of the afterlife. One of the more beautiful ones I have come across.

Nobody's dying here, but we are just about done with the rough chemo, and I am looking forward to getting our lives back. Thin ice indeed, but a new day...

08 February 2011

Flame War? Count me in!

Oh boy. The usually temperate RCentor over at MedRants has really stepped in it, commenting on a new study which showed that the utilization rate of CT scans doubled between 2001 and 2008. This would be categorized as "not news" and "holy cow you can get published by counting scans?" in my book. But Dr Bob decided to kick over the anthill with his commentary:

It appears that too often CT scanning takes the place of a careful history and physical examination. This can occur when the emergency physician is drowning in patients. But we should care! CT scans when accumulated likely cause cancers. Unnecessary CT scanning contributes to increased health care costs, not just from the cost of the scans, but from the chasing down incidentalomas that often follows a CT scan.

What solutions should we consider? The obvious first solution is to create an appropriate outpatient infrastructure in this country. We need to pay outpatient physicians better and allow them to spend time with patients. The next radical suggestion is that we should modify emergency medicine training. In the late 70s I spent a couple of years working in emergency rooms. My internal medicine training was highly worthwhile. I believe that emergency physicians need more inpatient experiences to better understand the natural history of disease.

My not-at-all-hyperbolic response was: Dr Centor is right! We *do* do too many CTs! I implore you all, lazy careless ED physicians to return to the True Path: Pneumoencephalograms and Peritoneal Lavage for trauma, VQ scans for PE, and a careful history and physical exam for Thoracic Aortic Dissection. (Did YOU check for pulsus paradoxus before ordering that CT? Lazy!)

Or maybe, just maybe, we are ordering more scans because they are USEFUL TOOLS. Yes, we have more access to them, yes, there's a fear of missing something, but really, ER docs are pure diagnosticians at heart. We want to find the answer, and CT can in many cases give it to us, or at least rule out the Bad Things [tm].  Which is truly the central part of our job.

Is there over-utilization? Sure -- I don't think anyone would dispute that. But more utilization does not in itself equate to more over-utilization. Maybe it's appropriate use of the technoilogy. Consider the study cited, which points out that among the greatest increase in use was for neck imaging. Why would that be, in the ER? Probably for non-contrast cervical spines after trauma. During the 8 years studied, there was a real shift in practice patterns in trauma imaging. High-resolution helical CTs became widely available. And multiple studies in multiple centers showed that CT was superior to plain films in detecting cervical spine fractures. So as the technology and the evidence both penetrated the market, there was a seismic shift away from plain films and towards CT scanning to detect the injuries.  It wasn't lazy ER docs who were unfamiliar with the natural history (!) of spinal injuries.  It was the emergence of a better technology backed by clinical evidence which addressed a common and vexing conundrum relating to a high-risk injury pattern.

I should also point out that ER docs undertook multiple huge multi-center trials to derive decision-making rules to select out patients who needed spinal imaging, in order to limit use of this technology to appropriately risk-stratified patients. There may be a fair question as to how assiduous community ER docs are in following the NEXUS or the Canadian C-spine rules. It's simply incorrect to suggest that the driver in use of this particular scan was failure to adhere to the rules rather than acceptance of the new technology.

There's a similar story regarding the other greatest increase in CT imaging, chest CT scans. During this time frame, CT completely replaced VQ scanning and aortography for PE, TAD, and Aortic trauma. I graduated residency in 2000, and I remember the debates then about whether CT or VQ was better, what quality of scan was needed for good enough images (again, helical scans being relatively new then), and what degree of specialization radiologists needed to interpret a CT pulmonary angiogram. Over time, the balance shifted conclusively towards CT, and now VQ is essentially only performed on patients who cannot take contrast dye. Similarly, aortography used to be the only way to diagnose Thoracic Aortic Dissections, and that's a very invasive screening test for a very uncommon diagnosis. And it's one that docs can most definitely get sued and lose big for missing. So now that better tools are available, we cast wider nets and catch more fish. (I'll also add as an aside that the three dissections I've recently seen on CT were all essentially unsuspected and would have been missed in the VQ era.)

The intimation of Dr Centor's post may not be too far from the truth, I have to admit. I do know docs who shotgun CTs and other tests indiscriminately. I suspect that anyone who works in an ER knows some docs like that. I don't know how to fix that problem within my own practice, let alone across the health care industry, and I don't think that it's possible: it's a personality type. Some docs are hasty, some are ignorant, and some are just really anxious. These high-utilizers will always be with us, whether it's in ordering too many tests or admitting too many patients, or needing too many consults. And we all should be mindful of the need to be selective in ordering studies with ionizing radiation. It is, however, wrong and quite unfair of Dr Bob to smear an entire specialty with the broad brush of "they order too many scans" and "they need to learn the natural history of disease" from the fairly limited bit of data in front of us.

I suspect a flood of irritated ER docs will be letting him know the same thing in his comments.

06 February 2011

Dueling Cellos

In honor of son #2:




This is pretty cool.


Super Bowl Open Thread



So who gets your vote for the greatest halfback ever?

03 February 2011

Not Dead Yet

Just really busy. Posting will probably be light through February as we progress through chemo, but never fear ... I'll be back.