Monthly Archives: July 2008

Grand Rounds, Vol 4, No 42 – The Seinfeld Edition

Most things in life can be related, one way or another, to an episode of Seinfeld.

It’s true. That TV show which claimed to be “about nothing” pretty much said everything that needed to be said about, well, everything.

Take this week’s Grand Rounds, the best of the Medical Blogosphere. It’s totally Seinfeld. Every post. Why I can hear Jerry, even now…

Grand Rounds? Can someone please explain what that’s about? I mean, is it Grand as in “large”? Or Grand is in “Isn’t that grand?”

No one says “Isn’t that grand?” anymore unless they’re 95 and in a nursing home for retired stage actors. In which case they should definitely not be practicing medicine.

And why do they call it “Rounds”? Is everyone standing in a circle singing Row, Row, Row Your Boat? What’s that got to do with medicine?

Or is it Rounds like a round of golf? D0 you guys keep score? “I shot a bogey on that appendectomy today. Lost a Titelist sponge somewhere behind the cecum.”

Doesn’t that make your nurse sort of like a caddy? “Nurse, hand me my 9 scalpel. Or do you think I should wedge it out?”

Grand Rounds. Now that I think if it, it sounds like some sort of Melba cracker you serve with cheese. “Would you like some Gruyere on a Grand Round? Oh do try it – It’s Grand!”

Cut to Jerry’s apartment, where his friend Dr Crippin, visiting from the UK, is ranting about how he is tired of the livers of his fellow citizens being given out to foreigners. Not an English citizen? NO LIVER FOR YOU!

Kramer tells the group he wants to listen in on doctor’s conversations, and wonders if Jerry’s deaf girlfriend, who reads lips, can hang out out in the OR and find out what they are saying. Joshua Schwimmer reminds Kramer about the fiasco when he tried that last time, and suggests that instead, Kramer hang out online in the Doctor’s Room at Friend Feed.

RL Bates has a great post on the retracted nipple – when it’s normal, when it’s not, and how to manage both. Elaine appears not to have that problem, as everyone who got her Christmas card can see.

Jerry may have gotten in trouble for using the F- Word in a Yogurt Shop, but Rural Doc finds out it can be pretty f*$#ing helpful in the Labor and Delivery Room. Great post!

When Kramer drops a Junior Mint into an open abdomen during surgery, the patient is miraculously cured. But Doc Gurly reminds us that lack of proper sterile technique can have disastrous consequences.

Dr Shock tells us that drug use does not appear to be related to drug policy, as countries with more stringent policies (e.g., the US) did not have lower levels of illegal drug use than countries with more liberal policies (e.g.,The Netherlands). Meanwhile Jerry and George wonder where Holland is.

Jerry, Elaine, George and Kramer are waiting at the Chinese Restaurant for a table. “You ever notice how happy people are when they finally get a table?” says Elaine. “They feel so special because they’ve been chosen. It’s enough to make you sick.” Dr Jokes overhears Elaine. “Hmm.. I wonder what would happen if the restaurant treated her as if she were sick, and used the medical office model?” Unfortunately, Elaine never finds out, because they never get a table.

The wait for the restaurant on the show occurs in real time – 23 minutes. During which time, basically nothing happens. Well, nothing other than the earth moving. And The Samurai Radiologist can tell you exactly how far it moved during that wait in the restaurant. Or during the time you had sex. Or any thing you happen to be doing. Pretty cool.

Dr Toni Brayer shows us just how impossible it can be to figure out what the costs are for a hospital procedure. Reminds me of the episode where George finds out be needs his tonsils removed.

GEORGE: (To Jerry) Let me ask you something.. How much do you think it would cost to have tonsils and adenoids removed in the hospital?

JERRY: Well, an overnight stay in a hospital? Minor surgery? I dunno, four grand.

GEORGE: Uh-huh. And how much does the healer charge?

KRAMER: First visit? Thirty-eight bucks.

GEORGE: Oh, yeah? Holistic.. that’s what I need. That’s the answer.

Elaine’s boss, J Peterman, is off again on a world jaunt, this time to visit his friend the traveling Doc Kate. She’s in Pakistan, training the locals on how to diagnose and treat Sexually Transmitted Infections. Stay safe, Dr Kate.

George has a massage that stimulates him in a way he’s a bit uncomfortable with. Next time he should just read Fixing Posture and learn to take care of his back himself. And if he decides on aquatic therapy, Dean Moyer at the Back Pain Blog has everything he needs to know.

Elaine can’t sleep because a dog is barking outside her window. Or, wonders Dr Nancy Brown, is it just her hormones?

Kramer loves his hot tub. It relaxes him. And it’s not just in his head. Relaxation techniques can favorably affect the expression of stress related genes, according to new research discussed at Neuroanthropology.

Elaine has a rash that needs diagnosis, but no doctor will look at her rash because she has been labeled as a difficult patient. Too bad she didn’t see House. He’d have figured it out, knows Monash Medical Student, just as he diagnosed this week’s case of subacute sclerosing pan-encephalitis.

When the conversation gets rough, try to find the humor, says Barbara Kivowitz at In Sickness and in Health. Maybe that’s why Julia Dreyfuss can’t stop laughing every time Mr Costanza tries to get off that famous line “You wanna’ piece of me?“

Kramer hires an intern to get all his stuff done. Too bad he didn’t read Apple Quack’s two part post on project management.

The group has a contest to see who can remain “Master of their Domain” the longest. Kramer is the first to go. Maybe it because he eats watermelon, which JC Jones tells us increases blood flow to the genitals and may increase libido.

Anesthesiaoboist has compiled a very nice gallery of Medicine in Art, including my favorites, the ancient Persian drawings. I think she might also have included this painting of the famous Dr Van Nostrand…

Did you know that it was Rodney Dangerfield who gave Jerry Seinfeld his biggest break, by featuring him on his HBO special? Maybe Diabetes needs a break too, says Amy at Diabetes Mine. It’s the Rodney Dangerfield of diseases, ranked by the public lower than other less serious diseases as a cause of mortality.

The Cockroach Catcher has a fascinating post this week about how dried Chinese plums can be used as natural oral rehydration therapy. Hmm..maybe Kramer should try some. Those pretzels are making him thirsty.

Kramer and Jerry’s landlord has replaced their shower heads with low flow models to save money on water, and no one feels like themselves without a good shower. That’s pretty much what the government has been trying to do with health care costs since Medicare was started. At least I think I got that right. It’s very complicated, and Covert Rationing does a great job of trying to explain it.

George’s girlfriend can’t have sex with him for 6 weeks, and he discovers that without sex, he gets smarter. Maybe he should have read Dr Alvarez’s post on brain health and found some other way.

David E Williams has written a fascinating post about how a man’s Google search led to his conviction for murdering his wife using ethylene glycol. Hmm.. Do you think George might have googled “wedding envelope glue death“?

Vitum Medicus compares the med school class of 1960 to that of 2010, in his post Are Today’s Medical Students Wusses?. Hopefully, they are nicer than Elaine’s boyfriend who breaks up with her after he becomes a doctor. Or, as he puts it “I’m sorry, Elaine. I always knew that after I became a doctor, I would dump whoever I was with and find someone better. That’s the dream of becoming a doctor.”

Elaine loves her Big Salad. But she’d better be careful- those tomatoes may have salmonella, says Paul Auerbach. Read his post for a great summary of the problem, plus some great advice on food handling.

R Murse summarizes California’s new regulations to help fight prescription drug abuse, but it’s too late to catch Jerry’s drug-using accountant, who’s already left the country.

For Chronic Babe, mixing it up occasionally is important in keeping healthy habits, whether it’s a change in routine or a new recipe. I’d say that’s something to dance about, wouldn’t you?

Kramer, as always, is the only member of the group with a heart (most of the time, anyway)… He’d have liked these following posts –
  • Little Hailey has an incurable and fatal disease, and her only hope may lie in an experimental treatment being done in China. InsureBlog’s Henry Stern asks whether the airline that was supposed to fly her there did the right thing by refusing to.
  • Dr Val tells the story of a young teenage mother who beats the odds in her review of the book Glori, a Different Story.
  • PalMD uses a special pen when he writes notes to the relatives of recently departed patients. It’s too important a task to relegate to anything else. What a nice post.
  • Susan Palwick of Rickety Contrivances has a wonderful post telling of a moving encounter she had with a pscyh patient.
  • One of Dr Rob’s favorite patients is dying. His post reminds me of all the wonderful patients I have, and how they enhance my life. Thanks, Dr Rob for a wonderful post.
  • Sudeep Bonsai wonders just how aggressive to be in treating an elderly depressed and very ill patient with congestive heart failure. Sounds to me like he did the right thing. See what you think.
  • How to Cope with Pain has some suggestions to awaken Joy. She’s clearly a glass half full person.
  • My heart goes out to Lisa, who has Cushing’s Disease. Stop on by and give her an encouraging word.
And that’s it, folks. Proof that everything in life, or at least in the medical blogosphere, can be related to Seinfeld.
Thanks to all who submitted posts. I tried to include everyone, although a few duplicate posts on the same topic came in, and so I took the one that arrived first. A few posts arrived late on Monday, and I’m sorry I just could not include them. If that was your first time submitting, and I didn’t include you, please don’t be discouraged – after all, there’s always next week!

Thanks as always to Nick Genes of Blogborygmi, who makes it all happen. Next week’s Grand Rounds will be held at Unprotected Text.

Just Another Nuisance Malpractice Case

I just heard from the lawyer defending a med mal case on which I gave expert opinion. The case was filed by a woman who claimed her miscarriage was caused by a hormonal birth control method that her doc initiated during an early pregnancy that she charges he should have diagnosed.

I can’t give further details, but suffice it to say that medically, this plaintiff had no case. The birth control in question does not cause miscarriages and there was no reason the doctor would have suspected that she was pregnant at the time the method was initiated. Although the doc did not do a pregnancy test, it would have been negative since the patient was only 1-2 days post conception at the time.

The case settled for $7,500 before any depositions were even taken.

The Defense Lawyer was thrilled. As far as she was concerned, $7,500 is “essentially nuisance”. With just a few hours work on my part, I had saved her thousands of dollars and countless man hours trying this case. Since the doc involved was a hospital employee, he was not named, so no harm was done. She wants to use me again as an expert.

The Plaintiff’s Lawyer made a few thousand bucks – not bad for a couple of hours work. He’s learned that these nuisance cases may not be windfalls, but if you file enough of them, they pay off. In fact, they’re the bread and butter of his practice, and are probably putting his kids through college.

The Plaintiff may not have gotten rich but this nuisance case has given her enough cash to pay off some credit card debt or take the kids to Disney World. Plus, she has a story to tell everyone she knows. Those doctors caused her miscarriage, and they had to pay. Not as much as she would have wanted, but they paid nonetheless. Her lawyer said something about “no admission of guilt”, but she doesn’t believe that – her lawyer just wasn’t as good as he could have been. Certainly not as good as her cousin’s lawyer, who’s promised her a hundred thousand dollars for her premature baby.

Friends, acquaintances and friends of friends of the plaintiff will hear the story. They will tell their friends, who will tell their friends. The story may even make it into an Internet chat room.

Some women using the same contraceptive method will hear the story and become worried. If it causes miscarriage, what will it do to their future fertility? More than a few will be frightened enough to stop their birth control, and will have an unplanned pregnancy. Perhaps an abortion. Perhaps another child they cannot afford to raise, either financially or emotionally.

I wouldn’t call this case a nuisance. I’d call it a tragedy.

Biking the Pine Creek Trail

These days spent in the Endless Mountains of Pennsylvania are like stepping back in time. The lack of development in the area has kept it preserved in so many ways.

But one nice development has been the completion of the Pine Creek Rail Trail – 62 miles of flat gravel that runs from just north of Williamsport through Pine Valley into the Pine Creek Gorge, known as the Grand Canyon of Pennsylvania, to the town of Wellsboro, Pennsylvania. There’s lots to do along Pine Creek, including hiking, fishing, swimming and birding. But it was the biking that attracted us.

We did a 22 mile ride in the mid-section of the trail yesterday, biking from Blackwell to Slate Run and back. Although this ride did not take us through the Grand Canyon, it’s a lovely ride through the Valley, perfect for those who might not want to pack food and picnic, because there are several places to stop and eat.

Blackwell to Cedar Run

Blackwell is a tiny town with a nice hotel/restaurant and that’s about it. There was plenty of parking available at the trail lot, so we parked there, despite the fact that the trail guide suggested that bikers use the Rattlesnake Rock access and leave Blackwell to the boaters. There are bathroom facilities and a pump for water.

As we took the bikes off the roof, we discovered that the nut holding my front wheel on had somehow come off. Luckily, we found a place that rented bikes.

No one was there, just the honor system, take a bike, leave the money in the locked box.

The bike could have used a bit of oil, but was good enough, and I had not trouble keeping up with Mr TBTAM and the girls.

The path is a 2% grade going N-S, so it’s easy biking either way. The gravel surface is well maintained, but its width is deceptive – it can drop off fairly steeply in places, so I wouldn’t ride more than 2 abreast.

There are a fair number of bridges to cross – old RR trestles and small foot bridges across tiny feeder streams.


Cedar Run is an adorable little town with nothing more than a general store and an Inn.

We arrived after 2 pm, and though lunch is served only from 11-2, they felt sorry for us and made us panini sandwiches, which we ate us on the shaded side patio.

Meanwhile, the front porch was a continuous stream of bikers and locals coming for their renowned homemade ice cream.

The Cedar Hill Inn is across the street. I’m told the restaurant is very good, and the rooms lovely (though no air conditioning, I assume from the fans in the windows).

Cedar Run to Slate Run

From Cedar Hill to Slate Run the trail winds through a wide valley. On this stretch, we saw a rattlesnake.

and hundreds of tiny, perfect little frogs hopping across the trail.

Mr TBTAM saw some great birds – one with a bright orange vest, and several hummingbirds.

There are camping grounds and primitive cabins along the creek as you approach Slate Run, where there is a large General Store with pretty much anything a person might need, including sandwiches, food, sundries, a huge bait and tackle shop and lucky for us, air for our tires.

I am told the nearby Manor Inn has a good restaurant for lunch, but we did not stop there.

The Ride Back

We put on speed on the return trip, with nothing more than a stop for water at Cedar Run. That’s the downside to doing a trail and not a loop – riding back over previously ridden ground. But it was a great work-out and a lot of fun, so we’re not complaining.

We plan to return again in early Fall to do the upper part of the Trail from Wellsboro to Blackwell, arranging with Pine Creek Outfitters to meet us at ride’s end and shuttle us back to your starting point, so that we can cover more ground in a one day trip.

Bottom Line

If you’re looking for a great place to bike for riders of all ages, the Pine Creek Trail is it. Make it a weekend, and stay in Wellsboro or one of the towns along the trail. Fall is probably best for the gorge, but summer is pretty darned beautiful as well.


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I used the antique settings on I Photo to make the photos look old. I’m having fun playing with my new MacBook…

Grand Rounds in Manhattan Next Week!

Central Park, NYC (Photo courtesy of Wiki Commons)

As you’re heading out for vacation this weekend, don’t forget that Grand Rounds will be held here next Tuesday 7/8/08.

Send your submissions to tbtam(at)rcn(dot)com by 8 pm Sunday, July 6.

The Marcellus Shale – Your Shi Poo Pi!

Turns out that our summer house in the Endless Mountains of Pennsylvania is sitting on top of a large vein of Marcellus Shale, which in turn is housing one of the largest natural gas fields in the United States. No one cared about the Marcellus Formation until recently, when new drilling techniques first used in Texas were applied to the Marcellus and lo and behold, there was gas in them thar hills!

Most of the drilling in the Marcellus Formation will be horizontal and underground, with large quantities of water used to create fractures in the rock to release the gas. It’s a process that allows a single visible well to extract gas from a very large underground acreage, making the entire process financially feasible and quite profitable. The Marcellus could potentially yield enough natural gas to supply the entire country for 2 years, with an estimated market value of trillions of dollars.

The Gas Rush is On

Land lease negotiations with the locals in our area are in full swing as gas companies compete for rights to drill wells on their land. The first to sign contracts got fairly low rates, but land owners have since learned to negotiate in groups, and the lease price has gone up considerably in the past year. Land leases in our county are currently going for $2000 an acre, with 15% royalties.

Part of me is really happy for the locals living in the sparsely populated rural areas being targeted for drilling. These folks deserve a break. And, if they play their cards right, they will surely get one. Why, farmers formerly earning a sustenance living could become millionaires if their wells produce as expected!

The Environmental Questions

Of course, there are many concerns about the environmental impact of the drilling. Although the underground nature of the process means a relatively small visible footprint, the huge quantities of water that must be used could threaten local water supplies. The trucks needed to carry that water from areas outside the drill zone can create noise and pollution and damage roads. There are also concerns about quality of the water in the area, since most of us get out water from wells. The Gas Companies tell us that the wells are drilled well below the water supply and with casings to protect the aquifers. But who ever trusted an energy company with the environment?

Last night was one of the first meetings on the environmental impact of what will likely be decades of natural gas development in the area. Some good advice came from the meeting, the most important of which was to test your water both before and after drilling starts and not to allow drilling within 200 yards of the water source. Given that most of the drilling is underground, I don’t see how the latter can be reliably enforced.

The DEP is getting involved, and advises landowners to be proactive in monitoring drilling going on on or near their properties, and to report any potential violations to the DEP.

I wonder if any of the folks over at The Pump Handle can comment on the potential health impact of natural gas drilling…

More Information

  • Penn State Extension is doing a marvelous job of educating the public about the issues. Their Natural Gas Wiki has everything you need to know, from how the gas is mined to how to negotiate a land lease contract.
  • Geology.com is another great source of information on the Marcellus Formation mining.
  • Catskill Mountainkeeper does a nice job of summarizing the environmental issues.
  • OGAP, the Oil and Gas Accountability Project, has a free downloadable 220 page booklet called Oil and Gas at Your Door, written specifically for landowners and others affected by oil and gas development.

Shi Poo Pi?

Of course, whenever I hear the name Marcellus, all I can think of is Marcellus Washburn, the Music Man’s lovable sidekick, played by the late Buddy Hackett. Hackett started his show biz career in the Catskills, another area on the Marcellus Slate Belt that is being targeted for natural gas mining. So I know that, were Hackett alive today, he’d be singing this song…

Shi-Poo-Pi!

Well, the well you dig on the very first try
Is usually a shy one
And the well you dig on the second time out
Is sure to be a dry one
But the well you drill on the third time around,
Slate on the top, gas in the ground!
That’s the well you’re glad you’ve found–that’s your
Shi-Poo-Pi!

Shi-Poo-Pi! Shi-Poo-Pi! Shi-Poo-Pi!
The gas that’s hard to get!

Shi-Poo-Pi!Shi-Poo-Pi!Shi-Poo-Pi
But you can mine her yet!