More U.S. Children Being Diagnosed With Youthful Tendency Disorder

REDLANDS, CA-Nicholas and Beverly Serna's daughter Caitlin was only four years old, but they already knew there was a problem.

Vaccine Smack

Mostly because I'm sick of seeing that scary Huckabee-Squirrel picture every time I pull up my site for link shortcuts, here's another Slate video, this time with some good old-fashion take-your-autonomy-and-shove-it vaccine cautionary tales.

To be clear, I think people who don't vaccinate their children are about as smart as people who eat their own poop. But I wouldn't kick someone out of my practice for any reason save concerns of personal harm, and I don't think it's particularly responsible for pediatricians to threaten parents that they will no longer be their child's pediatrician just because the parent smokes mercury-laced crack.

Don't punish a child just because the child's parents are idiots. The kid is going to have enough problems surviving 18 years with their anti-vaccine asshat mom and dad without getting fired by their pediatrician.

The day when I'm proud to be a redneck

So, much of my residency decisions have centered around not only geography, but that personal conception of self. Am I a fly-over country kind of guy, could I fit into the Smooth of the west coast, could I become snotty enough to make it in the Northeast? Those sort of existential questions.

Thankfully, the folks at Slate clarify this for me, with their highly enlightening segment, Can You Eat Squirrels?, in response to Mike Huckabee's claim that rural Americans will relate to him because he cooked squirrel in a popcorn popper while in college.

In point of disclosure, I do not support the eating of any animals, especially not ones that require such a large shotgun blast to hunt. But I'd like to have a better Explainer video: are there really people in this country so ignorant of Upland South culture that they don't know that people eat squirrels?

Seriously, watch these squirmy New Yorkers jaw-drop as they learn about burgoo, about using non-certified appliances for frying food, and the idea, that, oh my god, people eat meat that runs around in a forest when shotgun shells are cheaper than McDonald's. The latter is a little less relevant nowadays, but, yes, I had family that hunted squirrels because it was more accessible than McDonald's.

I've never been hunting in my life, but I had a hard time explaining the significance of Dick Cheney shooting that guy in the face with a 20-gauge while quail, realizing that my coastal city-folk friends couldn't even conceptualize the process of quail hunting, and how Cheney's inability to follow the most basic of safety precautions on a bird hunt was quite the microcosm for the administration's approach to the Iraq war.

But I digress.

If you don't know that people hunt squirrels, or if you couldn't select an appropriate firearm for doing so, then you have as much to learn about America as I do.

The Quotable Evangelical Evolutionist

Michael Dowd, author of Thank God for Evolution:

God communicates through science. Facts are God's native tongue. Who of us would let a first-century dentist fix our children's teeth? Yet every day we let first-century theologians fill our children's brains.

There's a difference between flat-earth faith and evolutionary faith. In flat-earth Christianity, the core insights -- sin, salvation, heaven and hell -- are understood in the same way as when people first formulated ideas. I still value the same concepts, but interpret them in a radically different way.

Sherwin Nuland on ECT

Nuland is the author of my favorite medical history text and a bunch of other more famous books I haven't read, a former Yale surgeon, and just an all-around brilliant kinda guy.

Joe Nuxhall, 1928-2007

Youngest ever player in the major leagues, Cincinnati icon, and the dude that called every baseball game I listened to growing up. Sad.

Nuxhall was just 15 years, 10 months and 11 days old when he pitched for the Reds against the Cardinals on June 10, 1944, in front of about 3,500 fans at Crosley Field.

He died Thursday from cancer, or being left-handed, you never can tell.

I highly recommend

The Stool Pigeon Memoirs.

Gee, never saw THAT one coming...

Pfizer said yesterday that it would stop selling Exubera, its inhaled insulin, less than two years after introducing the drug. Despite Pfizer’s heavy promotion, Exubera’s sales were minuscule, with prescriptions amounting to less than 1 percent of the insulin market.

Pfizer will take a charge of $2.8 billion for costs associated with Exubera, making it one of the most expensive failures in the history of the pharmaceutical industry.

Rarely does a pharmaceutical company actually feel such nasty repercussions for producing a more expensive product with little value added to the prior product. Needles may hurt, but so does interstitial lung disease. And you just look silly taking a hit of insulin from a bong.

Link Roundup: Comeback Edition

Alpha: JJ Abrams is going all kinda crazy on the new Star Trek movie. Brilliant casting movies include: Zachary Quinto (Sylar, from Heroes) as an iteration of Spock, Simon Pegg (Shaun of the Dead!) as Scotty, and John Cho (Harold, not Kumar) as Sulu. Could a Star Trek movie be a date movie? And can a Korean guy really play a Japanese guy in the 23rd century?

Beta: Wii Goodness: Wii Fit will be released in the states in 2008, giving West Virginia law makers something other than DDR to put in schools. I welcome my Nintendo weight-loss overlords, having just played some Wii Sports for the first time last night.

Gamma: Damn you, Jared! Cornell researchers find that folks underestimate the number of calories in a meal from Subway compared to McDonald's, because Subway is "healthier."

"We found that when people go to restaurants claiming to be healthy, such as Subway, they choose additional side items containing up to 131 percent more calories than when they go to restaurants like McDonald's that don't make this claim," said Brian Wansink, Cornell's John S. Dyson professor of marketing and applied economics and director of the Cornell Food and Brand Lab, in a news release.

"In estimating a 1,000 calorie meal, I've found that people on average underestimate by 159 calories if the meal was bought at Subway than at McDonald's," said Wansink.

That extra 159 calories could lead to an almost five-pound weight gain over a year for people eating at Subway twice a week compared to choosing a comparable meal at McDonald's with the same frequency, he said.

Delta: File under "study that has lots of data but no useful or surprising information." The Office of Substance Abuse and Mental Health Statistics issued a report stating that "personal care," "food preparation and serving," "community and social services," and "health care" workers have the highest rates of depression (and women are about twice as depressed in most of those fields as men). "Installation, maintenance and repair" and "engineering, architecture, and surveyors" have the lowest rates of depression. Self-selection much?

Epsilon: File under "stuff people didn't pay nearly as much attention to as they should have." A Pittsburgh physician (NOT associated with WPIC) was finally charged in August with involuntary manslaughter after a boy died of cardiac arresting while receiving chelation therapy for autism. It looks like the kid died from a possible mix-up:

The Centers for Disease Control and Prevention found that the boy was given a synthetic amino acid to rid his body of heavy metals, instead of a similar chemical with a calcium additive. Both are odorless, colorless liquids and may have been confused, the CDC found.

When you make a mistake giving real medical care, it's a tragedy, but bad things do happen to good people. When you kill someone with fake medical care that preys upon the hopes and vulnerability of loving parents, you deserve criminal charges, and a firm kick in the nuts.

Blogging Vacation

So, as I went back to full-time med school after finishing my master's, and finished up my residency application, I listed this blog as one of my "hobbies." Apparently something about claiming "ownership" freaked me out, or I was just busy, and I entirely got out of the habit of blogging. I kept bookmarking links and sticking them in a "bloggables" folder on my Firefox toolbar (and even opened a "bloggables2" folder, since the first one was so full), but I could never convince myself to actually sit down for the handful of minutes it might take to throw together something. The longer I took off, the more obligated I felt that my posts had to be really good, and few bloggers with real lives have time to make every post really good.

So, I tossed and turned, and almost decided to throw Sparkgrass to the wolves. It's hardly a community anymore, as Zuck, Pepper, and Geoff are swamped interns, and Kyle has finished up his Oxford thesis, and, while his personal blog is wonderful, he's just not as interested in the sorts of things that fit here. So, it's just me. And applying for residencies has brought, front and center, the idea that some day pretty soon, folks are going to be calling me doctor. That nauseates me, in an appropriate way. As a med student, your goal is to learn, and make the lives of the people in front of you feel better as they navigate the system. You learn how to be a decent colleague, and learn a very special kind of responsibility. At least, you're supposed to learn a special kind of responsibility, and I think I am doing so, but some of your colleagues make you wonder if they ever did. As a person that someone calls doctor, you're somebody who makes binding decisions for somebody's daily health. If someone feels like they're going to throw up, or sedated, or agitated, that might be because of the meds I proposed as their best bet. If you give a shit about the lives of the folks in front of you (and I certainly do), that's a huge deal.

I'll have patients googling me someday soon, and they'll find this site. That's weird.

I've missed a lot of world-changing events in my vacation from blogging; S-CHIP, Larry Craig, and a new Radiohead album all come immediately to mind. I'm not sure I had anything intelligent to say about any of these things that Ezra Klein or Matt Yglesias didn't say before I even heard the stories.

So, Sparkgrass is here to stay. But I have to acknowledge its limitations, and my limitations. I'm probably going to find a new, more anonymous blogging home sometime soon (a few offers on the table) where I'll get much more exposure than a personal, blogger-run site can offer. But I have to wait for S-CHIP to blow over. There are way too many people who either a) know more about health policy than I do, or b) simply THINK they know more about health policy than I do, but blather on and on and on, for me to hop in the debate there.

To offset the cute puppy

Lunetta P, Ohberg A, Sajantila A. Suicide by intracerebellar ballpoint pen. Am J Forensic Med Pathol. 2002 Dec;23(4):334-7.

Picture stolen from and explanation at Retrospectacle, one of the SEED Science Blogs written by UofM cochlear implant ninja Shelly Batts.

Not mine, but I'd take it

Cute Overload. Seriously.

The War on VBACs

For those who haven't stayed up all night checking to see if mom's ready to push, a VBAC is a Vaginal Birth After a C-section. During a Caesarian, besides cutting through mommy's belly, mommy's uterus gets cut as well. When a woman has another child, the worry is that since the uterus has already been cut before, the spot of healing isn't as structurally sound as the original uterine wall, thus the pressure placed on the uterine wall during subsequent pregnancies would then result in uterine rupture, and the need for emergent surgery. Emergent surgeries carry a multitude of greater risks than elective procedures.

But then some studies cited in this NPR story mention that the actual rate of uterine rupture in VBACs isn't that large, but when a uterine rupture DOES occur during a VBAC, outcomes are comparably terrible. This lead ACOG to recommend that adequate surgical faculty be available when a woman was attempting a VBAC. The problem arises when smaller hospitals simply don't have the resources to ensure those adequate surgical backups are at hand, and hospitals then ban VBACs because they simply can't afford to keep a full back up team on call.

Which creates the interesting public health versus personal autonomy dilemma we've all come to know and love. Women absolutely have a right to attempt a VBAC (and yes, "attempt" is the correct terminology) with a fairly low threshold for proceeding to a repeat caesarian should complications arise. And hospitals have a right to not offer services they simply can't afford to offer when medically acceptable alternatives exist. "Medically acceptable" and "personally acceptable" are, of course, not always in agreement.

Where I've trained, the VBAC was always an option, mostly because the hospital is equipped with the staff to handle any complication that could arise because patient volume and the high-risk patient population justify their use. On a population level, the risk is astronomical. On a personal level, the risk is miniscule.

Of course, the naturalist spin is that obstetricians are evil bastards who want to cut so they can go home and get some sleep so they'll have time to wake up early enough to spend their hefty salaries. Actually, obstetricians, like other physicians, don't like the idea of folks dying during an emergency from a partially preventable incident.

The woman in the NPR story gives the most revealing quote, however. She is rightfully upset that she is being forced to have a VBAC. When presented with the rationale for why this is so, she replies:

"That's what they hospital is there for, to handle emergencies. And so, in that respect, the policy never made sense to me."

No, emergency rooms are there to handle emergencies, as long as by "handle," you mean do the best that anyone can to stabilize an unstable situation, recognizing that some unstable situations simply cannot be stabilized, and should be avoided if possible.

Hospitals exist to provide inpatient medical care following complicated medical algorithms in which physicians and patients take action to minimize the risks associated with illness and treatment. If a particular hospital can't handle a particular risk, it shouldn't try to do so. It should refer to a tertiary care center, and it should be blatantly honest with its patients about local limitations.

We don't send burn victims or trauma victims to any old hospital and expect that hospital to be staffed to handle those emergencies. We have regional burn centers and a tiered-trauma centers so that patients can receive quality care, and our society can afford to provide that quality care.

A woman has every right to demand an attempt at a vaginal delivery after a caesarian section for a prior pregnancy. Heck, I imagine if I were a woman on my second pregnancy after having a C-section the first time, I would almost certainly demand a VBAC. However, no hospital can be expected to offer a service it simply can't afford to offer. If I want the VBAC, I have to go find a facility that does offer that service, since I'm probably unwilling to spend the extra zillion dollars required to keep sufficient surgical staff available during my delivery. And my current providers have an obligation to help me find that facility.

For the most part, Starbucks has an obligation to give you precisely what you want, because coffee isn't dangerous, and they can charge you whatever that coffee is worth to them.

For the most part, your medical provider has an obligation to give you precisely what you want, as long as what you want is reasonably safe, economically viable, and consistent with what can comfortably be called standard of care. For example, elective abortions and emergency contraception meet each of those criteria, and thus each woman has a right to receive them. In some contexts, a VBAC doesn't meet those criteria (according to ACOG... that's certainly up for further debate). Thus, the provider's obligation is limited to directing the patient to a context in which the patient's preferences do meet those criteria.

Update: The Onion offers the proper supplement to this story:

Woman Overjoyed By Giant Uterine Parasite

NEW BRIGHTON, MN— "I'm so happy!" Crowley said of the golf ball–sized, nutrient-sapping organism that will eventually require hospitalization in order to be removed.

Health Policy: SCHIP in danger

Recently, congress passed an expansion of the State Children's Health Insurance Program (SCHIP) to allow more children to enroll. Yay, for the kids. The Bush Administration threatened a veto claiming fears of socialized medicine. But going beyond this, the Bush Administration has issued a set of "rules" that would prevent any state from increasing their enrollment unless a slew of requirements are met:

Under the requirements, children must be without insurance for a year before they can be enrolled, and families of children in the program must pay fees for care similar to those paid by families with private insurance. In addition, the state must show that it has enrolled at least 95 percent of children below 200 percent of poverty and that the number of children insured through private companies has not dropped more than 2 percentage points over five years. The latter requirement is supposed to ensure that employers aren't dropping family coverage.

This is outrageous on a number of points. Firstly, it requires children to be without health insurance for a year in order to qualify. A lot can happen in a year (vaccinations, checkups, broken bones). Why would this Administration claim that the best way to insure children is to require them to be uninsured. Additionally, the 95% requirement is ridiculous, since most states simply can't achieve that level of enrollment. And finally, the whole point of these rules is to subvert a law passed by the legislative branch. The constitutional role of the executive is to enforce the law, not subvert it. If Bush wants to threaten a veto, then he's just a jerk who doesn't care about children, but when he continues to trample on the federal constitution then he's a criminal.

Rilo Kiley does 1973?

Under the Blacklight looked like a possible bright spot in a really boring music summer (I kinda grooved the new DadRock version of Wilco, and the new Rufus sounded very promising and tightly written, even if I can never make myself care enough to listen to more than three tracks. It's like, dude, I get it. You're really really gay.).

The reviews I can find online fall into two categories: a) Rilo Kiley without crunch guitar sucks, and b) hahaha omg watch the indie kidz squirm lol stfu!!1!

I can understand how pop critics would mess their pants anytime an indie band sells out whatever sound put them on the map. If you like pop music, this album is probably a really great pop album. But if you've bought a Rilo Kiley album before, it's probably because pop music bores you to tears. Call us pretentious, and we'll call you just plain bland.

I'd say there's a 35% chance this album will grow on me. But on first listen, this thing is 90% Sucks Ass. Even tracks I want to like figure out a way to push me away.

Jenny Lewis is Bob Dylan with good fashion sense. And even Bob Dylan shat out some incredibly terrible albums in the spirit of "experimentation." Rilo Kiley will probably sell more albums than ever before, but that's only because you can't take back an opened CD.

Update: EW's review is fair, if a bit forgiving. I just have to deal with the fact that this might be a good album, but a terrible Rilo Kiley album.

Hometown Pride Update

Welcome to 1997, cultural center of Northeastern Kentucky!

First Ashland Starbucks opening Monday

Friday Afternoon Vocabulary Expansion

I've recently run across two words that have instantly found a home in my "that's just a cool word" mental bin. So I must share.

First, steampunk.

Second, and much better for a general audience, crank bug. (4th paragraph)

To be clear, I claim the latter for the totally awesome indie grass band I will someday assemble.

Hometown Pride! The Duct Tape Bandit Strikes

You OWE IT TO YOURSELF to go watch the video. By the way, the hospital in the 15-second commercial prior the clip is the one in which I was born. And I graduated high school with the liquor store employee.

So apparently this was on the Today Show this morning. I saw it on Fark as well, so it must be a big deal, right? And Yahoo! news. Problem was, I heard it the night before from my mother, since this occurred about two miles away from my parent's house.

Without further ado, the Duct Tape Bandit!
This guy is obviously in need of a good forensic psychiatrist.

Restore the Draft? What a Bad Idea

Steve Levitt, of Freakonomics fame, hits one out of the park:

If the problem is that not enough young people are volunteering to fight in Iraq, there are two reasonable solutions: 1) take the troops out of Iraq; or 2) compensate soldiers well enough that they are willing to enlist.

The idea that a draft presents a reasonable solution is completely backwards. First, it puts the “wrong” people in the military — people who are either uninterested in a military life, not well equipped for one, or who put a very high value on doing something else. From an economic perspective, those are all decent reasons for not wanting to be in the military. (I understand that there are other perspectives — for example, a sense of debt or duty to one’s country — but if a person feels that way, it will be factored into his or her interest in military life.)

One thing markets are good at is allocating people to tasks. They accomplish this through wages. As such, we should pay U.S. soldiers a fair wage to compensate them for the risks they take! A draft is essentially a large, very concentrated tax on those who are drafted. Economic theory tells us that is an extremely inefficient way to accomplish our goal.

Critics might argue that sending less economically-advantaged kids to die in Iraq is inherently unfair. While I wouldn’t disagree that it’s unfair that some people are born rich and others poor, given that income disparity exists in this country, you’d have to possess a low opinion of the decision-making ability of military enlistees to say that a draft makes more sense than a volunteer army. Given the options they face, the men and women joining the military are choosing that option over the others available to them. A draft may make sense as an attempt to reduce inequality; but in a world filled with inequality, letting people choose their own paths is better than dictating one for them.

What a Difference a Decade Makes

In this video, Dick Cheney explains (in 1994) why the invasion of Baghdad just doesn't make sense...

h/t: Gladly Suffering Fools