Friday, January 22, 2010
On the ground in Haiti
Chinese Dulcimer Concert
The question of how the dulcimer, or yangqin, arrived in China is a mystery. There are three theories noted in Wikipedia, which I excerpt here.
One theory is that the yangqin came into contact with the Chinese through the Silk Road. The Silk Route stretches almost 5,000 miles reaching from China to the Middle East, including Iran (Persia). The Iranian santur, a dulcimer, has existed since ancient times. If any dulcimer was to influence China by land, it is likely to be this instrument. It is somewhat smaller in size, is same in shape, and is also played using two wooden mallets.
Here's the second theory. During the 16th century, the Age of Exploration in Europe reached its climax, and soon trade was established between China and Europe. Portuguese trading in Chinese waters began in the 1500s. Music historians report that the salterio, a hammered dulcimer, was played in Portugal, Spain, and Italy during this period. Thus, it is possible that the yangqin originated when the Portuguese, the English or the Dutch brought a dulcimer player to China who performed for locals.
The final theory that some music scholars support is the theory that the yangqin was developed within China itself, devoid of all foreign influence. These historians state two possible explanations for the instruments native origin. One is that the yangqin is a development from an ancient string instrument called zhu. The other is that the yangqin originated from Yangzhou, China itself.
Click here if you cannot view the video.
Thursday, January 21, 2010
Election's over. Problems remain.
This is from National Geographic. Please think about it as you decide what to do about health care.
Names of team members in Haiti
Our Team Names in no order.
Additional help from others who just arrived!
Grace Deveny RN MPH, international health program manager, MGH
Henry Salzarulo MD, anaesthesia, Seneca SC
Malcolm Smith MD, Ortho Trauma, Partners/MGH
Selwyn Rodgers MD, Gen/trauma surg, BWH
Denise Lauria RN, OR nurse, MGH
Nathaly Arredondo RN ERG, trauma nurse Lakeland Regional Medical Center, FL
Giliane Joseph MD, General internal medicine, Albert Einstein NY
Sachita Shah MD, ED doc Rhode Island Hospital, Providence RI
Kieth Antonangeli ST, MGHOR
Akshay Dalal MD, anaesthesia, MGH
George Dyer MD, Ortho Trauma, Partners/BWH& VA
Judy Wagoner RN., Trauma/surg nurse, BIDMC
Heather Bedlion RN, Cardiac step down, BWH.
Sergeline Lucien RN, Oncology nurse, BWH
Sarah Marsh Partners in Health, Women's Health
And expecting James Troussant Harvard, combined Ortho program, MGH resident (also Haitian) and others today.
From Haiti: "Life really just goes on"
Summary diary for today: Had a small disturbance this am when limited visitors at gate to reduce numbers of people in the hospital. As you may expect a lot of care of given by families. Settled when interpreter and I explained to crowd. Was really only shouting pushing and a few fists and was improving when I got there. Completely calm since, have asked DC for UN security to maintain safety but feel ok.
Argentinian UN military stopped for short visit then left promising to come back, did not. No more trouble. Lots of people but calm. Have been offered help from Congressman Capuano's office in DC. Sounds wonderful, hopefully can get supplies in to local soccer field by air. Expecting Akshay, our second anaesthetist tonight and James our own Hatian ortho resident with more MGH nurses to fly tomorrow Thank you Jeannette and everyone in Boston.
Medicine Sans Frontiers team visited today as did American coordinating nurse from somewhere nearby. Neither providing any help but supportive. It sounds the same elsewhere but many not getting it going as well. Working very well as a team ourselves, so impressed with these people. Have raided local warehouse for stores, found lots of unopened aid boxes, some gloves, drapes, etc but will need surgical supplies soon. Discovered the only blood tests we can do is a crit and cross match. No facilities to do electrolytes. Problem with rhabdo patients so watching urine colour and volume pushing fluid and diagnosing acidosis clinically. No iv bicarb so took advice and sent someone to buy baking soda to give orally not sure. Can someone ask our renal guys about renal protection in this situation?
Done 16 cases so far through 1 room in 3 days operating and 1 more to do tonight. Mainly massive soft tissue crush, including BK's AK's and hip disartic in basically MASH conditions all surgical patients improving. 3 deaths, 2 in ED mins after arrival and today a 24yr male with thigh buttock and leg compartment syndrome a week old. Died from rhabdo today just about the right time after injury. Have about 60 waiting most with wounds and open fx.
Had to operate for a short time with head lights when power cut this evening. Thank you Mary and LL Bean. Finally about to do our first laparotomy as have Selwyn* (BWH trauma surgeon) with us but being delayed by C section just happened, our anaesthetist helped baby looks fine. Life really just goes on.
---
*My note: I assume this is Dr. Selwyn Rogers at Brigham and Women's Hospital. Apologies if wrong.
Wednesday, January 20, 2010
Haiti updates
Aftershock this morning at 6.1 just west of Port au Prince. Apparently minimal damage as all that could fall down went down with the big one.
BIDMC is ready to field a new team but we are still waiting for the specifics from the field. At present we have over 90 volunteers, most of whom have been oriented, inoculated, and if they go, provided with the needed supplies and gear.
David Callaway is at a hospital in Jimini, just over the border in the Dominican Republic. He is completing the needs assessment and formulating what our next response should be. He is working closely with the Dominican government who supports our project to work out of the border hospital. There is a short note from him this morning below and we are waiting for a more detailed communication later today. We think this may be the best and most likely place for us to engage.
No further call in the last 2 days for volunteers from Partners in Health although they have said they expect needing staff soon.
We are in contact with the D-mat teams out of Worcester, anticipate that they may soon need help, and they are aware of our support.
We are reaching out to the Israelis who we have heard may soon be needing more personnel to see if they would be interested in working with us.
We have partnered with Denver Health who has 60 volunteers and is willing to have us coordinate for them.
We have made contact with Caritas who reportedly is helping to staff the ship Hope and is tied in with the Order of Malta. They are aware of our resources and will reach out to us with any needs.
Rich
-----Original Message-----
From: Callaway,David W. (BIDMC - Emergency Medicine) Limited access but have longer one to send. DR has disaster management needs. good ED medical needs as they just have rotating surgeons, no ED style system. we are trying to set one up. limited viz on haiti- i sent a team member yesterday and she is coming back today.
dc
---
I did hear from Dan Nadworny last evening via texting.... Over all, he is doing ok - he said it is the most traumatic scene he has ever witnessed. He is set up in a soccer field, with his IMSURT team of MDs and RNs...working in medical tents - the field is protected by armed Marines as there are many people trying to steal antibiotics and pain medication from the tents. He said on average they are doing about 5 OR cases in his tent alone per day. He is hoping to connect with Dave Callaway there - I asked him for a more detailed update for communications, but this is all he could text. His signal is not good - so we are getting spotty messages from him. I told him all of us are thinking about him and praying for his safe return.
Kirsten Boyd
More on practice variation: Hypertension


Here's the technical explanation, provided by a colleague at BCBS:
Two medicines -- ACE-inhibitors and Arbs (Angiotensin receptor blockers) are clinically interchangeable.* ACE-inhibitors cost substantially less than Arbs. The very high rate of Arb use (23% on average) is a good example of unexplained practice variation.
We see a wide spread in cost of treatment between the lowest quartile and the top quartile. A significant component of that, 30%, is accountable to the drug cost. And over 40% of the doctors have a use of Arbs that is above the network average.
And now look below at one particular 12-doctor primary care group, where the use of Arbs ranges from 13% to 55% and where three-quarters of the group are above the network average.

In a comment below, I quote Paul Batalden from a seminar I attended months ago:
Measurement is a reductive act. We measure an aspect of a phenomenon. We often start with one or a few measures. A "natural" reaction is to want a more representative picture of the phenomenon -- hence a "breeder reactor" for measurement.
His point, I think, is that you have to start somewhere and see what you can learn, but if you think you are ever going to satisfy all of the data needs that definitively prove something, you will never reach that point of certainty.
---
*There is one minor caveat: A small percent of the population has a sensitivity to ACE-inhibitors, such that they develop an annoying (though benign) cough. Most docs suggest that could be about 10 to no-more-than 15% of a patient population. So Arb would need to be used on that small group.
Tuesday, January 19, 2010
Personal update from a doctor in Haiti
From Cange, Central Plateau
Haiti
01-18-10
We arrived at Cange, in the Central Plateau, the heart of operations for Partners In Health/Zamni Lasante, yesterday. As we expected, things are incredibly busy. People are still arriving from Port au Prince. Those who have been fortunate enough to survive their injuries this long are now running into complications of wound infections, some of which have turned septic, and venous blood clots (from immobility and trauma). Patients have completely filled the hospital and we have set up makeshift wards in a nearby church and school. We have surgical and non surgical personnel working tirelessly. We are doing lots of wound evaluation, injury stabilization, and post-op care. We are planning to get the more complicated surgery cases out to the MERCY ship when it arrives in Port au Prince, hopefully tomorrow. We are also assisting in provision of acute care issues for the other, non-trauma patients on the wards here.
Patients are dazed. The disruption to their families and lives is beyond description. Many of our injured patients are not mobile, have few resources, have no home to return to, and many have lost their entire families. We care for their wounds. We listen. We grieve with them.
And yet amidst this darkness, there are rays of hope. Today a one day old baby girl was brought in, after being born on the streets of Port-au-Prince with clubbed feet. Her mother suffered lower extremity fractures in the quake and couldn't really move, but labored successfully, lying adjacent to the rubble of her home. The parents were so worried about the child that the baby’s father made his way to Cange with the child because he knew he could find care here. The baby will be casted and staff here will be shown how to recast her as she grows.
The Haitian medical staff of Partners In Health/Zamni Lasante and survivors of the quake are working with unimaginable valor and dedication, as many of them have lost several or most members of their family. And yet they remain here, working tirelessly to provide care for others. They are the true heroes. Those of us fortunate enough to be here to contribute to the immediate relief efforts labor by their side with complete humility. We are in awe of their strength, compassion and dedication.
In solidarity,
Jon
Practice variation: Real data
With help from friends at Blue Cross Blue Shield of MA, I offer an example. The issue here is the percentage of times that physicians choose to endoscopically examine and conduct a biopsy on patients with GERD, gastroesophageal reflux disease, which often presents as heartburn.
The top chart shows how the average cost per episode varies among the four quartiles of all cases. Note a variation of almost 100% in costs between the bottom and top quartiles. As noted by BCBS, the procedure cost is the single most important source of variation.
The second chart shows the variation, doctor by doctor, for use of endoscopies with biopsies. The charts shows that 74 of the 331 gastroenterologists have a significantly higher than average use of this procedure.
The question that follows is whether this degree of variation is accounted for by the variation within the patient population. That is, if one were applying standards of evidence-based medicine, would the distribution look like this? Or, is the distribution skewed by habit and predisposition of doctors? Is it influenced by a fee-for-service payment regime that encourages more procedures than are necessary? Are some doctors more fearful of malpractice suits and engaging in defensive medicine?
I often hear doctors say, when they are presented with these kinds of data, that "my patients are different," and that the data don't prove anything. But that assertion usually has no quantitative support.
BCBS is providing a valuable service in sharing these data with the hospitals in Massachusetts. The BIDMC data indicate that our doctors, like all others, vary within and across practice groups in management of the conditions at hand. We are finding this to be a useful tool in evaluating our practice patterns, both within our own practices and in comparison to others. In the face of these kinds of numbers, it is important to ask the questions.
Monday, January 18, 2010
Some good news from Haiti
Paul,
Thank you…thank you for all the support you showed to me and BIDMC community during Friday's prayer service for Haiti. I wanted to share some news with you.
I'm happy (overjoyed, elated, through the moon, jumping for joy and every emotion in between) to say that late Saturday night I was able to finally speak and locate my missing family members (two brothers, niece and nephew) who all said that they were doing well, considering the chaos that is happening around them. Both my parents are from Haiti and I have several family members who were directly effect by Tuesday's devastating quake. It's been an emotional roller coaster, the not knowing was torture, but the continued support that I received from colleagues and friends kept me sane and hopeful - I'm truly grateful.
I ask that you continue to keep the people of Haiti in your prayers, because we have a long road ahead of us. Again, thanks!
Valencia
Sunday, January 17, 2010
Boston --> Haiti play-by-play
From: Kelly,Sean P. (BIDMC - Medical Education)
Sent: Sunday, January 17, 2010 12:06 PM
To: Cherry,Robert (BIDMC Vice President - Support Services)
Cc: Pyne,William (BIDMC - Support Services); Wolfe,Richard E.
(Chief, BIDMC Emergency Medicine); Callaway,David W. (BIDMC -
Emergency Medicine)
Subject: Medical supplies for Haiti
Bob,
I am one of the ER docs going to Haiti tomorrow am with Dave Callaway.
Can you give me a call on my cell at 617 ***-**** to talk about
supplies for us to take with us? Here is a preliminary list of items
and we can go through quantities in greater detail on phone. As you
know our major mission this time out is not deliver of goods or care
on a large scale but we would still like to bring highest impact
stuff that we can carry and load into a car or van.
Gloves 20 boxes mostly medium-sized some large and two small
Sterile gloves various sizes mostly 7.0, 7.5, 6.5 and 8 Gowns
Sterile drapes Betadine 4 bottles Scrubs 20 Some saline Alcohol
wipes (500 cc or 1000cc bags NS for iv fluid - a couple boxes) IV
tubing, setup, supplies ( enought for 100-200 setups?) Angiocaths
(sizes 16,18, 20, and 22) approx 250?
Dermabond (how many could we take of the smallest kind?) Wound care
supplies like sterile bandages Some wound closure materials like
sutures (4-0, 5-0, and 6-0 nylons and something absorbable)
Irrigation supplies (xirowet caps and bowls) Bandaids (bunch of
boxes) Other bandages like tegaderm and xeroform etc.
Sean
---
From: Cherry,Robert (BIDMC Vice President - Support Services)
Sent: Sunday, January 17, 2010 1:04 PM
To: Hopkins,John J. (BIDMC - Material Logistics)
Subject: FW: Medical supplies for Haiti
John,
This is the list requested by Dr Kelly. Can you review this, and
send me the list of what you are sending [through PIH]. Of course, if we can add
these items that would be great, but we can not short the hospital.
---
Sunday, January 17, 2010 2:17 PM
Hi Bob,
The courier is here now. I am going to load the van with him and
then go to the east to load some more.
After that Dr Sean Kelly will be arriving here in his own car. I
will try and supply him with goods also. When he is gone I will
begin to put a list together of the inventory of items taken based
on handwritten list of item numbers I have here.
It will take a while to do this.
John.
---
Sunday, January 17, 2010 3:12 PM
John,
Thanks for doing this on a Sunday afternoon. I assume Dr. Kelly is
going to get goods for the others docs flying out tomorrow as well.
Let me know if you run into any complications.
Thanks,
Bob
---
Sunday, January 17, 2010 5:38 PM
Hi Bob,
Dr Kelly was here and I believe he was very pleased with the
supplies we got for him. We checked off nearly all of what he needed
and he couldn't carry anymore. We also filled the PIH van until
there was no more space, again with very relevant supplies of the
same kind. I will convert my handwritten list of item numbers
dontated to the Haitian project into a proper list of what we issued
today and will email it to you but I will leave that until tomorrow
afternoon as it will take quite a while in itself to do this.
Have a good weekend.
John
---
Sunday, Jan 17, 2010, at 6:18 PM
John,
That is fantastic. i appreciate you taking care of this on your day
off. You should feel great about helping our docs and the people of
Haiti. Enjoy the rest of the weekend.
Bob
---
Sunday, January 17, 2010 9:08 PM
I agree. Thanks to all. You rose above and beyond the call of duty.
Thank you for giving us these life saving supplies.
John and Carl did a fantastic job of getting us what we needed on
short notice on a holiday weekend.
We will do our best to put this stuff to good use.
Sean
Disproportionate action by Israel
A friend writes: "Israel, a nation of 7.5 million people, has sent a team of 220 people that include medical personnel and will establish the largest field hospital in Haiti, treating up to 5000 people a day, an experienced search and rescue team and medical supplies. As in previous earthquake disasters, such as in Gujarat India in 2001 and in Turkey, in the bombings in Kenya, Israel has been one of the most generous givers of aid and assistance."
The major media outlets are quick to publish stories when Israel is accused of disproportionate use of force in other situations. Their failure to do so when it offers a disproportionate humanitarian response is disheartening.
Saturday, January 16, 2010
For Haiti in a time of need
Here is our latest staff memo on the issue (with emails and phone numbers omitted or amended in the text to prevent web-based spamming from this blog post).
To: BIDMC Community
- 4 kiosks with international phone lines and computers/internet access reserved for Haitian emergency use only
- 2 additional computer kiosks
- 6 international telephone lines
- 4 computers
Pastoral Care, Social Work and Employee Relations – To reach these services, call the page operator to page the Administrative Clinical Supervisor: from inside BIDMC, dial 123 and select pager #*****, or from outside BIDMC dial (617) ***-**** and select pager #*****
Employee Assistance Program – 1-800-***-**** (available 24 hours a day)
Friday, January 15, 2010
Equal protection from taxation?
[T]he White House on Thursday broke the last major logjam blocking enactment of far-reaching health-care legislation, cutting a deal with organized labor on how to tax high-cost insurance policies.
The agreement, forged in a marathon negotiating session that included White House officials and seven prominent labor leaders, would exempt union members from a proposed surtax on expensive insurance plans until 2018, five years after the legislation would take effect.
This is extraordinary. If passed, the bill would establish different rates of taxation for citizens depending on whether they are members of a union. I know that we have established classes of citizens based on income. But I do not know of any example in which tax rates are based on membership in a bargaining collective.
So, to my attorney readers out there, would this pass Constitutional muster if it were brought before the Supreme Court?
Israel visit -- Part 6
If you are looking for a simple summary or explanation for what goes on in Israel, you will be disappointed. Israel is a land of complexities.
This little country has a political system that is incomprehensible to Americans. Here, we vote for candidates, whether for the legislative or executive positions. There, they vote for a political party. No names of people appear on the ballot. Since no party wins a majority in the parliament, every government is a coalition. The prime minister’s job must be to hold the coalition together, or the government ends and a new election is held. In the USA, if a President loses the majority in Congress, he remains as President for the rest of the term and continues to decide on foreign policy and on the execution of the laws.
Israel remains surrounded by countries and political movements that refuse to acknowledge its right to exist and that are dedicated to destroying it. Because of the country’s small size and the location of its neighbors, there is essentially no geographic buffer zone to protect it. It responds to this situation by investing in a strong security force but also by initiating counter-terrorist operations. When it does so, it is criticized by many in the world community. That same world community remains essentially silent when other countries attack their neighbors or minorities within their borders.
Israel is criticized for holding on to territory seized after wars of aggression against it. Those territories help provide security. There is an expectation among many that it should be required to return that territory, although it is hard to think of other countries that have been held to this standard following wars of aggression against them -- much less those countries that have acquired territory as a result of their own aggression.
There are more journalists in Jerusalem than in any other city in the world, save three. Every aspect of Israeli society is laid bare for the world to see. In contrast, its neighbors strongly control the access of their countries to the media.
As David Brooks noted in the New York Times this week, Israel has an exceptional concentration of scientists, engineers, and other people who have created a vibrant economy. They thrive because of an entrepreneurial environment and freedom of expression. And yet, there are areas of poverty and hunger in parts of the country, social inequalities, and other such problems that face every democracy in the world.
The Holocaust during the Nazi regime is often given as the reason for establishing a Jewish homeland in the Middle East; but the Zionist movement existed well before that, and there were Jews who had returned to the area decades earlier. This is the ancestral home for this faith. The region, though, is also the homeland for others. This leads to the final contradiction:
The creation of a Palestinian state is an existential requirement for the future of Israel as a Jewish state. But, the creation of a Palestinian state which has a credo of denying Israel’s right to be a Jewish state is an existential threat to the future of Israel. Resolution of that contradiction is the job facing this country and the world community.
Israel visit -- Part 5
If I had any doubt about Israeli policy before our visit, it would relate to this fence. After all, it brings back memories of other fences and walls created for other purposes. For my generation, the Berlin Wall is the one most etched in our minds, and we associate it with a totalitarian regime.
But things are different in the Middle East. For several years, Israel found itself attacked by suicide bombers and others who were entering the country from the Palestinian areas. Their task was to kill civilians and to do so in a brutal and terrorizing fashion.
Here’s where you need to understand the real estate situation. Israel is roughly the size of New Jersey. East Jerusalem is literally across the street from Jerusalem. Other parts of the West Bank are closer than your daily commute to work. A terrorist, therefore, can easily walk or drive from one part of the country to another.
The Israeli government decided to construct a physical barrier to control and slow the passage of people from one area to the other. They closely screen people going through the gates between the two in an attempt to deter and catch possible terrorists. Clearly, this creates an inconvenience and, as you see, a visual and aesthetic barrier between sections of the city and sections of the country.
Lawsuits against the fence and against the particular location of many segments were brought to the Israeli Supreme Court. That there is an expectation of such a judicial review is a statement in itself about the legal rights of all people living in Israel and already distinguishes this structure from those like the Berlin Wall. The Court issued a decision allowing the structure, saying that the security needs of the population had to be weighed against the other concerns raised by the plaintiffs. However, the Court required the government to provide a substantive basis for the choice of the fence’s route. After reviewing many dozens of complaints, it found that only a few had to be configured to reflect local concerns.
On the overall merits of the issue: The fence has been successful in eliminating terrorist attacks against the Israelis where it has been in place. For those of us living elsewhere, it might remain an uncomfortable sight, but it is hard to argue with its success.
Thursday, January 14, 2010
Israel visit -- Part 4
As we we fly over and out of Jerusalem, you can clearly see the old city, with the Western Wall and the Temple Mount (minute 1:40). A monastery is visible just north of the city at minute 2:25, built into a narrow canyon.
A memorable moment is when you are flying several hundred feet above the river valley and the altimeter says sea level! There are lots of irrigated acres of crops (3:00).
The ruins you see at minute 3:15 of the video (and in the photo above) are Roman (including the amphitheater and cardo) near Beit She'an, built on the site of an even older Greek city called Scythopolis. Nearby are the mountains of Gilboa, made famous in the Bible during the reign of Saul.
As you approach the Sea of Galilee, you will see the city of Tiberias (3:30) on its coast. This is near the site of the story of Jesus feeding the multitudes.
If you cannot view the video, click here.
Israel visit -- Part 3
Just outside of the wall of the old city of Jerusalem is an area known as the City of David. This is thought to be the site of the early Jewish kingdom, from biblical times. But as is often the case, there are many layers. Here is a video of an area known as the Shiloach Pool. Two centuries ago, it was the site of a large mikvah, or ritual bath, from which people would traverse along a protected stairway to the Temple just up the hill. When the Temple was destroyed in 70AD, things went into disuse and were eventually buried underneath the following developments of the city.
Now, under the auspices of the City of David ("Ir David") Foundation, the old buildings are being uncovered. The video is the story of the newly discovered passageway. That's the stairway to the right, characterized by a double step separated by a flat section all the way up.
If you cannot view the video, click here.
Israel visit -- Part 2
General Galant is in charge of the Israeli Southern Command and was responsible for coordinating Operation Cast Lead in Gaza in mid-2009. This series of attacks was carried out in response to over 8000 rockets from Gaza being launched on Israeli civilian areas over four-year period.
I recognize that people will disagree over the merits of Israeli and Palestinian political and negotiating positions, but I think most people would agree that it is the responsibility of a nation to protect its citizens from these kinds of attacks. The difficulty in this situation is that rockets are launched and war materiel is stored in an urban setting. Indeed, the military installations in Gaza are often in the very same buildings as residential, education, or health care institutions.
Much has been written on this operation, pro and con, with lots of descriptions. General Galant made a very persuasive case that it was carried out in a way to minimize harm to noncombatants. He also made the case that the invasion was necessary to disrupt and disarm the Palestinians, who were accumulating rockets with longer fly ranges, which would be able to get beyond the rural villages and reach larger population centers.
Since the operation, the number of rockets being launched towards Israeli communities has been reduced by 95%. "The area is quiet," reports the General.
Footsteps in the snow

She notes, "I am not sure that they will ever see their work...but a small group of us really enjoyed watching them. I assume that they were Brigite and Sarah! You can see them walking away having just finished."
A stark contrast with the school environment in the post below . . .