As we learned in FFFF 85, the works of Shakespeare are plentifully populated with medical musings. Tis unfortunate, however, that poor Bill did not have the benefit of accessing LITFL through some form of Elizabethan difference engine precursor. Sadly, the Bard only had access to stale tomes such as Pliny the Elder’s Natural History, Dr. William Clowes’s treatises on treatment of wounds and perhaps an early edition of Tintinalli…

Things may well have been easier for the bard, and LITFL may well have in turn read quite differently, if things were otherwise:

Thou Extant Covenant inst the Fleeting Road, dot com

A site of great learning and merriment
By The Gentleman Physician Mike Cadogan and his worthy aside, the knave Oslerphile Chris Nickson

This week featuring:

Master Le Cong – espousing the parley’s admixal of potassium
Sir Kane Guthrie – with a bounteous sonnet of all that cometh from the web
The gallant Cliff Reid – who cometh forth so stridently with tales of breath lost
The honey-tongued minstrel Scott Weingart – who diveth to thon depths
Thou flowering young-eyed Ed Burns – to persuade thee that all truth lies within flutterd lines
AND the King’s Men – a cast of many players o! so true of heart yet crafty in their wooing of their art
And perchance, to answer, What piece of work, is man?

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

At LITFL we love the website WhoNamedIt?, a great resource for the eponymophile. We also love pithy quotations. So, in this week’s FFFF we’re going to play a game called ‘who said it?’.

Can you, in all your funtabulosity, figure out who said what?

Question 1

Who said:

“A good Doctor can foresee the fatal outcome of an incurable illness, when he cannot help, the experienced Doctor will take care not to aggravate the sick person’s malady by tiring and injurious efforts; and in an impossible case he will not frustrate himself further with ineffective solicitude.”

Reveal the funtabulous answer!

Question 2

Who wrote:

“Doctors are just the same as lawyers; the only difference is that lawyers merely rob you, whereas doctors rob you and kill you, too.”

Reveal the funtabulous answer!

Question 3

Who said:

“We all labour against our own cure, for death is the cure of all diseases.”

Reveal the funtabulous answer!

Question 4

Who defined ‘dentist’ as the following: 

“DENTIST, n. A prestidigitator who, putting metal into your mouth, pulls coins out of your pocket.”

Reveal the funtabulous answer!

Question 5

Who said:

“Drug therapies are replacing a lot of medicines as we used to know them.”

Reveal the funtabulous answer!

Want An Easy Way To Score Higher On The FFFF?

It’s easy — write the questions yourself!
You can submit a question to the FFFF using this form.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

This FFFF is a selection of passages from Ancient Classical Literature, which make reference to Emergency Medicine.

The true definition of what Ancient Literature is has been hotly debated by those standing nearest to the dip at parties, but on the whole seems to be agreed upon to be any literature written prior to the fall of the Roman Empire, or approximately 400 AD.  It is quite beautiful to see some of these descriptions, and realise they saw many of the same injuries and illness that we do now, just without quite so many evidence based treatments, not to mention drug company provided research and pens.

So, let’s put pen to papyrus, and look at Emergency Medicine in Ancient Classical Literature.

Question 1

Who wrote this?

But as he drew back, Meriones let fly at him a bronze-tipped arrow, and smote him on the right buttock, and the arrow passed clean through even to the bladder beneath the bone. And sitting down where he was in the arms of his dear comrades he breathed forth his life, and lay stretched out like a worm on the earth; [655] and the black blood flowed forth and wetted the ground.

Reveal the funtabulous answer!

• Homer from The Iliad (Homer.  Iliad xiii 640-655)
• There are a great many references to wounds, both lethal, and recoverable within the epic poems of Homer, all sustained on the battlefield of the Trojan War. The Iliad is the celebration of the tenth and final year of the war, reputedly over one woman, written in the 8th century BC.
• Homer also describes some fairly rudimentary and unusual treatment regimes for such battle wounds, including grated goat cheese and barley sprinkled in hot wine. You may recall though that the greatest teacher of medicine and healing in Homer’s writing was, in fact, Chiron, who taught both Achilles and his Lover, Patroclus, the art of healing.  He was a centaur.

Click image fro source

Question 2

What text is this passage from?

And the Lord spoke to Moses and Aaron, saying, “Speak to the children of Israel, and say to them: ‘When any man has a discharge from his body, his discharge is unclean. And this shall be his uncleanness in regard to his discharge…’

Reveal the funtabulous answer!

Question 3

Who wrote this?

King Darius in hunting beasts lept from a horse and was sprained in his foot. And it was sprained somehow rather violently; for his ankle-bone went out of its socket. Then, because he was accustomed even earlier to have those of the Egyptians who were thought to be first in the physician’s art round him, he made use of those. But they by twisting and forcing the foot worked a greater evil.

Reveal the funtabulous answer!

• This piece is from Herodotus — Histories (volume 1 and volume 2).
• These were extraordinary volumes of work which covered the mostly factual account of the colossal confrontation between the Greeks and the Persians. They examined the huge geo-political issues of the the times, but also described minutia of every day.  The passage quoted describes the fracture dislocation of the ankle of King Darius following a fall from his horse, and the initial botched relocation.
• Herodotus spends some time paying accolades to the great Physician, Democodes, who Herodotus describes as the most skilful Physician of his time. Democodes goes on to heal the ankle without further trauma, and was rewarded with the pleasure of dining with the King.

Click image for source

Question 4

Who wrote this?

At first – oh wretched man! – he prayed in calm
of mind, rejoicing in his lovely garment;
but when the gory flame began to blaze
up from the offerings on the sappy pine,
sweat covered all his body, and the robe
clung to his sides as if glued by a craftsman
to every joint; and from his very bones
shot up spasmodic, stinging pangs: the poison,
like some detested, bloody snake’s, devoured him

Reveal the funtabulous answer!

• Sophocles — from his lesser known play Trachiniae, also known as ‘The Women of Trachis’ or ‘The Trachinian Maidens‘, written in 430 BCE.
• The actual passage is long and describes the death of Heracles, who sits high among the many Greek heroes. Heracles is given the gift of a coat, via his wronged wife, which has been strewn through with a poison taken from the blood of an animal killed by a toxic spear.  It is thought by most academics to be a description of the zoonotic disease, anthrax.
• Virgil, in his Georgic poems, written in 29 BCE, also describes anthrax in book III (which, oddly enough, is a tome mostly dedicated to the poetry of animal husbandry). He describes a fatal disease, transmitted on a garment, coming from sheep, cattle and horses.

Click image for source

Question 5

Who wrote this?

And ready-witted Prometheus he bound with inextricable bonds, cruel chains, and drove a shaft through his middle, and set on him a long- winged eagle, which used to eat his immortal liver; but by night the liver grew as much again everyway as the long-winged bird devoured in the whole day.

Reveal the funtabulous answer!

Want An Easy Way To Score Higher On The FFFF?

It’s easy — write the questions yourself!
You can submit a question to the FFFF using this form.

via GraphJam.com (click for source)

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Much has been made of diagnosing potential abnormalities and consistent ‘normalities’ within the ECG of athletes.

However, little research has been afforded other significant ECG changes consistent with emotional disturbances manifesting as electrical pertubations within the electrocardiograph.

The LITFL team call upon the wider academic cardiological community to fund research into the under-diagnosed conditions of ‘calligraphitis‘ or literary heart syndrome and the positive electropenogram

Calligraphitis is often seen within the cardiac tracings recorded on the more sensitive and artistic members of our patient community.

Diagnostic criteria: Concordant, complex oscillatory changes throughout all leads.

Implied association: Patients presenting with calligraphitis are more often sensitive, caring individuals with strong artistic tendencies and prone to spontaneous outbursts of song, excessive rhyming and/or alliteration.

Professor Throckmorton, our new Head of the Committee Of Continuing Knowledge, has spent the last 13 years investigating Wolkenkuckucksheim and ithyphallic activity occurring in Electrocardiographs.

After an exhausting 12 month statistical analysis by the backroom boffins, the retrospective review of 26 832 ED cardiac tracings has finally been completed. The results of this BACCHUS-II trial are open to interpretation, lack little scientific credibility and are on the whole inaccurate. However, in this world of eminence based medicine where the statistics never lie it is prudent to take note of the studies findings.

• Resting Positive Electropenograms were recorded in 2.6% of the general population, 3.4% of inmates and 13% of administrators (p = 0.02; 95% confidence interval, 1-99%)
• The maximum prevalence of Positive Electropenograms occurred on Friday and Saturday evenings (80%) with a staggerring 93% on Public Holidays.

As yet it is uncertain as to what a positive Electropenogram might mean for the patient but some of the LITFL team have their theories…

EPG positive

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Lest we forget…

I had the great fortune to pick up an original edition of “Diseases and Remedies – 1898″ on a recent second hand book shopping spree in Dunedin, New Zealand.

I love looking back through the old texts to revisit conditions we no longer see or infrequently treat. But my interest is not solely in the diseases we have virtually eradicated through vaccination programs and the advancement of modern medical treatment, but also as a reflection on those conditions that still trouble the modern day physician.

There is a lot we can still learn from the pharmaceutical and lifestyle interventions advocated in the old texts.

Firstly we can reflect upon older remedies which were in frequent use, but have been lost in the mists of time. Such pharmacopoeia may have potential benefit in modern day medicine if the active ingredient for success can be defined, processed and evaluated.

After all, we are still reliant on the pharmacological derivative of the foxglove (Digitalis purpurea) more than 200 years after William Withering brought it back to the worlds attention. Records indicate that the foxglove had been used for various purposes for many centuries but by 1745 had fallen into disrepute through injudicious use. Following the re-evaluation of digitalis in the treatment of dropsy (pulmonary oedema) modern medicine has done little more than to change the derivative plant type to Digitalis lanata

…in spite of opinion, prejudice, or error, Time will fix the real value upon this discovery, and determine whether I have imposed upon myself and others, or contributed to the benefit of science and mankind. - William Withering 1785

Secondly, it can be both disheartening and uplifting to read of the same generic plants/chemicals being advised for treatment 100+ years on…such as in the treatment of angina pectoris

Thirdly, we must never rest on our laurels…”we can never be certain…of anything“.

As our knowledge and understanding grows…we are able to define, then re-define the pathophysiological processes underpinning medical disease allowing us to further refine treatment remedies, preventative protocols and lifestyle adjustments.

“The Lord Privy Seal is neither a lord, nor a privy, nor a seal” and “‘seborrhoeic’ warts have no relationship to seborrhoea.”

I find some of the older, more literal descriptions, easier to visualise and empathise with. For example “Apoplexy” [unconsciousness or incapacity resulting from a cerebral haemorrhage or stroke]

Finally, “some things change…some stay the same”

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Desperately Seeking Symmetry - Jad and Robert set out in search of order and balance in the world around us, and ask how symmetry shapes our very existence–from the origins of the universe, to what we see when we look in the mirror.

This striking Radiolab video made by Everynone was inspired by Radiolab’s Desperately Seeking Symmetry episode. Filmmakers Will Hoffman, Daniel Mercadante, and Julius Metoyer III play with our yearning for balance, and reveal how beautiful imperfect matches can be.

Energised by the evocative audio and inspirational images….

http://www.youtube.com/watch?v=zEQskIsHKT8

…one can look deeper

http://www.youtube.com/watch?v=b5ykdE7B-qQ

…searching for the exalted anticipatory pause

http://www.youtube.com/watch?v=BTOfEv0nWfA

…and the silent nod of acceptance and appreciation

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

The Necessary Evil of Examinations

In two weeks the next flock of lambs to the slaughter climbers on the biannual ascent of an educational Everest will be taking on the ACEM Fellowship Part II exams. These happy few are the fortunates who have already overcome the perils of the written examination, and must now stand face-to-face with their examiners for the clinical component.

Even Osler agreed that exams were something of a menace to the true student of medicine:

“Perfect happiness for student and teacher will come with the abolition of examinations, which are stumbling blocks and rocks of offense in the pathway of the true student.”
— William Osler, from Aequanimitas, 3rd edition, 1932.

Perhaps this is because no examination can be passed by knowing the subject matter alone. One must also master the ‘hidden curriculum’, the unwritten rules of engagement. Only the foolish, the preternaturally brilliant, or the interminably lucky dare remain ignorant of these invisible hurdles. As such, a great deal of effort must be spent, not only learning about how to care for patients and the manifestations of disease, but about how to pass the quiz. Of course, knowing how to play the game is, in itself, not enough. One must find a way to acquire the necessary knowledge.  For this, we must embrace what Osler has called the Philosopher’s Stone, that which turns base lead into gold, his Master Word: Work.

“With too many, unfortunately, working habits are not cultivated until the constraining dread of an approaching exam is felt, when the hopeless attempt is made to cram the work of two years into a six month’ session, with results only too evident to your examiners.”
— William Osler, from  Introductory Lecture on the Opening of the Forty-Fifth Session of the Medical Faculty, McGill University. 1877.

For all the sweat and tears that these perilous stumbling blocks extract, they are not without purpose. Examinations are an undeniable spur to action. They force us to investigate our deficiencies and expose our many weaknesses. When done as part of perfect preparation, we may be strengthened in time for the test, as well as for the rest of our careers.

“I do not know of any stimulus so healthy as knowledge on the part of the student that he will receive an examination at the end of his course. It gives sharpness to his dissecting knife, heat to his Bunsen burner, a well worn appearance to his stethoscope, and a particular neatness to his bandaging.”
— William Osler, from an address to medical students at the University of Pennsylvania, 1885.

So, ultimately, we must accept that examinations are necessary. Offensive rocks though they may be. Yet we do well to remember that examinations are just the toll gates at which we must all pay our dues as we embark on an endless journey. An endless journey in search of mastery in medicine.

“In its subject matter there is everything in its favour, and it is the easiest possible thing to carry out John Locke’s primary canon in education — arouse an interest… It is hard to name a dry subject in the curriculum. And yet in an audience of medical students such a statement nowadays raises a smile. Why? Because we make the examination the end of education, not an accessory in its acquisition. The student is given early the impression that he is in the school to pass certain examinations, and I am afraid the society in which he moves grinds this impression into his soul.”
— William Osler, from ‘An Introductory Address on Examinations, Examiners and Examinees. Lancet. 1913; 1047-50.

“If the license to practise meant the completion of his education how sad it would be for the practitioner, how distressing to his patients! More clearly than other the physician should illustrate the truth of Plato’s saying that education is a life-long process.”
— William Osler, from ‘The Importance of Post-graduate Study.’ Lancet. 1900 (2):73-75.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Thanks to a regular diet of vitamin FFFF, LITFL managed to fight off a malign malware miasma last week. Unfortunately, with the blog’s immune system occupied, FFFF 051 had to be delayed… But, finally, it’s here!

With two weeks of FFFF withdrawal symptoms kicking in, this week’s FFFF megadose might not be well tolerated by the usual route of administration. Feel free to experiment with other routes and let UCEM’s PR Supervisor know if the bioavailability is improved.

Questions

Can you match these opening lines or paragraphs to the appropriate book? Each book is somehow, often only tenuously, related to some aspect of medicine or previous LITFL posts…

Q1. Name the book that opens with:

“It was inevitable: the scent of bitter almonds always reminded him of the fate of unrequited love.”

Show answer

“We were somewhere around Barstow on the edge of the desert when the drugs began to take hold. I remember saying something like ‘I feel a bit lightheaded; maybe you should drive . . .’ And suddenly there was a terrible roar all around us and the sky was full of what looked like huge bats, all swooping and screeching and diving around the car, which was going about a hundred miles an hour with the top down to Las Vegas. And a voice was screaming, ‘Holy Jesus! What are these goddamn animals?’”

Show answer

Q3. Name the book that opens with:

“Far out in the uncharted backwaters of the unfashionable end of the Western Spiral arm of the Galaxy lies a small unregarded yellow sun. Orbiting this at a distance of roughly ninety-eight million miles is an utterly insignificant little blue-green planet whose ape-descended life forms are so amazingly primitive that they still think digital watches are a pretty neat idea.”

Show answer

“Life’s like a penis:
When it’s soft you can’t beat it;
When it’s hard you get screwed”

Show answer

“It was love at first sight. The first time Yossarian saw the chaplain he fell madly in love with him”

Show answer

Q6. Name the book that opens with:

“Dr. Iannis had enjoyed a satisfactory day in which none of his patients had died or got any worse.”

Show answer

Q7. Name the book that opens with:

“In eighteenth-century France there lived a man who was one of the most gifted and abominable personages in an era that knew no lack of gifted and abominable personages.”

Show answer

Q8. Name the book that opens with:

“The beginning is simple to mark.”

Show answer

Q9. Name the book that opens by quoting Daniel Defoe:

“It is as reasonable to represent one kind of imprisonment by another, as it is to represent anything that really exists by that which exists not.”

Show answer

Q10. Name the book that opens with:

“They’re out there. Black boys in white suits up before me to commit sex acts in the hall and get it mopped up before I can catch them.”

Show answer

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

One day, in a town not far from here, the Urology team were about to perform a radical prostatectomy on a middle aged man. He had a wry smile on his face, as we gassed him down. Must be the midazolam, thought the anaesthetist.

When he was fully asleep, he was stripped bare, but hidden in his jocks was a bit of paper. On that piece of paper there was a poem, which read…

Note to Dick Doc

Hey dear Doc,
I love my cock,
And have a girlfriend
Young and hot.

Now I may not be
The worlds best Bard,
But my girlfriend likes it
When I’m hard.

So I won’t ask
If you can spare a dime,
Perhaps another place,
And another time.

But my sex life
Is on upward curve,
So hey there buddy,
Can you spare a nerve?

This had the whole team in hysterics. The operation proceeded well, and the surgeon, presumably flattered by the effort, and unable to conceal his own aspirations at Shakespearean fame, composed his reply…

Response to Eric

Oh brave patient!
Your wishes are ancient!
With crafty words hidden
Down low, near forbidden.

A reminder to us,
The nerves are a must!
So to protect them for certain,
We raised up a curtain.

Now the Evil is gone,
Your member will live on.
A reminder to all
Who this disease will befall,
That with modern surgical skill,
We are sure to Fulfil!

The Anaesthetist, not to be outdone, composed her own response, although the final word may have been altered to protect the innocent.

Dear Eric

To save your bits,
We did our best!
Mother Nature
Must do the rest.

For your wit,
You do deserve
To keep the power
In the all-important nerve.

With some surgical finesse,
And a bit of luck.
Your lovely girlfriend
Will remain a lucky duck.

The Anaesthetic Registrar, having come back from his 12^th tea break for the morning, was rather proud of his contribution. He wrote…

Ode to Eric

Hi Eric!
You had us in hysterics,
You made us smile,
With your style.

So we shaved you there,
Because we care,
To get it right
Up, without a fight.

We did remember
To spare your member.
And with Viagra,
She’ll want to shag ya!

We wish you luck,
With every… year!

The poems were photocopied onto a double-sided A4 paper, and placed back “down there”.

Eric woke with a smile…

Life in the Fast Lane Medical Blog - Emergency Medicine education blog

Learning about the life of Sir William Osler (1849-1919) is perhaps the ultimate lesson in how to live life and practice medicine. Yet, he doesn’t go to war, he doesn’t fight or kill anyone, he doesn’t change the Fates of Nations… How can reading about such a man be interesting?

Well, what Osler did do was that he did things ‘right’ — he constantly found ways to enjoy his life and work, he helped and inspired others, and despite an insane work schedule always made people feel like he had time for them. No one who learns of Osler can fail to be swept away by his incredible personal charisma and his infectious enthusiasm for both work and learning, and — I suspect — no one in medicine can afford not to be!
Probably the most accessible and up-to-date biography of Osler is by Canadian writer Michael Bliss: ‘William Osler: A Life in Medicine‘ (2002). Incidentally, Bliss also wrote an excellent book on ‘The Discovery of Insulin‘, which I also highly recommend.

The obsessive and compulsive oslerphile will want to wade through Harvery Cushing’s classic Pulitzer Prize-winning biography, “The Life of Sir William Osler“. This magnum opus was published in 1925 and  clocks in at well over a thousand pages and is littered with excerpts from the many letters of the great man himself. It took nearly all of my sleep-deprived intern year to read it, back in the day. An impressive online version is being put together here.

Aside from the traditional biographies, there are at least two other books on Osler that I recommend to all. The first is Silverman et al’s organized collection of over a thousand of Osler’s quotations, namely ‘The Quotatable Osler‘. Osler had a peerless mastery of the written word and his axioms and insights continue to resonant across the centuries. Secondly, there is Charles S. Bryan’s wonderful 1997 book, ‘Osler: Inspirations from a Great Physician‘. This unusual book is almost a self-help book based on the way that Osler lived life. It is a pleasure to read and provides highly nutritious food for thought.

These days, though, no one actually reads books.

So where should the webified Oslerphile turn for an fix of Osleriana? Fortunately, Osler is alive and well on the web. These resources demand your perusal:

• Osler’s Web — the website of the John P. McGovern Historical Collections & Research Center is the place to turn. If something is written by or about Osler and it is on the web, look here first.
• The Oslerian Archive at The American Osler Society — regular updates from the Oslerian world.
• Among Osler’s writings on the web are his biographical essays on the great physicians of the past in ‘An Alabama Student’ and his addresses to students, nurses and practitioners of medicine in ‘Aequanimitas‘.
• Whonamedit — The article on Osler is a great summary of the man’s life, and there are links to all of Osler’s eponyms.

Of course, there is much about Osler to be found on LifeInTheFastLane.com too:

• Aequanimitas — Osler’s inspired watch word and the basis of the opening post of my original blog before Aequanimitas started ‘living in the fast lane’.
• Egerton Y. Davis — meet Osler’s mischievous alter ego.
• Penis captivus — one of medicine’s greatest practical jokes and a priaprismic lesson in the flawed nature of the medical literature.
• Pimping in perspective — yes, even Osler was a pimp!
• The Breakfast Club — the source of my own case of Oslerophilia and an introduction to one of my greatest teachers.
• The Lessons of Osler —
  001 The Master Word
  002 Have fun and cultivate your sense of humo(u)r
  003 Learn the Art of Observation
  004 Treat the patient, not the disease

Once you’ve learned the Art of Observation, seeing what this image really shows will come as no surprise…

Photograph by luc.viatour

…  And, finally, I must not fail to mention the great-grandson of William Osler’s alter ego, UCEM’s very own Council Hygienist and PR Supervisor, the renowned psychiatric surgeon Egerton Y. Davis IV!

You can also follow him on Twitter.

Life in the Fast Lane Medical Blog - Emergency Medicine education blog