Top 7 Things You Should Know About Swine Flu:

As of now, there are about 1400 cases reported from Mexico with about 100 deaths so far. Swine flu has now been reported from Canada, Mexico, United States, New Zealand and several European countries. In the US, there are about 40 reported cases from 5 states – New York, Ohio, California, Texas and Kansas - New York City leads all states with 28 confirmed cases. The World Health Organization’s director-general, Margaret Chan, said the outbreak of the never-before-seen virus is a very serious situation and has “pandemic potential.”

Top 7 Things You Should Know About Swine Flu:
Incubation is short – 1 to 3 days but period of communicability (i.e. you can giev it to others) – extends from the day before onset of symptoms to the time when all symptoms are gone or at a minimum 7 days after symptom onset.
Swine Flu is an Influenza A Virus – it will be positive on rapid screens for Influenza A.
Tamiflu and Relenza both are likely to be efficacious if used within the first 48 hours of illness. Amantadine and Ranantidine have not been helpful in prior swine flu cases over the years and therefore should not be used.
There is a significant difference in clincal manifestation between Mexico and US. The mortality rate in Mexico is impressive while symptoms appear to be mild in other countries despite the virus being identical in the US and Mexico.
The swine flu virus identified is a fusion of genes from swine flu, avian flu and human flu. It is a novel virus strain and does have the potential to cause a pandemic as happened with Spanish flu in 1918.
The US has declared a public health emergency and is recommending that Americans avoid non-essential travel to Mexico.
The disease is not transmitted by eating pork. Human-to-human transmission of swine flu can also occur. This is thought to occur in the same way as seasonal flu occurs in people, which is mainly person-to-person transmission through coughing or sneezing of people infected with the influenza virus. People may become infected by touching something with flu viruses on it and then touching their mouth or nose.

What of President Obama’s meeting with a man who apparently succumbed to Swine Flu hours later? Well, it has been a week since he visited the Museo Nacional de Antropologia in Mexico City Thursday, where the meeting took place and he is fine. You can bet the house that he was under tight medical surveillance during that time and given anti-viral medications (Tamiflu/Relenza) immediately upon discovery of that info.

“The president’s trip to Mexico has not put his health in any danger,” said spokesman Robert Gibbs.


by Sarah Fox

Stroke of Bad Luck in the Senate

As if any of you residents or med students need this, would like to remind you that your health is precious and this case of a bright, active, generally healthy Senator form South Dakota, helps to remind us of that.
Senator Tim Johnson (D) of South Dakota was conducting a conference call yesterday with reporters when he began stuttering and according to the Associated Press report, became somewhat incoherent. He recovered enough to ask if there were any additional questions but “appeared ill” to his staffers - ill enough to rush him to George Washington University Hospital. (When they heard a VIP politician was coming, as I’m sure they are pre-warned of political emergencies such as these, how many of them thought Cheney was on the way again?)

Shortly after the conference call, spokesperson Julianne Fisher said he was undergoing evaluation for stroke-like symptoms.
Upon arrival to the ED, it’s likely that he was sent directly for CT or angio (or both) to rule out intracranial bleed and/or stroke. In the meantime, their stroke team was activated as there has been a push in the medical world to more aggressively address acute cerebrovascular events. Many hospitals, particularly large academic tertiary centers have established stroke teams with fancy names like GWU’s “Brain Attack Team”.’s physicians were obviously not in the radiology bullpen when the image came across but what they saw impressed them enough to take him for “emergent surgery,” according to numerous reports. [We wonder whether it was the resident who first viewed the shots and how quickly he called his attending? Pretty damn quickly we would guess.]
Sometimes when media reports “surgery” they do not differentiate between interventional procedures and open surgical intervention, so we were skeptical that perhaps they found an aneurysm that could be coiled or a thrombus that could be lysed.
However, the AP stated that doctors had to “drain blood from the brain” which implies a surgical evacuation to relieve pressure. Thus, the images most likely showed fresh blood with a midline shift and urgent need to relieve the pressure and stop further bleeding and permanent damage to cerebral architecture.
Following the surgery Senator Johnson is most likely recovering in the neuro ICU with very close attention paid to intracranial pressures and further bleeding episodes. This will be a very telling few days for the politician and his family as his mental status and recovery prognosis will come into focus. But until he can be removed from sedation and off the tube (ventilator) very little can be assessed besides brain stem reflexes and electroencephalgographic (EEG) findings (which will be blunted by sedation).
On the educational tip, an anteriovenous malformation (AVM) is a cluster of congenital arteriovenous communications without intervening capillaries. The arteries and veins are tortuous and dilated and they are more commonly supratentorial, occuring in the parietal lobe, middle cerebral, posterior cerebral, and anterior cerebral territories in decreasing frequencies. Only about 10% of them are infratentorial, i.e. cerebellar and below.
Here are the cold hard numbers with regard to AVMs: In an unruptured AVM, the incidence of first bleed and the annual re-bleed is about 4%. The annual mortality rate due to an AVM is 1%, with the mortality at the first bleed being 10%. In patients presenting with a bleed, the possibility of recurrence was 25% in the next four years, and that of a third bleed is 25%within one year of the second episode.
Studies suggest that only 34% of patients with AVM remained symptom free; 26% become symptomatic and partially disabled; 11% are severely disabled. Hemorrhage is the most common presentation with an incidence of about 70%. Unlike an aneurysm, AVMs bleed, more frequently during sleep and are unrelated to stress, trauma, or hypertension.

Digital angiography is still the imaging mode of choice. A detailed study of the arterial feeders, the nidus and venous drainage is mandatory.

Surgery remains the gold standard. Other modalities are considered only if a safe surgical excision without any long-lasting morbidity is not feasible. If possible, surgery is usually delayed for a few weeks (as the rebleed risk is much less unlike in aneurysms) unless the hematoma requires emergency evacuation.

Worthy links: - Nice summary - Nice images - Sweet video of the procedure


Appendiceal Surprise of Big Pack of Lies?

Our favorite VIP patient and frequent topic of this column, La Lohan, has been admitted again.

It’s really a shame that it happened during such a tender time for the 20-year-old party girl-turned-AA-member. She was just getting used to normal blood alcohol levels and then wham! – an acute abdomen.

The details of how and when she got admitted are hazy, as per usual, but piecing together various stories, the most likely scenario sounds like she saw a doctor sometime Wednesday.

The physician sent her to Century City Hospital in Los Angeles to have it snipped out, where she most likely stayed in one of their luxe VIP suites (seen in pic). Ooooh la Lohan.

We’re quite sure she’s a good judge of hospital VIP suites by now. Maybe she would consider doing a Top 5 Best Hospital VIP Suites for

Why is it that Lindsay keeps returning as an inpatient? Is it the young interns? The pain meds? The swing-arm TV?

Now, we would have given Blohan the benefit of the doubt had we not seen’s new video clip of her jaunting out of the hospital on post-op day #1 (POD#1).

There is no question that the party princess would have had her appy done by laparoscopic approach. This way, surgeons could easily hide the 1-2 cm scars below her ischial spines and inside her umbilicus (belly button). And yes, that is less painful and often results in quicker recovery – but 24 hours??? That is really pushing it from a pain tolerance and medical standpoint. It just seems silly that she would not give the trocar incision sites at least until the evening to heal up a little. Which brings up another interesting quandary: what type of pain meds did she get, being that sh is trying to clean up her act?
Typically, surgical patients, even those as young as 20, are observed for at least 24 hours to watch for any signs of infection (fever, chills, nausea, vomiting) and to make sure their gut is active again. That’s the best part. Gut activity is determined by the resumption of bowel peristalsis, or muscle contraction, forcing stool and air down the gut towards the rectum. Thus, docs determine if the gut is active by asking patients about flatus, aka ass-wind. I can just imagine the doctors asking LaLo if she beefed yet? Lucky bastards.
But if it was not her vestigial appendix what could it be? There are too many possibilities for what really could have happened, but here’s a short list:

- More “fatigue/exhaustion/anxiety/cocaine hangover
- Elective abortion – It’s a same-day procedure that is often well-tolerated and quite safe
- Some minor plastic surgical procedure
- Gastroenteritis

Regardless of whether the Queen of Teen had an inflamed appendix or not, we would like to thank her for providing this column with so much fodder this past year. We wish Lohan the best of luck and health in the future and look forward to her returning several times in 2007.


Anna Nicole Smith

Wow. We did not see this one coming.

There is barely a differential diagnosis to discuss in such a sad case. It is a safe bet that drugs were involved as they are in almost every youthful Hollywood death, and when we say drugs, we mean opioids (heroin and the like), benzodiazepines, or less likely, barbiturates. Whether it was intentional or not is out of the realm of this column, as it is pure speculation and we will not guess whether Anna Nicole was in so much pain as to wish for the end of her life.

We have to admit that a part of us feels sorry for the persistent badgering and exploitation she suffered at the hands of a ruthless media. Constantly being pegged as a terrible mother, a gold-digger, a bimbo, an adulterer had to eventually take its toll on her psyche. And finally, at the end of her life, she was sued as part of a class-action lawsuit for advocating the use of TrimSpa, a weight-loss supplement.

Born Vickie Lynn Hogan in Houston, Texas, Smith worked in a fast food store in nearby Mexia while a 17-year-old, and met and married one of the cooks, Billy Smith, then aged 16.

After a few years of working in topless clubs around Houston, she struck oil when she was chosen as a Playboy model and in 1993 became the famous magazine’s Playmate Of The Year.

Now being hailed as the “the next Marilyn Monroe” by the media and calling herself Anna Nicole Smith, she continued working the clubs and in GiGi’s met 89-year-old billionaire oil mogul J Howard Marshall, whom she married.

“He is the only person in my life who does not care about what other people say about me. He truly loves me and I love him for it.”

But the oil mogul passed away just 14 months after the wedding and a battle ensued between Smith and his son over Marshall’s fortune.

In 1995 the model was admitted to hospital after mixing prescription drugs with alcohol and was later dogged by claims of drug abuse.

In 2002 the Anna Nicole Show - an Osbourne-style reality television series starring the model - was aired. This was really the beginning of thge end as she almost seemed ot relish the negative media attention as a substitue for no attention at all. Her massive weight gain and platinum blonde hair pegged her as the ultimate failed starlett. But through it all, there were actually moments of real sentiment in her show whenever her son showed up.
Four years and a lot of dieting later, Anna Nicole finally seemed to be normalizing with the birth of a baby girl. But tragedy was to follow her to the Bahamas when her 20-year-old son, Daniel, died of a lethal combination of methadone and antidepressants - [Aside: Torsades de Pointe (TdP) is a known complication of high doses of methadone, usually above 200 mg]. And then this.

There is not much else to say, but it is worthwhile to note that we can count on one hand the number of young Hollywoodites who have not been attached to stories of drugs and debauchery (see: 20 yo Lindsay Lohan) - it is a slippery slope that these young stars are on and it might be worth their while to pause and reflect on this tragedy to avoid their own.


The Proof is Next to the Pudding

Can we stop speculating about why and how Anna Nicole died yet? posted images today of the contents of the tragic centerfold’s refrigerator at the time of her death:
- Methadone
- Slim-Fast
- TrimSpa
- French’s Worcestershire Sauce
- Yoghurt
- Unidentified injectable badness

Regardless of how TMZ crossed the line to get these photos, they confirm everything people assumed about the starlett’s drug-addled lifestyle. We all know in medicine that common things happen commonly. Thus, when a young female with a history of polysubstance abuse is found dead in a hotel room with a fridge full of narcotics, one, two and three on our differential is drug-related death.


Notre Dame Head Coach Sues for Botched Bypass

Charlie Weis, head coach of the Notre Dame Fighting Irish and former Super Bowl winning offensive coordinator, testified yesterday in his lawsuit against two surgeons from prestigious Massachusetts General, who he claims were negligent following his gastric bypass surgery.

According to, the now svelte Weis said he spent more than a month in various hospitals, and following his release, had problems walking and could get around only with the help of a wheelchair or electric cart. His lawyer, Michael Mone, told the jury during opening statements Tuesday that Weis still suffers nerve damage in his legs.

How was his ambulation when he tipped the scales at 400 lbs? And his diabetes? And HTN? And obstructive sleep apnea, etc etc?

I am astonished that someone who signed a contract for $30-40 million over 10 years and is now healthy enough to walk the sidelines and handle a high-stress job like his, would sue doctors who are at the top of their field and clearly did not mean any harm.

Gastric bypass is inherently a complicated procedure and when a morbidly obese individually undergoes the surgery, this is explained to him or her. If the physicians made a erred during the surgery and corrected their error enabling him to successfully drop weight and return to coaching, what is he suing for?

Obviously, we are not privy to the details of the case but we do know he is coaching and that hey are Harvard surgeons who want the bet for their patients - especially high-profile ones like Weis.

Can the Fighting Irish fans sue Weis for their pitiful performance in Bowl games?


This is Getting TB Ridiculous

One day after his 3rd sputum culture came back negative, the grandstanding has hit a fever pitch. Regardless of the microbiology or the actual facts of the case, politicians had there time in the TB spotlight today as the House of Representatives launched missives against the federal authorities in charge of stopping the Mycobacterial terrorist.

In referring to the agent who allowed Mr. Speaker to cross over into the United States from Canada, Rep. Dan Lungren (R-Calif.) said, “I hope you’ll consider firing this person and anyone else involved.”

Nice. As if a thorough investigation and “administrativbe leave” was not enough for the agent with almost 20 years experience, now a politician is calling for his head. Way to take a stand Rep. Lundgren! You’re doing a wonderful thing by jumping on the bandwagon and calling for someone’s job. Ahhh, democracy.

But the pedestal was not left empty for long as the patient was also called to task: “Mr. Speaker obviously wanted to have his wedding cake and eat it, too, and that is unfortunate because he put a lot of people at risk,” said Rep. Al Green (D-Texas). Ooooh, witty and caustic.

I know we keep harping on this and maybe we are not reading the right material (which I’m sure will be pointed out to us by our ever-astute readers) but whre is the evidence that he is infective?

What we know is that he has 3 negative sputum cultures.

What has been reported in some place is that he has a lower lobe mass seen on chest x-ray (CXR) - which, by the way, is not typical of TB pulmonary radiographic presentation.

We have also read in prior reports that there is a “smear positive”. From where? And when? Did they repeat it? Could it hadve been an error?

At this point, we have moved far away from the actual clinical scenario adn what is real and not real. The politicians have grabbed hold of this story and turned it into a story of international bio-terror concerns and the safety of our travel and our borders.

Doctors are even jumping in to say they did not tell him he was not infective, they told him he was not highly infective. Way to go guys, stick to your guns.

And all the while Mr. Speaker sits in a hospital room with a mask on watching the world turn his case into a public forum. What ever happened to HIPAA laws?


Owen Wilson Attempts Suicide

Owen Wilson, the quirky star of college humor movies like Wedding Crashers and You, Me, and Dupree as well as cult faves like Bottle Roclet, is recovering at Cedars Sinai Medical Center today, one day after being rushed to St. John’s hospital in Santa Monica, Calif. on Sunday, August 26, by ambulance following a 911 call.

The rumor around the web is that Wilson was found by his brother after attempting suicide and found with some type of intoxication as well as superficial wrist cuts, according to the National Enquirer.

Wilson has released a statement saying, “I respectfully ask that the media allow me to receive care and heal in private during this difficult time.”

Well, there’s not too much to say about this from a medical standpoint. Obviously, we do not enjoy trivializing something that is so serious with our presumptive diagnoses. However, the point of the article is to provide some medical background about a condition that nearly resulted in a demise.

Let’s make a few assumptions first (and we know the risk about assumptions but for the purpose of the article we must make some as we do not have the facts). We are not going to delve into the ‘why’ of the suicide attempt (if that it is indeed what it was), because if someone is so distraught as to attempt ending their own life, there must be an element of major depression or bipolar disorder and we are not psychiatrists.

Instead, let us assume that Wilson swallowed too many pills and discuss the results of toxic ingestions, which have an overall mortality rate that is less than 1%. One might further rationalize that he either made a call to someone before or after the ingestion as he was found in prior to losing consciousness.

The physicians would approach the patient like all others and obtain a set of vital signs which include heart rate, blood pressure, oxygen saturation and respiration frequency. In addition, for toxic exposure patients, their pupils and mental status are equally important. These characteristics may differ significantly depending on the ingested substance e.g., if it was a sedative, his pulse rate and BP would most likely would be low as would his respiration frequency despite having a low oxygen saturation. Other clues to a sedative ingestion would be dilated pupils and somnolence. On the other hand, if he took a bunch of speed his pupils would be miotic (or constricted) and he would be tachycardic, hypertensive and probably tachypneic as well. Importantly, he might also be alert and able to relay some type of history.

Intravenous access should be obtained (usually by the ambulance), and the airway should be assessed with a short threshold for endotracheal intubation (putting a breathing tube in) if there is doubt about the patient’s ability to protect that airway and avoid aspiration. In essence, patients who are sedated may not receive the normal stimulus to breathe, or, they may not be able to protect their own airway from objects not supposed to be entering it (e.g. vomit, blood, digested food).

Whether or not the doctors give charcoal or lavage his GI tract (aka “pumped his stomach”) would be based upon the specific poison(s) ingested, time from ingestion to presentation, presenting symptoms, and predicted severity of poisoning. However as one can easily picture, these patients are not the best historians and in fact have a vested interest in not telling you what they ingested (if they were serious about the suicide attempt). Thus, some type of GI decontamination is routinely recommended for all patients unless the agent ingested was clearly nontoxic.

Nowadays, many EDs will empirically give naloxone to reverse opiate overdose if there is even the smallest suspicion that this is the cause. If you are on the TV show House you can send your residents to search the patient’s residence for whatever s/he might have ingested but in the real world we usually depend on the patient’s friends or relatives to relay this information.

There are a host of typical physical exam findings that tip docs off to specific agents - e.g. pupil size and movement, odors, skin findings, temperature, and alterations in HR and BP – but there is not enough room on the page to cover them all. Also, some poisons cause typical changes on the electrocardiogram; even x-rays can be helpful, particularly in the case of drug mules, whose swallowed packets usually show up on plain films (e.g chest x-rays).

After initial assessment and empiric treatment, toxicology screens for typical drugs of abuse and ingested poisons can be sent (especially to look for things like acetaminophen, the outcome of which is exquisitely dependent on time).

If the agent is discovered quickly, the proper therapy should be instituted ASAP. With a targeted history and physical, a detailed physical exam and prompt supportive therapy, the vast majority of patients will stay alive until a more specific antidote can be given. A call to the poison control center should invariably be made to ask for guidance and report an ingestion.

Here are some addtional interesting facts from the 2001 annual report of the American Association of Poison Control Centers toxic exposure surveillance system:
• While only 1-2% of hospitalized patients died from their toxic ingestion, 59 percent of poison fatalities occurred in individuals aged 20 to 49
• The most commonly implicated poisoning exposures were due to pain medications (10.6 percent),
• Sedative-hypnotics and cough and cold preparations each accounted for about 4-5% of poison exposures.


Donda West: Our Best Guess On What Happened

Cases like that of Donda West are exactly why we started this column. When an unusual medical case enters the purview of the public forum , details are often murky at best and we are here to sort through the vague press releases and nonspecific symptomology to provide you with as accurate a medical assessment as possible. Please understand that we are not the physicians or caregivers in this scenario and are sort of akin to color commentators watching the evolution of an interesting, but sad, medical mystery i.e. please refrain from chastising us for being irresponsible.

While potentially a bit morbid, we mean no offense by our medical curiosity and only wish to begin a dialogue about something that is already quite prevalent in the lay press.

Here’s what we know:

- Donda West died Saturday night at age 58 at Centinela Freeman Regional Medical Center in Marina del Rey after she stopped breathing at her home, according to Deborah Ettinger, a hospital vice president; she was taken to the hospital by paramedics in response to a 9-1-1 call.
- Dr. Jan Adams, the surgeon, told celebrity gossip site that he performed a tummy tuck (abdominoplasty) and breast reduction (mammoplasty) on Donda West, but that she might have died from a heart attack, pulmonary embolism, or massive vomiting.
- Lt. Fred Corral, a county coroner spokesman said preliminary information suggested Donda West died from “complications of surgery”.
- A plastic surgeon, Dr. Andre Aboolian of Beverly Hills, said Monday that West had approached him months ago about having cosmetic surgery. He said he never performed the procedure, telling her he was worried about a pre-existing condition she had.

OK, this should be enough info to at least start the discussion. So we know that Ms. West had some type of elective cosmetic surgery and that she made it home to her house. It would be nice to know exactly what day post-operative she was as that would greatly influence our list of possible diagnoses. We will assume then that she had an uneventful recovery from surgery and went home on the 3rd or 4th day after surgery.

Post-operative bleeding becomes much less likely since any bleeding that is likely to be significant would be picked up on the days (or hours) immediately following surgery. Unless the surgical complication is frank wound dehiscence, it is hard to imagine such an acute decompensation related to a plastic surgical procedure occurring more than 3 days post-op.

Furthermore, we can safely rule out complications associated with anesthesia since it is several days following the surgical procedure. Organ failure, usually liver, is not a rapid demise and would not likely present with an emergent call to EMS.

So what is most likely? In a non-cardiac surgery, one of the most common and likely culprits is pulmonary thromboembolism, or pulmonary embolus (PE). This is caused by the migration of a clot, usually sitting in the large veins of the pelvis, to the lungs thus causing obstruction of blood flow to the lungs and then to the heart. Some of the risk factors for PE include prolonged periods of immobility (like that which occurs post-surgery), pregnancy, malignancy, hereditary clotting abnormalities and surgical procedures, particularly orthopedic. The clinical picture of a patient going home healthy post-operatively and presenting with sudden death so classic it sounds like a test question.

Less likely but also in the differential are cardiac problems to which the press-loving Dr. Aboolian alluded. Unless Ms. West had a very significant cardiac history, like an intracoronary stent or recent heart attack, it is very unlikely that her death was secondary to a cardiac etiology. As far as Aboolian’s claim that he turned down the case because he demanded that she undergo pre-op screening is absurd. Internists and cardiologists are often called to evaluate patients prior to surgery to evaluate the likelihood that the stress of the surgery will cause a cardiac event. Nowadays this is more of a courtesy to the referring physicians than anything else. The result of pre-operative screening rarely changes the management and the most recent American College of Cardiology guidelines for pre-op screening suggested that unless the patient is experiencing active chest pain or very recently had an MI, the patient can proceed with the vast majority of elective surgeries.

At, we like to remind our readers of those jaded clichés thrown around by the older attendings because more often than not, they are true. You can choose any one you lie because they all teach the same lesson:

“Common things occur commonly.”

“If it walks like a duck and looks like a duck, it’s probably…”

” Go where the money is.”

In this case, our money is on PE.


Celebrity Illness: Clooney Cracks Rib

George Clooney took a break from his Lake Como digs to enjoy the beautiful scenery of Weehawken, NJ? Unfortunately, the scenic motor bike ride was marred by a slight amsh-up in which the actor fractured a rib and his girlfriend broke her foot when the two were knocked off his motorcycle the actor’s spokesman said. Weehawken is probably most famous for its 15-second spot in the Sopranos intro as Tony exits the Lincoln Tunnel .

Clooney, 46, and his companion, Sarah Larson, were treated for their injuries at the Palisades Medical Center, across the Hudson River from Manhattan, and were released, spokesman Stan Rosenfield said.

“He was treated for a hairline fracture of a rib and road rash,” he said. Larson, who was a passenger on the motorcycle driven by Clooney, suffered a broken foot. Both were wearing helmets.

David Sciumbata, 32, witnessed the accident, which took place outside his home. “I thought he looked like George Clooney and the girl was very pretty, so it figured. She seemed really hurt and had a cut on her face.

“He was saying, ‘It’ll be all right. Don’t move.’ He seems to really care about her.”

Sciumbata said they rode a rented light-blue Harley-Davidson that his neighbor, musician Jerry Zaslavsky, stored for Clooney after the accident.

Rosenfield told Reuters the accident occurred when a motorist signaled a left-hand turn, but turned right and struck Clooney’s motorcycle. The publicist said he did not know whether the driver of the car was cited for the accident.

Clooney was enjoying his day off from production on his latest film, the Coen brothers’ “Burn After Reading,” co-starring Brad Pitt, John Malkovich and Frances McDormand.