Viraj's Weblog

Insurance companies require doctors to write codes for patients for reimbursement purposes. Turns out this medical coding occupation is set to grow enormously in the coming years.

This American Life had a good episode on the health industry and coding. Turns out there is a medical code for spacecraft injury too.

Planet Money had a really good episode on bill collectors. I thought the most important thing the collector said was that after speaking with so many people he felt that most don't understand the concept of compound interest.

Here is a good explanation.

Another good quote from Genetic Rounds:

It was not because I'm a brilliant diagnostician or because I'm a sensitive listener that I happened to make the diagnosis of acute intermittent porphyria in Nicole and her mother (a diagnosis that was ultimately confirmed through the demonstration of a deficiency of the enzyme uroporphyrinogen I synthase in the girl's red blood cells). Had I seen this family one year before, I'm sure I would have failed, just like the dozen other specialists who had seen Nicole in the past. No, in the case of Nicole Ludlow, I was able to come up with the correct diagnosis simply through dumb luck: the Ludlows and I had managed to run into each other in exactly the right place at exactly the right time.

Dumb luck is an important factor in the lives of clinical geneticists. Dumb luck and hunches, and a little bit of knowledge of weird rare facts, are pretty much all that keep me in business.

The author gives a harrowing story about an infant born with a debilitating disease, to its possible association with vampires:

... After repeated exposure to light, people with CEP [congenital erythropoietic porphyria] become more and more disfigured: their skin becomes covered with scars, and some areas on their scalp lack hair whereas some areas on their skin sprout hair indiscrimately.

Interestingly, it is the presence of these clinical features that has led some medical historians to speculate that individuals with CEP served as the origin of the legend of the vampire, an ancient myth that is present in a large number of diverse cultures. Vampires are portrayed as deceased individuals who find themselves rejected by the hallowed earth of cemeteries because they have been cursed in some way. Unable to achieve a state of peace in their own graves, they metamorphosize into the undead or the living dead, trapped between the worlds of the living and the dead. Hideously ugly and constantly in need of sustenance, vampires are destined to walk the earth after dark, looking to feed on the blood of the innocent.

Now consider individuals with CEP. Because the porphyrins in their bloodstream result in photosensitivity, these people's faces are scarred. And because of the photosensitivity, coupled with their psychological sensitivity, they learn early in life to leave their homes only at night. Finally, because of the deposition of the abnormal red porphyrins in the structure of their teeth, people with CEP develop erythrodontia (literally, "red teeth"), giving the uninformed the impression that they have been drinking blood. It's not difficult to understand how, in an age when superstition and ignorance ruled, the birth of an infant with CEP might have led to the beginning of a tale of the undead that ultimately grew into today's legend.

He goes on:

It's never difficult to figure out when Edwin has been admitted to the hospital: he's the one in the room in which the shades have been drawn, the lights have been turned out, and the light switch has been taped into the off position. In his hospital crib, Edwin lies behind an orange Plexiglas sheet that blocks out most of the wavelengths of light that would prove most harmful to his skin. Because of the careful precautions taken by his parents, Edwin's skin is not terribly scarred at this point. But how can a child live like this? How can he grow and develop, make friends, go to school, and live in society with a condition that allows him to exist outside his home only in the dark?

However, the postscript to this story has a happy ending. Through a bone marrow transplant this boy was eventually cured.

I'm reading another fascinating book called Genetic Rounds about a medical geneticist's experiences. In one chapter, the author describes a mother who comes in with her baby, Jarett, suddenly not wanting to eat any more and whose body is becoming floppy. The discussion steers towards his sibling, Shadow, and her oatmeal breakfast:

"We let her use honey," she replied. "Never more than one or two teaspoons."

"Refined honey?" I asked, again knowing the answer before I asked the question.

"Of course not," the mother replied, repeating that angry look. "The refining process strips the honey of all its natural goodness. We allow only pure, unrefined honey in our house. Everything we put into our bodies is pure and natural. That's why our family has always been so healthy."

I continued: "Ms. Fox, we have to do some tests, but I think Jarrett's going to be okay. I'm pretty sure he's got botulism."

The doctor then imagines a scenario where the older sibling spoonfeeds her little baby brother some honey-laced oatmeal. A possibility. He then goes on:

Like Ms. Fox, most Americans believe that when applied to foods, terms like pure and natural are synonymous with healthy and nutritious. Although this thinking may be accurate for many foods, in the case of honey, eating it in its natural state can lead to serous disease or even death. Because of the environment in which it's produced, unprocessed honey often contains spores of Clostridium botulinum, the bacterium that causes botulism. In most humans, the presence of these spores presents no significant problem: the environment of the stomach and intestinal tracts of older children and adults readily destroys the toxin. But in children under one year of age, infants whose intestinal tracts are still immature, the presence of the toxin, which can survive its stay in the gut unscathed, spells big trouble: after traveling through the gut's lining and entering the bloodstream, the spores are carried throughout the body, where they bind to peripheral nerves and thus prevent them from being able to carry messages from the central nervous system to the muscles. Within hours of ingesting even tiny amounts of contaminated honey, these previously healthy infants become profoundly floppy, lethargic, and placid, unable to smile or cry or suck. If the dose of spores is large enough, every muscle, including those involved in breathing, becomes paralyzed. If not recognized quickly, affected infants may simply stop breathing, suffering respiratory failure so severe that death occurs within minutes.

Think twice about so-called natural foods.

I'm not a big fan of the various medical TV shows, but I do like books written by doctors. Recently I read Something For the Pain, a really good account of one doctor's experiences in the ER.

Here are some quotes I like. This one is about dealing with drunks:

But other drunks, the ones who've gotten in fights or wrecks trying to outrun the cops, are combative, angry, dangerous people. And we all know that the same guy who spits at you through bloody lips and calls you motherfucker will be sober when he sues you if there's a bad outcome in his care. In court, his face will be freshly shaved, his hair carefully combed. He'll be contrite for having been intoxicated. His lawyer will be baffled by the way doctors let him injure himself while he was incapacitated.

To let hostility show is a failure. A failure of boundaries, a failure of self-control. If you counted on human compassion to keep you from smacking one of these guys, you'd be in trouble by the third day on the job. And if you let them get to you to the point where it shows, you have no business being an ER doc.

And he goes on later about making the decision to send to rehab or not:

If I had my way, we'd just total up the costs: rehab, trauma, and medical care. Then tax alcohol sales accordingly. Let the cost of a six-pack or a bottle of wine reflect the true cost to society. Use the money to pay for rehab. But I don't have my way. I'm just the guy who has to ask an alcoholic or a crack addict if he has insurance.

The type of patients in the ER of course vary quite a bit:

The polar symmetry of the two cases struck me, and I hesitated before picking up the next chart. I went to the bathroom, and splashed my face. They lady with the head bleed was going to the ICU, stuck on a respirator, not quite dead, not quite alive. I thought about the teenaged girl with the tiny fetus being squeezed out by the thick fist of her uterus. Of course, this fetus was doomed, just like the woman with the head bleed. The cells may have still been physiologically active, the mitochondria still as busy as the pistons in the engines of the Titanic, the heart still pumping furiously, but futily. For both the forty-three-year-old with the brainful of blood and the tiny fetus, death was only on hold.

Here is a great long talk on Ableton and a cool MIDI device he made. A quote from him on Ableton's site:

What are your weaknesses as a musician?

I cannot play an instrument. I cannot remember melodies. I cannot sing. I have bad timing. I know way too little about counterpoint. I am just someone who is addicted to sound and who under any circumstances wants to create music with electronic instruments. This is what has kept me doing it for almost 20 years.

Today I was stuck with a bad sore throat and did some practicing with Ableton. This software constantly amazes me, and there is just so much to learn in it.

I found a great collection of Ableton articles on proper leveling and such. Here is my first attempt to follow the strategies from those articles, mainly keeping the master track at -6dB. The melody is pretty simple, but I use lots of effects and loud drums. It seems most of the music I make really is just a few bars of a melody looped over and over again, slowly building up with more noise. Call it the Bolero effect . I read somewhere that Ravel was possibly going insane when he wrote that.

Oh, this is an AAC/M4A file. Hope you can play it.

This weekend I drove up to the Brava Theater in the Mission district to check out a hiphop and Jewish folklore interpretation of Dante's Inferno. It was a small independent theatre so I wasn't expecting much, but was pretty blown away by the performance. It's basically a retelling of Dante's story modernized and interspersed with musical breaks. There was a beat boxer, a flute player (also the storyteller), a cellist, and a drummer. A really strange combination, and all made a great band. The beat boxing and cello playing was really amazing. The cello player had a loop sampler, and he did a solo where he would overdub track on track of himself playing to create an amazing mix of cello playing. It was really beautiful. For someone to do that live on stage without flaws is pretty incredible.

The beat boxer spent about 10 minutes showing off his skills in a solo and he too was extremely talented. The best part with him was a scene where he was a bouncer at a nightclub for birds (there are very strange things in this story, though I'm pretty sure the bird was from Dante). He'd do the thumping bass with a microphone to his throat as if the door to the nightclub was closed. Every time he'd let someone in, the music would come out blaring. The way the whole band transitioned in and out of this with the abrupt volume changes was so cool. Oh and there was a beat boxer and drummer battle which just has to be seen to be believed.

They are performing for a month. If you are in town, definitely go check it out. It was a cheap $20, and for this show I would have spent more.

Excellent interview with Atul Gawande on improving health care. Having doctors go through a checklist decreases mortality by almost 50%. Such a simple strategy taken from the airline industry. A quote:

DR. ATUL GAWANDE: Well, in all of my writing, I’m interested in where the individual meets systems. And in medicine, what I’ve noticed as a surgeon is that we have become overwhelmed by complexity. We have trouble getting things right, because the volume of knowledge we’ve created in science has overwhelmed our ability as individuals to follow through. And we’ve seen ideas like “use a checklist” as a sign of weakness. We’ve not gone where aviation has gone in embracing these kinds of ideas. But for people on the receiving ends of care, they see the gaps, they see things falling through. And we’ve been slow to embrace some of these very simple ideas.