James S. Newman, MD, FACP

The Aspen were turning a golden brown, the cattle were fattened for market, and Doc Marsden was drunk again. His head lay on the two planks that served as a bar in what could only charitably be called a saloon. There were two places for a man to drink in Timberline, and this was Doc’s preferred watering hole.

Earlier that day Doc had been busy enough. There’d been a big brawl at the Triple H, and Billy Harkness had shot his younger brother, Lukas, after a lucky punch had broken Billy’s overlarge nose. It wasn’t a bad wound; Lukas had ducked, and the bullet had skimmed his back and lodged in his calf.

Doc had dressed the back wound with a poultice and fished the 0.45 slug from the gastrocnemius. He knew that much anatomy, but not much more. His hands had shaken ’till he had swigged a few swallows of what passed for bourbon. It was nervous work whittling on a Harkness. Luckily Lukas and Billy were a sight more intoxicated than Doc, and their big brother Boone Harkness was somewhere up the trail. The eldest Harkness brother had restless snake eyes. Boone never missed a thing, especially a target. He made Doc Marsden sweat. Doc gave Lukas a spoonful of laudanum, and his patient was soon snoring peacefully on the door they had used as an operating table. Doc took a small swig himself.

After he was sure that the Harkness boy was settled down and Doc’s helper Marty Johnson was there to watch over Lukas, Doc headed for the saloon and started drinking again. He pondered how he had ended up in Timberline. This hadn’t been his plan when he’d left Philadelphia all those years ago.

Back in Philadelphia his name had been Antonio Lombano. His parents had been immigrants, and he had been lucky to work for a butcher. He’d grown sick of slicing meat, and when the war came he enlisted. Anything to get away from the smell of blood and hanging beefs.

When he enlisted with the 37th infantry he’d expected to learn to shoot a gun and maybe even to die. He might have to kill a couple of Rebs, but at least he would leave Philadelphia. Instead, when they learned he had worked as a butcher, he was relegated to the cook’s tent. He was back to slicing meat. For two months the only flank he outmaneuvered was with his cutting blade.

He had been disemboweling a steer one day when a group of surgeons walked by, looking for an eyeball to dissect. They watched approvingly as he wielded his blade. Three days later he had been reassigned to the medical service as a surgeon’s assistant.

Antonio was assigned to work with Dr. Marsden, a fine surgeon from Boston. He watched with admiration as the surgeon amputated shattered arms and legs, sometimes twenty in a session. Antonio’s job was to help staunch the flow of blood with tourniquet or cautery, to brush the maggots from open wounds, and to count and burn the severed limbs. He was handling meat again.

During the months with Dr. Marsden, Antonio kept his eyes open and watched the doctor’s technique. When things got too busy, he would take up the knife as well. He became expert at sounding bullet wounds and was competent at below-the-knee amputations.

The war dragged on, and Antonio grew tired of endless surgery that seemed to be alleviated only by weeks of boredom. Dr. Marsden had been lying sick in his bunk for a week, febrile, jaundiced, and vomiting blood. Antonio suspected he’d picked up yellow jack in Texas. One day, he walked into the tent and found the surgeon dead. Without further thought, Antonio loaded the surgeon’s books and surgical kit into a bag, mounted a blue roan, and rode away from the war.

Fourteen years later, he sat with his head on a bar, vertiginous from the cheap liquor. He had become Old Doc Marsden, who liked a drink but sure was handy with a blade. He had pulled a thousand arrowheads, had sounded even more bullet wounds, and set countless fractures. He kept to the rough mining towns and frontier spaces where there was no shortage of injuries and no questions were asked. Timberline was just his speed. Recently, a second doctor had come to town. He did not mind the competition; in fact, he was glad to have someone to whom he could send the tougher cases.

Time passes.

It was a cool fall morning. There was a frost on the ground, and Doc Marsden was hung-over, sitting on his porch rolling his first morning cigarette. Boone Harkness had returned to town those many months ago with a wife, and she was pregnant. The new doctor in town had taken her case. Doc was glad; he wanted nothing to do with either Snake-Eye Harkness or his bride. He’d seen her only once, walking in town, and that was enough. She seemed a tiny china doll next to the tough man with the narrow hips and wide shoulders.

A rider approached his house. Some cowboy had probably been shot last night, or had stumbled down drunk and broken his leg. But it was Billy Harkness. He told Doc he was wanted on the Harkness ranch, pronto. The new doctor, Jenkins, was having trouble with Helena Harkness and wanted Doc’s help. That could only mean things were bad, real bad. Doc had foaled a few in his time, but he was no hand at tricky birthing. Doc Marsden said he’d be by shortly. Billy looked at him with pity. Snake-Eye had said now.

Doc ran into his home and took a quick drink from his whisky bottle, then grabbed his bag and his Colt. They rode out in the cool morning air, Billy leading the way. Doc Marsden thought about the gun in his holster. It would not be hard to put a slug in Billy’s back and make for the high country. He might get away. But then he’d spend the rest of his days looking over his shoulder. He might as well face his doom straight up. He was a fake and a drunk, but he was no coward. He had never shot a man, and he wouldn’t start now.

Halfway to the Harkness spread, Billy pulled up. He had another chore to run, he said; he’d be up at the big house later that day. This was Doc’s chance. He might not be willing to shoot Billy and run for it, but he was mounted, and the road was open to the north and west. He thought about the scene in the ranch house: thin-legged Helena trying to squeeze out that big Harkness baby, bleeding, crying, dying. If she died so would Doc, no question about that.

Doc turned north and headed up the road a mile, then stopped. He looked out over the prairie. He thought about the immigrant boy, the butcher shop, the war, the bullets and arrows. Philadelphia was a lifetime away. Antonio Lombano was long dead. He was Doc Marsden. He took a deep breath of mountain air, thought about the bottle in his saddlebag, and left it there. He turned the blue roan with the double snake brand south and headed toward the Harkness ranch. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The Aspen were turning a golden brown, the cattle were fattened for market, and Doc Marsden was drunk again. His head lay on the two planks that served as a bar in what could only charitably be called a saloon. There were two places for a man to drink in Timberline, and this was Doc’s preferred watering hole.

Earlier that day Doc had been busy enough. There’d been a big brawl at the Triple H, and Billy Harkness had shot his younger brother, Lukas, after a lucky punch had broken Billy’s overlarge nose. It wasn’t a bad wound; Lukas had ducked, and the bullet had skimmed his back and lodged in his calf.

Doc had dressed the back wound with a poultice and fished the 0.45 slug from the gastrocnemius. He knew that much anatomy, but not much more. His hands had shaken ’till he had swigged a few swallows of what passed for bourbon. It was nervous work whittling on a Harkness. Luckily Lukas and Billy were a sight more intoxicated than Doc, and their big brother Boone Harkness was somewhere up the trail. The eldest Harkness brother had restless snake eyes. Boone never missed a thing, especially a target. He made Doc Marsden sweat. Doc gave Lukas a spoonful of laudanum, and his patient was soon snoring peacefully on the door they had used as an operating table. Doc took a small swig himself.

After he was sure that the Harkness boy was settled down and Doc’s helper Marty Johnson was there to watch over Lukas, Doc headed for the saloon and started drinking again. He pondered how he had ended up in Timberline. This hadn’t been his plan when he’d left Philadelphia all those years ago.

Back in Philadelphia his name had been Antonio Lombano. His parents had been immigrants, and he had been lucky to work for a butcher. He’d grown sick of slicing meat, and when the war came he enlisted. Anything to get away from the smell of blood and hanging beefs.

When he enlisted with the 37th infantry he’d expected to learn to shoot a gun and maybe even to die. He might have to kill a couple of Rebs, but at least he would leave Philadelphia. Instead, when they learned he had worked as a butcher, he was relegated to the cook’s tent. He was back to slicing meat. For two months the only flank he outmaneuvered was with his cutting blade.

He had been disemboweling a steer one day when a group of surgeons walked by, looking for an eyeball to dissect. They watched approvingly as he wielded his blade. Three days later he had been reassigned to the medical service as a surgeon’s assistant.

Antonio was assigned to work with Dr. Marsden, a fine surgeon from Boston. He watched with admiration as the surgeon amputated shattered arms and legs, sometimes twenty in a session. Antonio’s job was to help staunch the flow of blood with tourniquet or cautery, to brush the maggots from open wounds, and to count and burn the severed limbs. He was handling meat again.

During the months with Dr. Marsden, Antonio kept his eyes open and watched the doctor’s technique. When things got too busy, he would take up the knife as well. He became expert at sounding bullet wounds and was competent at below-the-knee amputations.

The war dragged on, and Antonio grew tired of endless surgery that seemed to be alleviated only by weeks of boredom. Dr. Marsden had been lying sick in his bunk for a week, febrile, jaundiced, and vomiting blood. Antonio suspected he’d picked up yellow jack in Texas. One day, he walked into the tent and found the surgeon dead. Without further thought, Antonio loaded the surgeon’s books and surgical kit into a bag, mounted a blue roan, and rode away from the war.

Fourteen years later, he sat with his head on a bar, vertiginous from the cheap liquor. He had become Old Doc Marsden, who liked a drink but sure was handy with a blade. He had pulled a thousand arrowheads, had sounded even more bullet wounds, and set countless fractures. He kept to the rough mining towns and frontier spaces where there was no shortage of injuries and no questions were asked. Timberline was just his speed. Recently, a second doctor had come to town. He did not mind the competition; in fact, he was glad to have someone to whom he could send the tougher cases.

Time passes.

It was a cool fall morning. There was a frost on the ground, and Doc Marsden was hung-over, sitting on his porch rolling his first morning cigarette. Boone Harkness had returned to town those many months ago with a wife, and she was pregnant. The new doctor in town had taken her case. Doc was glad; he wanted nothing to do with either Snake-Eye Harkness or his bride. He’d seen her only once, walking in town, and that was enough. She seemed a tiny china doll next to the tough man with the narrow hips and wide shoulders.

A rider approached his house. Some cowboy had probably been shot last night, or had stumbled down drunk and broken his leg. But it was Billy Harkness. He told Doc he was wanted on the Harkness ranch, pronto. The new doctor, Jenkins, was having trouble with Helena Harkness and wanted Doc’s help. That could only mean things were bad, real bad. Doc had foaled a few in his time, but he was no hand at tricky birthing. Doc Marsden said he’d be by shortly. Billy looked at him with pity. Snake-Eye had said now.

Doc ran into his home and took a quick drink from his whisky bottle, then grabbed his bag and his Colt. They rode out in the cool morning air, Billy leading the way. Doc Marsden thought about the gun in his holster. It would not be hard to put a slug in Billy’s back and make for the high country. He might get away. But then he’d spend the rest of his days looking over his shoulder. He might as well face his doom straight up. He was a fake and a drunk, but he was no coward. He had never shot a man, and he wouldn’t start now.

Halfway to the Harkness spread, Billy pulled up. He had another chore to run, he said; he’d be up at the big house later that day. This was Doc’s chance. He might not be willing to shoot Billy and run for it, but he was mounted, and the road was open to the north and west. He thought about the scene in the ranch house: thin-legged Helena trying to squeeze out that big Harkness baby, bleeding, crying, dying. If she died so would Doc, no question about that.

Doc turned north and headed up the road a mile, then stopped. He looked out over the prairie. He thought about the immigrant boy, the butcher shop, the war, the bullets and arrows. Philadelphia was a lifetime away. Antonio Lombano was long dead. He was Doc Marsden. He took a deep breath of mountain air, thought about the bottle in his saddlebag, and left it there. He turned the blue roan with the double snake brand south and headed toward the Harkness ranch. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

The Aspen were turning a golden brown, the cattle were fattened for market, and Doc Marsden was drunk again. His head lay on the two planks that served as a bar in what could only charitably be called a saloon. There were two places for a man to drink in Timberline, and this was Doc’s preferred watering hole.

Earlier that day Doc had been busy enough. There’d been a big brawl at the Triple H, and Billy Harkness had shot his younger brother, Lukas, after a lucky punch had broken Billy’s overlarge nose. It wasn’t a bad wound; Lukas had ducked, and the bullet had skimmed his back and lodged in his calf.

Doc had dressed the back wound with a poultice and fished the 0.45 slug from the gastrocnemius. He knew that much anatomy, but not much more. His hands had shaken ’till he had swigged a few swallows of what passed for bourbon. It was nervous work whittling on a Harkness. Luckily Lukas and Billy were a sight more intoxicated than Doc, and their big brother Boone Harkness was somewhere up the trail. The eldest Harkness brother had restless snake eyes. Boone never missed a thing, especially a target. He made Doc Marsden sweat. Doc gave Lukas a spoonful of laudanum, and his patient was soon snoring peacefully on the door they had used as an operating table. Doc took a small swig himself.

After he was sure that the Harkness boy was settled down and Doc’s helper Marty Johnson was there to watch over Lukas, Doc headed for the saloon and started drinking again. He pondered how he had ended up in Timberline. This hadn’t been his plan when he’d left Philadelphia all those years ago.

Back in Philadelphia his name had been Antonio Lombano. His parents had been immigrants, and he had been lucky to work for a butcher. He’d grown sick of slicing meat, and when the war came he enlisted. Anything to get away from the smell of blood and hanging beefs.

When he enlisted with the 37th infantry he’d expected to learn to shoot a gun and maybe even to die. He might have to kill a couple of Rebs, but at least he would leave Philadelphia. Instead, when they learned he had worked as a butcher, he was relegated to the cook’s tent. He was back to slicing meat. For two months the only flank he outmaneuvered was with his cutting blade.

He had been disemboweling a steer one day when a group of surgeons walked by, looking for an eyeball to dissect. They watched approvingly as he wielded his blade. Three days later he had been reassigned to the medical service as a surgeon’s assistant.

Antonio was assigned to work with Dr. Marsden, a fine surgeon from Boston. He watched with admiration as the surgeon amputated shattered arms and legs, sometimes twenty in a session. Antonio’s job was to help staunch the flow of blood with tourniquet or cautery, to brush the maggots from open wounds, and to count and burn the severed limbs. He was handling meat again.

During the months with Dr. Marsden, Antonio kept his eyes open and watched the doctor’s technique. When things got too busy, he would take up the knife as well. He became expert at sounding bullet wounds and was competent at below-the-knee amputations.

The war dragged on, and Antonio grew tired of endless surgery that seemed to be alleviated only by weeks of boredom. Dr. Marsden had been lying sick in his bunk for a week, febrile, jaundiced, and vomiting blood. Antonio suspected he’d picked up yellow jack in Texas. One day, he walked into the tent and found the surgeon dead. Without further thought, Antonio loaded the surgeon’s books and surgical kit into a bag, mounted a blue roan, and rode away from the war.

Fourteen years later, he sat with his head on a bar, vertiginous from the cheap liquor. He had become Old Doc Marsden, who liked a drink but sure was handy with a blade. He had pulled a thousand arrowheads, had sounded even more bullet wounds, and set countless fractures. He kept to the rough mining towns and frontier spaces where there was no shortage of injuries and no questions were asked. Timberline was just his speed. Recently, a second doctor had come to town. He did not mind the competition; in fact, he was glad to have someone to whom he could send the tougher cases.

Time passes.

It was a cool fall morning. There was a frost on the ground, and Doc Marsden was hung-over, sitting on his porch rolling his first morning cigarette. Boone Harkness had returned to town those many months ago with a wife, and she was pregnant. The new doctor in town had taken her case. Doc was glad; he wanted nothing to do with either Snake-Eye Harkness or his bride. He’d seen her only once, walking in town, and that was enough. She seemed a tiny china doll next to the tough man with the narrow hips and wide shoulders.

A rider approached his house. Some cowboy had probably been shot last night, or had stumbled down drunk and broken his leg. But it was Billy Harkness. He told Doc he was wanted on the Harkness ranch, pronto. The new doctor, Jenkins, was having trouble with Helena Harkness and wanted Doc’s help. That could only mean things were bad, real bad. Doc had foaled a few in his time, but he was no hand at tricky birthing. Doc Marsden said he’d be by shortly. Billy looked at him with pity. Snake-Eye had said now.

Doc ran into his home and took a quick drink from his whisky bottle, then grabbed his bag and his Colt. They rode out in the cool morning air, Billy leading the way. Doc Marsden thought about the gun in his holster. It would not be hard to put a slug in Billy’s back and make for the high country. He might get away. But then he’d spend the rest of his days looking over his shoulder. He might as well face his doom straight up. He was a fake and a drunk, but he was no coward. He had never shot a man, and he wouldn’t start now.

Halfway to the Harkness spread, Billy pulled up. He had another chore to run, he said; he’d be up at the big house later that day. This was Doc’s chance. He might not be willing to shoot Billy and run for it, but he was mounted, and the road was open to the north and west. He thought about the scene in the ranch house: thin-legged Helena trying to squeeze out that big Harkness baby, bleeding, crying, dying. If she died so would Doc, no question about that.

Doc turned north and headed up the road a mile, then stopped. He looked out over the prairie. He thought about the immigrant boy, the butcher shop, the war, the bullets and arrows. Philadelphia was a lifetime away. Antonio Lombano was long dead. He was Doc Marsden. He took a deep breath of mountain air, thought about the bottle in his saddlebag, and left it there. He turned the blue roan with the double snake brand south and headed toward the Harkness ranch. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Who was Eddie and why would anyone want a piece of him? That was the question that troubled me for decades. “Bum bum baba bum bum bum bum … I want a piece of Eddie.” Every time I heard that song by The Ramones, it drove me to distraction. I couldn’t stand the band. It wasn’t their Proto-Punk cacophonic guitar jams or their dysfunctional family antics—it was Eddie. Why did they want a piece of him? It was a mystery I couldn’t solve.

Then last year I was listening to a radio piece on The Ramones when they mentioned that song. It turns out that the lyrics are actually, “I want to be sedated.” I want to be sedated? Not a piece of Eddie? How odd, and then how hilarious. Suddenly I was singing the song in my head. What a relief: There was no Eddie. It would be the prefect theme song for an anesthesiologist. I wanted to be sedated!

Terms that sound alike are called homonyms; whole phrases are called oronyms. Some examples are stuffy nose and stuff he knows; pullet surprise and Pulitzer Prize; and delicate and delegate. There is an oronym poem that has circulated the Internet that goes, “Eye halve a spelling chequer, it came with my pea sea … ”

What Eddie and I had experienced was a mondegreen. This term was coined by Sylvia Wright in an article published in 1954 in Harper’s Magazine. It comes from a 17th-century ballad. Its line sounds like “And Lady Mondegreen,” but in fact it is “and laid him on the green.” The term refers specifically to song lyrics that are misunderstood. Here are some of my favorite examples; the mondegreen is followed by the actual lyric;

• “There’s a bathroom on the right”/”There’s a bad moon on the rise” by Credence Clearwater Revival
• “ ’Scuse me while I kiss this guy”/“ ’Scuse my while I kiss the sky” by Jimi Hendrix
• “The girl with colitis goes by”/“The girl with kaleidoscope eyes” by The Beatles
• “I’ll never leave your pizza burnin’ ”/“I’ll never be your beast of burden” by The Rolling Stones
• “Oh, Louisa Brown”/“All the leaves are brown” by The Mamas and the Papas
• “No ducks of Haslem in the classroom”/“No dark sarcasm in the classroom” by Pink Floyd
• “Bring me an iron lung”/“Bring me a higher love” by Steve Winwood
• “Midnight after you’re wasted”/“Midnight at the oasis” by Maria Muldaur

You get the idea.

It is not always songs that get “misunderheard.” The complex lingo of medicine is also difficult for the neophyte or—worse—the patient to comprehend. When I started medical school, the most practical advice given to me was from my friend Jon’s father, who worked in the related profession of alcohol distribution. He told me to learn the buzzwords. I took his advice to cardia.

So there I was on rounds, a third-year medical student. A patient had an Na of 116. I wisely stroked my beard, and said that we should watch out for central pontoon myelinolysis. I guess they weren’t listening too carefully to what I had exactly said. For the next 14 years, I uttered dire warnings about central pontoon myelinolysis, until a first-year medical student corrected me. Oh, pontine, the pons—now that makes more sense!

I had made a malapropism, which comes from the character Mrs. Malaprop in an 18th-century play. (The name came from mal a propros, or French for “inappropriate”).

There is no specific term for medical malapropisms, or mondegreens. However, I call them roaches, after the famous “roaches in the liver” (cirrhosis). We have all seen these lists of roaches, whether generated by patients or bad dictation skills. Some examples are:

• The patient was treated for Paris Fevers (paresthesias);
• It was a non-respectable (unresectable) tumor;
• A debunking (debulking) procedure was performed;
• Nerve testing was done using a pink prick (pinprick) test;
• I had smiling mighty Jesus (spinal meningitis);
• She used an IOU (IUD) and still got pregnant;
• He has very close veins (varicose);
• She had postmortem (post partum) depression;
• Heart populations and high pretension (palpitations and hypertension);
• A case of headlights (head lice);
• Sick as hell anemia (sickle cell anemia); and
• The blood vessels were ecstatic (ectatic).

These roaches are generally amusing. They are certainly not anything a hospitalist would ever say or hear, though. Our patients are well informed, and our communications skills are flawless. We all know the medical malpractice risk of poor communication, and all of our patients are medically savvy and sesquepedalinistically erudite (whatever that means).

The next time you tell a patient they have a PE, remember they may be wondering what their medical condition has to do with monkey (an APE) and why you need to spell it out, or how their dyspnea is related to a high-school gym class (PE). You will have to excuse me now, I’ve got another hyponatremic patient and have to go hypertonic sailing. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Who was Eddie and why would anyone want a piece of him? That was the question that troubled me for decades. “Bum bum baba bum bum bum bum … I want a piece of Eddie.” Every time I heard that song by The Ramones, it drove me to distraction. I couldn’t stand the band. It wasn’t their Proto-Punk cacophonic guitar jams or their dysfunctional family antics—it was Eddie. Why did they want a piece of him? It was a mystery I couldn’t solve.

Then last year I was listening to a radio piece on The Ramones when they mentioned that song. It turns out that the lyrics are actually, “I want to be sedated.” I want to be sedated? Not a piece of Eddie? How odd, and then how hilarious. Suddenly I was singing the song in my head. What a relief: There was no Eddie. It would be the prefect theme song for an anesthesiologist. I wanted to be sedated!

Terms that sound alike are called homonyms; whole phrases are called oronyms. Some examples are stuffy nose and stuff he knows; pullet surprise and Pulitzer Prize; and delicate and delegate. There is an oronym poem that has circulated the Internet that goes, “Eye halve a spelling chequer, it came with my pea sea … ”

What Eddie and I had experienced was a mondegreen. This term was coined by Sylvia Wright in an article published in 1954 in Harper’s Magazine. It comes from a 17th-century ballad. Its line sounds like “And Lady Mondegreen,” but in fact it is “and laid him on the green.” The term refers specifically to song lyrics that are misunderstood. Here are some of my favorite examples; the mondegreen is followed by the actual lyric;

• “There’s a bathroom on the right”/”There’s a bad moon on the rise” by Credence Clearwater Revival
• “ ’Scuse me while I kiss this guy”/“ ’Scuse my while I kiss the sky” by Jimi Hendrix
• “The girl with colitis goes by”/“The girl with kaleidoscope eyes” by The Beatles
• “I’ll never leave your pizza burnin’ ”/“I’ll never be your beast of burden” by The Rolling Stones
• “Oh, Louisa Brown”/“All the leaves are brown” by The Mamas and the Papas
• “No ducks of Haslem in the classroom”/“No dark sarcasm in the classroom” by Pink Floyd
• “Bring me an iron lung”/“Bring me a higher love” by Steve Winwood
• “Midnight after you’re wasted”/“Midnight at the oasis” by Maria Muldaur

You get the idea.

It is not always songs that get “misunderheard.” The complex lingo of medicine is also difficult for the neophyte or—worse—the patient to comprehend. When I started medical school, the most practical advice given to me was from my friend Jon’s father, who worked in the related profession of alcohol distribution. He told me to learn the buzzwords. I took his advice to cardia.

So there I was on rounds, a third-year medical student. A patient had an Na of 116. I wisely stroked my beard, and said that we should watch out for central pontoon myelinolysis. I guess they weren’t listening too carefully to what I had exactly said. For the next 14 years, I uttered dire warnings about central pontoon myelinolysis, until a first-year medical student corrected me. Oh, pontine, the pons—now that makes more sense!

I had made a malapropism, which comes from the character Mrs. Malaprop in an 18th-century play. (The name came from mal a propros, or French for “inappropriate”).

There is no specific term for medical malapropisms, or mondegreens. However, I call them roaches, after the famous “roaches in the liver” (cirrhosis). We have all seen these lists of roaches, whether generated by patients or bad dictation skills. Some examples are:

• The patient was treated for Paris Fevers (paresthesias);
• It was a non-respectable (unresectable) tumor;
• A debunking (debulking) procedure was performed;
• Nerve testing was done using a pink prick (pinprick) test;
• I had smiling mighty Jesus (spinal meningitis);
• She used an IOU (IUD) and still got pregnant;
• He has very close veins (varicose);
• She had postmortem (post partum) depression;
• Heart populations and high pretension (palpitations and hypertension);
• A case of headlights (head lice);
• Sick as hell anemia (sickle cell anemia); and
• The blood vessels were ecstatic (ectatic).

These roaches are generally amusing. They are certainly not anything a hospitalist would ever say or hear, though. Our patients are well informed, and our communications skills are flawless. We all know the medical malpractice risk of poor communication, and all of our patients are medically savvy and sesquepedalinistically erudite (whatever that means).

The next time you tell a patient they have a PE, remember they may be wondering what their medical condition has to do with monkey (an APE) and why you need to spell it out, or how their dyspnea is related to a high-school gym class (PE). You will have to excuse me now, I’ve got another hyponatremic patient and have to go hypertonic sailing. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Who was Eddie and why would anyone want a piece of him? That was the question that troubled me for decades. “Bum bum baba bum bum bum bum … I want a piece of Eddie.” Every time I heard that song by The Ramones, it drove me to distraction. I couldn’t stand the band. It wasn’t their Proto-Punk cacophonic guitar jams or their dysfunctional family antics—it was Eddie. Why did they want a piece of him? It was a mystery I couldn’t solve.

Then last year I was listening to a radio piece on The Ramones when they mentioned that song. It turns out that the lyrics are actually, “I want to be sedated.” I want to be sedated? Not a piece of Eddie? How odd, and then how hilarious. Suddenly I was singing the song in my head. What a relief: There was no Eddie. It would be the prefect theme song for an anesthesiologist. I wanted to be sedated!

Terms that sound alike are called homonyms; whole phrases are called oronyms. Some examples are stuffy nose and stuff he knows; pullet surprise and Pulitzer Prize; and delicate and delegate. There is an oronym poem that has circulated the Internet that goes, “Eye halve a spelling chequer, it came with my pea sea … ”

What Eddie and I had experienced was a mondegreen. This term was coined by Sylvia Wright in an article published in 1954 in Harper’s Magazine. It comes from a 17th-century ballad. Its line sounds like “And Lady Mondegreen,” but in fact it is “and laid him on the green.” The term refers specifically to song lyrics that are misunderstood. Here are some of my favorite examples; the mondegreen is followed by the actual lyric;

• “There’s a bathroom on the right”/”There’s a bad moon on the rise” by Credence Clearwater Revival
• “ ’Scuse me while I kiss this guy”/“ ’Scuse my while I kiss the sky” by Jimi Hendrix
• “The girl with colitis goes by”/“The girl with kaleidoscope eyes” by The Beatles
• “I’ll never leave your pizza burnin’ ”/“I’ll never be your beast of burden” by The Rolling Stones
• “Oh, Louisa Brown”/“All the leaves are brown” by The Mamas and the Papas
• “No ducks of Haslem in the classroom”/“No dark sarcasm in the classroom” by Pink Floyd
• “Bring me an iron lung”/“Bring me a higher love” by Steve Winwood
• “Midnight after you’re wasted”/“Midnight at the oasis” by Maria Muldaur

You get the idea.

It is not always songs that get “misunderheard.” The complex lingo of medicine is also difficult for the neophyte or—worse—the patient to comprehend. When I started medical school, the most practical advice given to me was from my friend Jon’s father, who worked in the related profession of alcohol distribution. He told me to learn the buzzwords. I took his advice to cardia.

So there I was on rounds, a third-year medical student. A patient had an Na of 116. I wisely stroked my beard, and said that we should watch out for central pontoon myelinolysis. I guess they weren’t listening too carefully to what I had exactly said. For the next 14 years, I uttered dire warnings about central pontoon myelinolysis, until a first-year medical student corrected me. Oh, pontine, the pons—now that makes more sense!

I had made a malapropism, which comes from the character Mrs. Malaprop in an 18th-century play. (The name came from mal a propros, or French for “inappropriate”).

There is no specific term for medical malapropisms, or mondegreens. However, I call them roaches, after the famous “roaches in the liver” (cirrhosis). We have all seen these lists of roaches, whether generated by patients or bad dictation skills. Some examples are:

• The patient was treated for Paris Fevers (paresthesias);
• It was a non-respectable (unresectable) tumor;
• A debunking (debulking) procedure was performed;
• Nerve testing was done using a pink prick (pinprick) test;
• I had smiling mighty Jesus (spinal meningitis);
• She used an IOU (IUD) and still got pregnant;
• He has very close veins (varicose);
• She had postmortem (post partum) depression;
• Heart populations and high pretension (palpitations and hypertension);
• A case of headlights (head lice);
• Sick as hell anemia (sickle cell anemia); and
• The blood vessels were ecstatic (ectatic).

These roaches are generally amusing. They are certainly not anything a hospitalist would ever say or hear, though. Our patients are well informed, and our communications skills are flawless. We all know the medical malpractice risk of poor communication, and all of our patients are medically savvy and sesquepedalinistically erudite (whatever that means).

The next time you tell a patient they have a PE, remember they may be wondering what their medical condition has to do with monkey (an APE) and why you need to spell it out, or how their dyspnea is related to a high-school gym class (PE). You will have to excuse me now, I’ve got another hyponatremic patient and have to go hypertonic sailing. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Dr. Mann looked out the reinforced window at the acutely curving horizon. He saw a vista of lifeless craters under a harsh gray sky. Robotic equipment excavated along the sides of the craters for rare minerals. For about the thousandth time he asked himself what he was doing on this god-forsaken asteroid. He looked down at his scheduling terminal. Three patients were listed on his roster for the day: two burns and a fracture. They were all basic humanoids—what a bore.

When Hugh Mann was hired as a locum, he was excited. He had trained in humanoid medicine as well as xeno-geno-biology. He was in the top half of his class at the University of Ganymede—no easy accomplishment in a galaxy of overachieving life forms. His minority status as a native Terran had helped him get into school, but his sheer determination and long hours had made him successful.

He had served during the Great Rigellian War, followed by 10 solar standard years of private practice on Ios-3. Now he was getting fed up with the assortment of life forms he was treating. Dealing with the usual high platinum levels, impacted crillobars, and tentacular torsion had grown old. Even the few human patients who were grateful for a physician of their own species wasn’t enough to keep him satisfied.

When the invitation to work for Pro Lo—interstellar Locums—arrived on his screen, he was ready for adventure. An asteroid mine in the outer ring of Nebulon sounded exotic. He knew the choice locations went to those doctors who had worked with the company for years, but it was worth the risk. Or so he had thought. The mine colony was dull. There was no nightlife, not even any vaguely humanoid females for recreation. Two more weeks and his three-month tour of duty would be over. It had been at best unexciting, but he had made some serious dinars. Maybe the next assignment would be more interesting.

His self-pity was interrupted by his greatest source of annoyance. It was the pathetic excuse for a robot assistant with which he had been saddled. Some perverse designer had come up with the Old Chap 7. Perhaps the basic model had been a fairly functional assistant—175 years ago. This one had been modified to resemble an old Earth-style English butler, down to the bowler, umbrella (like it ever rained on this rock) and “Cheerio!” vernacular. He shook his head in dismay. The robot looked at him and printed out “Stiff upper lip old bean.” Dr. Mann just groaned. Worse than its pseudo-British façade, the robotic unit was severely out of date. The data banks were loaded with the Annals of Interstellar Medicine for the past 500 years, but nothing for the past three decades. That might be interesting for an archivist, but he had never seen any value in studying history. He’d taken to calling the robot Jeeves.

Dr. Mann looked out the window again at the star-filled sky. Suddenly there was a great flash of light at the horizon line. Alarms started to blare. A message came across the screen. A small asteroid had hit an Imperial transport vehicle. An emergency docking at mine base Nebulon was requested.

The mine’s director, an obstreperous Vegan named Weezul, barged into Dr. Mann’s clinic space, nervously rubbing his furry tentacles.

“Get ready for action,” he bellowed. “We have a VILF coming.”

A very important life form? This was what Dr. Mann had been waiting for. Then the bad news: The vessel had been transporting the Rigellian ambassador. This was bad news on multiple fronts. Dr. Mann had never treated a Rigellian, though he’d seen a lot of them incinerated during the war. They were allies—at least for now.

Dr. Mann called Jeeves over, and they reviewed what information there was about these enormous creatures. The Rigellian races evolved in a low gravity environment and were huge—often 24 meters or longer. They were aquatic and had two lower limbs and four upper. They had a circulatory system with a carbon monoxide-based metabolism and some strange religious beliefs about modern medicine.

The damaged ship’s lifeboat landed with two passengers—the captain and the Rigellian ambassador himself—as well as an entourage of support, translator, and protocol robots. Talk about extreme VILFs!

The captain’s injury seemed minor. An Iogan, his thick outer cortex had been lacerated. Iogans tend to have an unpleasant personality, and the captain was no exception. His rigid mouth worked to form Lingua words Dr. Mann could understand: “Don’t worry about me you fool, see to the ambassador.” Good advice, coming from a creature that looked like a giant lima bean.

The ambassador lay floating in a large, rapidly improvised tub of clear oil, supporting its large body in the higher artificial gravity of the asteroid. It would take hours to decrease the radial spin of the mine to diminish the gravitational pull to more tolerable levels. The left lower appendage was out of alignment. Donning a somewhat snug space suit, Dr. Mann climbed into the tub. With great difficulty he manipulated the injured limb. To his credit, the ambassador never winced. Dr. Mann had no way to image the limb with its tough cartilage. It would not fit into the mine’s limited scanner facility, and the portable unit would not function in liquid. Using an elastic waterproof wrap he managed to put the limb back into alignment. He hoped it would be sufficient.

Dr. Mann wanted to give the ambassador something for pain. The protocol robot came forward. “Rigellians will accept no medicine that is not derived from their home world.” Dr. Mann never liked to have a patient of any life form in pain, but if the ambassador could stand it, so could he.

Dr. Mann climbed out of the tank and checked on the captain. Jeeves had finished the dressing and had administered Iogian pain medication from stock. “I hope you are not allergic,” Dr. Mann quipped to the captain, who glared in response.

It looked like the emergency was over. Dr. Mann was pleased with himself.

Suddenly, though, things got ugly. It started with the captain. His normally green skin became spotted with blue wheals. It looked like an allergic reaction to the pain medication. Dr. Mann had Jeeves administer Moruvian pineal extract. It usually did the trick on these sentient legumes.

Dr. Mann thought he’d better check the ambassador. When he walked over to the tank something seemed wrong. The injured limb had grown to twice its normal size, and the ambassador seemed to be struggling to respire. A grim realization hit Dr. Mann: A clot had formed in the limb and embolized to the ambassador’s breathing apparatus.

Dr. Mann ran to Jeeves and accessed the medical data banks. There was nothing about the Rigellian coagulation cascade. Jeeves’ bank had only a few vague references to Rigellian physiology. The species refusal to use medication only made things worse. If he did not act quickly his patient might die. And Dr. Mann did not want to be responsible for a resumption of interstellar conflict.

He stared at Jeeves. He had never seen a robot look nervous before, but the Old Chap 7 was showing some odd behavior, taking off his hat and spinning his umbrella. Dr. Mann tried to concentrate. He had Jeeves pull up everything he had on the treatment of embolism. The modern treatment was to inject clot-eating bacteria, modified to the specie. This was out of the question; the nearest xeno-genome lab was two days from the asteroid.

He looked further back in the medical journals. Before bacteria lysis it was Q-beam radiation, and before that mini-robots with lasers. He had no Q-beam facility and rigging up mini-robots with lasers would take at least two days.

Jeeves poked him with his umbrella. What was wrong with the crazy robot? Dr. Mann had gone all the way back to the 20th century looking for an option. Then it hit him. He had read about something called an IVC filter. Perhaps he could fashion something to block the ambassador’s oversize vessel—but what? Jeeves poked him again.

Dr. Mann grabbed the umbrella from the robot and was about to snap it in two when an idea hit him. He pulled the fabric from the metal skeleton, ran to the radiation sterilizer, and sanitized the remains of the umbrella. One hour later it was inserted in the ambassador’s main vessel, ready to catch any further errant clot. Hopefully he’d live until a cruiser with a well-stocked sickbay arrived

Dr. Mann stared at Jeeves. Perhaps he had been wrong about his robot assistant. It had helped save the ambassador. Then Dr. Mann checked the captain, noticing for the first time how ancient the being looked. The captain had worsened acutely, its breathing labored, a sick wheezing sound coming past the rigid fiber that made up the upper part of its mouth.

Dr. Mann grabbed an intubation tube. The captain needed to be on a ventilator. Luckily Dr. Mann had had experience with this type of geriatric vegetable-like creature. He tried three times unsuccessfully, but managed on the fourth to slide the tube pass the rigid maxilla.

Dr. Mann sat on the floor. He was exhausted by the efforts of the day, especially the stressful intubation. Jeeves rolled over to him, and placed his bowler on Dr. Mann’s head. With a sly robotic wink his print out read, “Stiff upper lip, old bean” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Dr. Mann looked out the reinforced window at the acutely curving horizon. He saw a vista of lifeless craters under a harsh gray sky. Robotic equipment excavated along the sides of the craters for rare minerals. For about the thousandth time he asked himself what he was doing on this god-forsaken asteroid. He looked down at his scheduling terminal. Three patients were listed on his roster for the day: two burns and a fracture. They were all basic humanoids—what a bore.

When Hugh Mann was hired as a locum, he was excited. He had trained in humanoid medicine as well as xeno-geno-biology. He was in the top half of his class at the University of Ganymede—no easy accomplishment in a galaxy of overachieving life forms. His minority status as a native Terran had helped him get into school, but his sheer determination and long hours had made him successful.

He had served during the Great Rigellian War, followed by 10 solar standard years of private practice on Ios-3. Now he was getting fed up with the assortment of life forms he was treating. Dealing with the usual high platinum levels, impacted crillobars, and tentacular torsion had grown old. Even the few human patients who were grateful for a physician of their own species wasn’t enough to keep him satisfied.

When the invitation to work for Pro Lo—interstellar Locums—arrived on his screen, he was ready for adventure. An asteroid mine in the outer ring of Nebulon sounded exotic. He knew the choice locations went to those doctors who had worked with the company for years, but it was worth the risk. Or so he had thought. The mine colony was dull. There was no nightlife, not even any vaguely humanoid females for recreation. Two more weeks and his three-month tour of duty would be over. It had been at best unexciting, but he had made some serious dinars. Maybe the next assignment would be more interesting.

His self-pity was interrupted by his greatest source of annoyance. It was the pathetic excuse for a robot assistant with which he had been saddled. Some perverse designer had come up with the Old Chap 7. Perhaps the basic model had been a fairly functional assistant—175 years ago. This one had been modified to resemble an old Earth-style English butler, down to the bowler, umbrella (like it ever rained on this rock) and “Cheerio!” vernacular. He shook his head in dismay. The robot looked at him and printed out “Stiff upper lip old bean.” Dr. Mann just groaned. Worse than its pseudo-British façade, the robotic unit was severely out of date. The data banks were loaded with the Annals of Interstellar Medicine for the past 500 years, but nothing for the past three decades. That might be interesting for an archivist, but he had never seen any value in studying history. He’d taken to calling the robot Jeeves.

Dr. Mann looked out the window again at the star-filled sky. Suddenly there was a great flash of light at the horizon line. Alarms started to blare. A message came across the screen. A small asteroid had hit an Imperial transport vehicle. An emergency docking at mine base Nebulon was requested.

The mine’s director, an obstreperous Vegan named Weezul, barged into Dr. Mann’s clinic space, nervously rubbing his furry tentacles.

“Get ready for action,” he bellowed. “We have a VILF coming.”

A very important life form? This was what Dr. Mann had been waiting for. Then the bad news: The vessel had been transporting the Rigellian ambassador. This was bad news on multiple fronts. Dr. Mann had never treated a Rigellian, though he’d seen a lot of them incinerated during the war. They were allies—at least for now.

Dr. Mann called Jeeves over, and they reviewed what information there was about these enormous creatures. The Rigellian races evolved in a low gravity environment and were huge—often 24 meters or longer. They were aquatic and had two lower limbs and four upper. They had a circulatory system with a carbon monoxide-based metabolism and some strange religious beliefs about modern medicine.

The damaged ship’s lifeboat landed with two passengers—the captain and the Rigellian ambassador himself—as well as an entourage of support, translator, and protocol robots. Talk about extreme VILFs!

The captain’s injury seemed minor. An Iogan, his thick outer cortex had been lacerated. Iogans tend to have an unpleasant personality, and the captain was no exception. His rigid mouth worked to form Lingua words Dr. Mann could understand: “Don’t worry about me you fool, see to the ambassador.” Good advice, coming from a creature that looked like a giant lima bean.

The ambassador lay floating in a large, rapidly improvised tub of clear oil, supporting its large body in the higher artificial gravity of the asteroid. It would take hours to decrease the radial spin of the mine to diminish the gravitational pull to more tolerable levels. The left lower appendage was out of alignment. Donning a somewhat snug space suit, Dr. Mann climbed into the tub. With great difficulty he manipulated the injured limb. To his credit, the ambassador never winced. Dr. Mann had no way to image the limb with its tough cartilage. It would not fit into the mine’s limited scanner facility, and the portable unit would not function in liquid. Using an elastic waterproof wrap he managed to put the limb back into alignment. He hoped it would be sufficient.

Dr. Mann wanted to give the ambassador something for pain. The protocol robot came forward. “Rigellians will accept no medicine that is not derived from their home world.” Dr. Mann never liked to have a patient of any life form in pain, but if the ambassador could stand it, so could he.

Dr. Mann climbed out of the tank and checked on the captain. Jeeves had finished the dressing and had administered Iogian pain medication from stock. “I hope you are not allergic,” Dr. Mann quipped to the captain, who glared in response.

It looked like the emergency was over. Dr. Mann was pleased with himself.

Suddenly, though, things got ugly. It started with the captain. His normally green skin became spotted with blue wheals. It looked like an allergic reaction to the pain medication. Dr. Mann had Jeeves administer Moruvian pineal extract. It usually did the trick on these sentient legumes.

Dr. Mann thought he’d better check the ambassador. When he walked over to the tank something seemed wrong. The injured limb had grown to twice its normal size, and the ambassador seemed to be struggling to respire. A grim realization hit Dr. Mann: A clot had formed in the limb and embolized to the ambassador’s breathing apparatus.

Dr. Mann ran to Jeeves and accessed the medical data banks. There was nothing about the Rigellian coagulation cascade. Jeeves’ bank had only a few vague references to Rigellian physiology. The species refusal to use medication only made things worse. If he did not act quickly his patient might die. And Dr. Mann did not want to be responsible for a resumption of interstellar conflict.

He stared at Jeeves. He had never seen a robot look nervous before, but the Old Chap 7 was showing some odd behavior, taking off his hat and spinning his umbrella. Dr. Mann tried to concentrate. He had Jeeves pull up everything he had on the treatment of embolism. The modern treatment was to inject clot-eating bacteria, modified to the specie. This was out of the question; the nearest xeno-genome lab was two days from the asteroid.

He looked further back in the medical journals. Before bacteria lysis it was Q-beam radiation, and before that mini-robots with lasers. He had no Q-beam facility and rigging up mini-robots with lasers would take at least two days.

Jeeves poked him with his umbrella. What was wrong with the crazy robot? Dr. Mann had gone all the way back to the 20th century looking for an option. Then it hit him. He had read about something called an IVC filter. Perhaps he could fashion something to block the ambassador’s oversize vessel—but what? Jeeves poked him again.

Dr. Mann grabbed the umbrella from the robot and was about to snap it in two when an idea hit him. He pulled the fabric from the metal skeleton, ran to the radiation sterilizer, and sanitized the remains of the umbrella. One hour later it was inserted in the ambassador’s main vessel, ready to catch any further errant clot. Hopefully he’d live until a cruiser with a well-stocked sickbay arrived

Dr. Mann stared at Jeeves. Perhaps he had been wrong about his robot assistant. It had helped save the ambassador. Then Dr. Mann checked the captain, noticing for the first time how ancient the being looked. The captain had worsened acutely, its breathing labored, a sick wheezing sound coming past the rigid fiber that made up the upper part of its mouth.

Dr. Mann grabbed an intubation tube. The captain needed to be on a ventilator. Luckily Dr. Mann had had experience with this type of geriatric vegetable-like creature. He tried three times unsuccessfully, but managed on the fourth to slide the tube pass the rigid maxilla.

Dr. Mann sat on the floor. He was exhausted by the efforts of the day, especially the stressful intubation. Jeeves rolled over to him, and placed his bowler on Dr. Mann’s head. With a sly robotic wink his print out read, “Stiff upper lip, old bean” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Dr. Mann looked out the reinforced window at the acutely curving horizon. He saw a vista of lifeless craters under a harsh gray sky. Robotic equipment excavated along the sides of the craters for rare minerals. For about the thousandth time he asked himself what he was doing on this god-forsaken asteroid. He looked down at his scheduling terminal. Three patients were listed on his roster for the day: two burns and a fracture. They were all basic humanoids—what a bore.

When Hugh Mann was hired as a locum, he was excited. He had trained in humanoid medicine as well as xeno-geno-biology. He was in the top half of his class at the University of Ganymede—no easy accomplishment in a galaxy of overachieving life forms. His minority status as a native Terran had helped him get into school, but his sheer determination and long hours had made him successful.

He had served during the Great Rigellian War, followed by 10 solar standard years of private practice on Ios-3. Now he was getting fed up with the assortment of life forms he was treating. Dealing with the usual high platinum levels, impacted crillobars, and tentacular torsion had grown old. Even the few human patients who were grateful for a physician of their own species wasn’t enough to keep him satisfied.

When the invitation to work for Pro Lo—interstellar Locums—arrived on his screen, he was ready for adventure. An asteroid mine in the outer ring of Nebulon sounded exotic. He knew the choice locations went to those doctors who had worked with the company for years, but it was worth the risk. Or so he had thought. The mine colony was dull. There was no nightlife, not even any vaguely humanoid females for recreation. Two more weeks and his three-month tour of duty would be over. It had been at best unexciting, but he had made some serious dinars. Maybe the next assignment would be more interesting.

His self-pity was interrupted by his greatest source of annoyance. It was the pathetic excuse for a robot assistant with which he had been saddled. Some perverse designer had come up with the Old Chap 7. Perhaps the basic model had been a fairly functional assistant—175 years ago. This one had been modified to resemble an old Earth-style English butler, down to the bowler, umbrella (like it ever rained on this rock) and “Cheerio!” vernacular. He shook his head in dismay. The robot looked at him and printed out “Stiff upper lip old bean.” Dr. Mann just groaned. Worse than its pseudo-British façade, the robotic unit was severely out of date. The data banks were loaded with the Annals of Interstellar Medicine for the past 500 years, but nothing for the past three decades. That might be interesting for an archivist, but he had never seen any value in studying history. He’d taken to calling the robot Jeeves.

Dr. Mann looked out the window again at the star-filled sky. Suddenly there was a great flash of light at the horizon line. Alarms started to blare. A message came across the screen. A small asteroid had hit an Imperial transport vehicle. An emergency docking at mine base Nebulon was requested.

The mine’s director, an obstreperous Vegan named Weezul, barged into Dr. Mann’s clinic space, nervously rubbing his furry tentacles.

“Get ready for action,” he bellowed. “We have a VILF coming.”

A very important life form? This was what Dr. Mann had been waiting for. Then the bad news: The vessel had been transporting the Rigellian ambassador. This was bad news on multiple fronts. Dr. Mann had never treated a Rigellian, though he’d seen a lot of them incinerated during the war. They were allies—at least for now.

Dr. Mann called Jeeves over, and they reviewed what information there was about these enormous creatures. The Rigellian races evolved in a low gravity environment and were huge—often 24 meters or longer. They were aquatic and had two lower limbs and four upper. They had a circulatory system with a carbon monoxide-based metabolism and some strange religious beliefs about modern medicine.

The damaged ship’s lifeboat landed with two passengers—the captain and the Rigellian ambassador himself—as well as an entourage of support, translator, and protocol robots. Talk about extreme VILFs!

The captain’s injury seemed minor. An Iogan, his thick outer cortex had been lacerated. Iogans tend to have an unpleasant personality, and the captain was no exception. His rigid mouth worked to form Lingua words Dr. Mann could understand: “Don’t worry about me you fool, see to the ambassador.” Good advice, coming from a creature that looked like a giant lima bean.

The ambassador lay floating in a large, rapidly improvised tub of clear oil, supporting its large body in the higher artificial gravity of the asteroid. It would take hours to decrease the radial spin of the mine to diminish the gravitational pull to more tolerable levels. The left lower appendage was out of alignment. Donning a somewhat snug space suit, Dr. Mann climbed into the tub. With great difficulty he manipulated the injured limb. To his credit, the ambassador never winced. Dr. Mann had no way to image the limb with its tough cartilage. It would not fit into the mine’s limited scanner facility, and the portable unit would not function in liquid. Using an elastic waterproof wrap he managed to put the limb back into alignment. He hoped it would be sufficient.

Dr. Mann wanted to give the ambassador something for pain. The protocol robot came forward. “Rigellians will accept no medicine that is not derived from their home world.” Dr. Mann never liked to have a patient of any life form in pain, but if the ambassador could stand it, so could he.

Dr. Mann climbed out of the tank and checked on the captain. Jeeves had finished the dressing and had administered Iogian pain medication from stock. “I hope you are not allergic,” Dr. Mann quipped to the captain, who glared in response.

It looked like the emergency was over. Dr. Mann was pleased with himself.

Suddenly, though, things got ugly. It started with the captain. His normally green skin became spotted with blue wheals. It looked like an allergic reaction to the pain medication. Dr. Mann had Jeeves administer Moruvian pineal extract. It usually did the trick on these sentient legumes.

Dr. Mann thought he’d better check the ambassador. When he walked over to the tank something seemed wrong. The injured limb had grown to twice its normal size, and the ambassador seemed to be struggling to respire. A grim realization hit Dr. Mann: A clot had formed in the limb and embolized to the ambassador’s breathing apparatus.

Dr. Mann ran to Jeeves and accessed the medical data banks. There was nothing about the Rigellian coagulation cascade. Jeeves’ bank had only a few vague references to Rigellian physiology. The species refusal to use medication only made things worse. If he did not act quickly his patient might die. And Dr. Mann did not want to be responsible for a resumption of interstellar conflict.

He stared at Jeeves. He had never seen a robot look nervous before, but the Old Chap 7 was showing some odd behavior, taking off his hat and spinning his umbrella. Dr. Mann tried to concentrate. He had Jeeves pull up everything he had on the treatment of embolism. The modern treatment was to inject clot-eating bacteria, modified to the specie. This was out of the question; the nearest xeno-genome lab was two days from the asteroid.

He looked further back in the medical journals. Before bacteria lysis it was Q-beam radiation, and before that mini-robots with lasers. He had no Q-beam facility and rigging up mini-robots with lasers would take at least two days.

Jeeves poked him with his umbrella. What was wrong with the crazy robot? Dr. Mann had gone all the way back to the 20th century looking for an option. Then it hit him. He had read about something called an IVC filter. Perhaps he could fashion something to block the ambassador’s oversize vessel—but what? Jeeves poked him again.

Dr. Mann grabbed the umbrella from the robot and was about to snap it in two when an idea hit him. He pulled the fabric from the metal skeleton, ran to the radiation sterilizer, and sanitized the remains of the umbrella. One hour later it was inserted in the ambassador’s main vessel, ready to catch any further errant clot. Hopefully he’d live until a cruiser with a well-stocked sickbay arrived

Dr. Mann stared at Jeeves. Perhaps he had been wrong about his robot assistant. It had helped save the ambassador. Then Dr. Mann checked the captain, noticing for the first time how ancient the being looked. The captain had worsened acutely, its breathing labored, a sick wheezing sound coming past the rigid fiber that made up the upper part of its mouth.

Dr. Mann grabbed an intubation tube. The captain needed to be on a ventilator. Luckily Dr. Mann had had experience with this type of geriatric vegetable-like creature. He tried three times unsuccessfully, but managed on the fourth to slide the tube pass the rigid maxilla.

Dr. Mann sat on the floor. He was exhausted by the efforts of the day, especially the stressful intubation. Jeeves rolled over to him, and placed his bowler on Dr. Mann’s head. With a sly robotic wink his print out read, “Stiff upper lip, old bean” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Editor’s note: It has been several years since the story you are about to read took place, but my experiences as a hospitalist have given me a new perspective to this bittersweet tale.

My wife and I never contemplated a future without her. She was a part of our new family. Aside from a few rough black spots that needed to be removed, she seemed in perfect shape. She had been at our wedding, and we had spent countless days sunning on the beach and taking long drives with her through the Texas Hill Country spotting wildflowers. The Hill Country is where she got her nickname. Everyone called her Bluebonnet; the name just seemed to fit her. She brought special meaning to the number 69. People who saw her would just stop and wave. We were proud to be seen with her.

I left the house one fateful morning and found her in the street, motionless. I did everything I could to get her to move. I was sure she was dead. I could not get her to turn over. I ran inside and called for help. It seemed like forever until I could get someone on the phone. It was not long until the emergency vehicle arrived. A few quick maneuvers were made to get her going, but the efforts seemed doomed to failure. My wife and I watched sadly as she was carried away. Driving behind those eerie flashing lights, not a word was spoken.

We spent forever in a cheerless waiting room with antiquated magazines and lukewarm bitter coffee. The television mounted high on the wall blared a moronic game show. Imagining the worst-case scenario was far scarier than knowing the truth. Finally, a young man came to talk to us. His uniform was splattered with stains, and he looked like he hadn’t slept in a few days. He bellowed our name across the waiting room. I guessed there would be no privacy here.

He said that Bluebonnet was not going anywhere soon. He mentioned something about giving fluids and checking levels, but we did not understand the terminology. He said a specimen of fluid looked milky and the differential seemed abnormal and a pressure measurement was high. Was this supposed to mean something to us? He talked so fast, and no matter whether you know the lingo or not, when it’s a loved one it’s hard to concentrate.

Another hour went by. I stared at the receptionist, but she would not let me catch her eye. Sometime later, another man came out to meet with us. He wore a clean uniform and looked less harried. He said he was a Specialist in this kind of problem. What kind of problem was unclear to me. He never told us his name.

He started with the good news. He told us that Bluebonnet was responding now, that her balance was good, though her joints were worn out and that she had no gross motor abnormalities. It could be a disk problem, but probably not. This all seemed like good news. But then came the kicker; he had heard something strange during his evaluation. It was an odd rumbling sound and the Specialist wanted another opinion. He wanted the Expert.

By now we had accepted the fact that we were not going anywhere. We had been absorbed into the system, a fixture in the waiting room. Another set of pale faces was now illuminated by the television screen, searching for information, hoping for good news, but not expecting it. The coffee was starting to seem not that bad.

When the Expert came out he was friendly and invited us to watch while he made his comprehensive evaluation. He seemed thorough and competent. He did not ask us any questions; perhaps his colleagues had filled him in. Bluebonnet was not going to be doing any talking, that was obvious. The Expert’s nonchalant demeanor evaporated as he pulled his hand out from beneath her, his finger covered in something black and tarry. He suggested more testing and hooked her up to an erratically beeping monitor. He told us that his evaluation might take a while, and perhaps we should leave. He would call us when he had a better picture of what was going on. We sadly trudged home.

When we returned the next day we met with the Expert again. He said he had found the problem. Bluebonnet needed her valve replaced. As best I could understand it, there were two problems: The valve would not open completely so flow was obstructed, and the valve would not close completely either. I put my head on my wife’s more stoic shoulder and began to cry. We were not ready to make this kind of decision; Bluebonnet seemed too old for a procedure this aggressive.

We reminisced about the good times and the bad. We considered the cost and risks. There was no guarantee that a valve replacement would do the trick. A time comes in existence when the good memories can outweigh common sense. In the end, however, I had them remove her from the monitors. I drove her home, not knowing what to expect.

The next month was fairly quiet. I made sure she was turned over as much as possible. There were no problems, but she barely went out. It seemed like she was missing her usual spark. One warm Sunday, with much trepidation, I took her shopping. Half way to the mall she started to cough, then shook uncontrollably. I looked frantically around; what would I do if she died right in the street? I was in luck however, there was a small facility right on the corner and I nervously pulled into the entrance.

It was a small, private place. A few friends had gone there and were pleased with the results. It was run by an efficient young woman who immediately helped us. She ran the facility on her own—no big corporation telling her what to do and monitoring her bottom line. She listened to the whole story, and checked out Bluebonnet thoroughly. She patted Bluebonnet affectionately; you could tell she cared. She smiled as she told us that the new valve would last for years. It was not the valve at all, only bad gas.

We had several more years with her, and then she was gone. But we never forgot our time with our 1969 Cadillac convertible, Bluebonnet.

Rust in peace. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Editor’s note: It has been several years since the story you are about to read took place, but my experiences as a hospitalist have given me a new perspective to this bittersweet tale.

My wife and I never contemplated a future without her. She was a part of our new family. Aside from a few rough black spots that needed to be removed, she seemed in perfect shape. She had been at our wedding, and we had spent countless days sunning on the beach and taking long drives with her through the Texas Hill Country spotting wildflowers. The Hill Country is where she got her nickname. Everyone called her Bluebonnet; the name just seemed to fit her. She brought special meaning to the number 69. People who saw her would just stop and wave. We were proud to be seen with her.

I left the house one fateful morning and found her in the street, motionless. I did everything I could to get her to move. I was sure she was dead. I could not get her to turn over. I ran inside and called for help. It seemed like forever until I could get someone on the phone. It was not long until the emergency vehicle arrived. A few quick maneuvers were made to get her going, but the efforts seemed doomed to failure. My wife and I watched sadly as she was carried away. Driving behind those eerie flashing lights, not a word was spoken.

We spent forever in a cheerless waiting room with antiquated magazines and lukewarm bitter coffee. The television mounted high on the wall blared a moronic game show. Imagining the worst-case scenario was far scarier than knowing the truth. Finally, a young man came to talk to us. His uniform was splattered with stains, and he looked like he hadn’t slept in a few days. He bellowed our name across the waiting room. I guessed there would be no privacy here.

He said that Bluebonnet was not going anywhere soon. He mentioned something about giving fluids and checking levels, but we did not understand the terminology. He said a specimen of fluid looked milky and the differential seemed abnormal and a pressure measurement was high. Was this supposed to mean something to us? He talked so fast, and no matter whether you know the lingo or not, when it’s a loved one it’s hard to concentrate.

Another hour went by. I stared at the receptionist, but she would not let me catch her eye. Sometime later, another man came out to meet with us. He wore a clean uniform and looked less harried. He said he was a Specialist in this kind of problem. What kind of problem was unclear to me. He never told us his name.

He started with the good news. He told us that Bluebonnet was responding now, that her balance was good, though her joints were worn out and that she had no gross motor abnormalities. It could be a disk problem, but probably not. This all seemed like good news. But then came the kicker; he had heard something strange during his evaluation. It was an odd rumbling sound and the Specialist wanted another opinion. He wanted the Expert.

By now we had accepted the fact that we were not going anywhere. We had been absorbed into the system, a fixture in the waiting room. Another set of pale faces was now illuminated by the television screen, searching for information, hoping for good news, but not expecting it. The coffee was starting to seem not that bad.

When the Expert came out he was friendly and invited us to watch while he made his comprehensive evaluation. He seemed thorough and competent. He did not ask us any questions; perhaps his colleagues had filled him in. Bluebonnet was not going to be doing any talking, that was obvious. The Expert’s nonchalant demeanor evaporated as he pulled his hand out from beneath her, his finger covered in something black and tarry. He suggested more testing and hooked her up to an erratically beeping monitor. He told us that his evaluation might take a while, and perhaps we should leave. He would call us when he had a better picture of what was going on. We sadly trudged home.

When we returned the next day we met with the Expert again. He said he had found the problem. Bluebonnet needed her valve replaced. As best I could understand it, there were two problems: The valve would not open completely so flow was obstructed, and the valve would not close completely either. I put my head on my wife’s more stoic shoulder and began to cry. We were not ready to make this kind of decision; Bluebonnet seemed too old for a procedure this aggressive.

We reminisced about the good times and the bad. We considered the cost and risks. There was no guarantee that a valve replacement would do the trick. A time comes in existence when the good memories can outweigh common sense. In the end, however, I had them remove her from the monitors. I drove her home, not knowing what to expect.

The next month was fairly quiet. I made sure she was turned over as much as possible. There were no problems, but she barely went out. It seemed like she was missing her usual spark. One warm Sunday, with much trepidation, I took her shopping. Half way to the mall she started to cough, then shook uncontrollably. I looked frantically around; what would I do if she died right in the street? I was in luck however, there was a small facility right on the corner and I nervously pulled into the entrance.

It was a small, private place. A few friends had gone there and were pleased with the results. It was run by an efficient young woman who immediately helped us. She ran the facility on her own—no big corporation telling her what to do and monitoring her bottom line. She listened to the whole story, and checked out Bluebonnet thoroughly. She patted Bluebonnet affectionately; you could tell she cared. She smiled as she told us that the new valve would last for years. It was not the valve at all, only bad gas.

We had several more years with her, and then she was gone. But we never forgot our time with our 1969 Cadillac convertible, Bluebonnet.

Rust in peace. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Editor’s note: It has been several years since the story you are about to read took place, but my experiences as a hospitalist have given me a new perspective to this bittersweet tale.

My wife and I never contemplated a future without her. She was a part of our new family. Aside from a few rough black spots that needed to be removed, she seemed in perfect shape. She had been at our wedding, and we had spent countless days sunning on the beach and taking long drives with her through the Texas Hill Country spotting wildflowers. The Hill Country is where she got her nickname. Everyone called her Bluebonnet; the name just seemed to fit her. She brought special meaning to the number 69. People who saw her would just stop and wave. We were proud to be seen with her.

I left the house one fateful morning and found her in the street, motionless. I did everything I could to get her to move. I was sure she was dead. I could not get her to turn over. I ran inside and called for help. It seemed like forever until I could get someone on the phone. It was not long until the emergency vehicle arrived. A few quick maneuvers were made to get her going, but the efforts seemed doomed to failure. My wife and I watched sadly as she was carried away. Driving behind those eerie flashing lights, not a word was spoken.

We spent forever in a cheerless waiting room with antiquated magazines and lukewarm bitter coffee. The television mounted high on the wall blared a moronic game show. Imagining the worst-case scenario was far scarier than knowing the truth. Finally, a young man came to talk to us. His uniform was splattered with stains, and he looked like he hadn’t slept in a few days. He bellowed our name across the waiting room. I guessed there would be no privacy here.

He said that Bluebonnet was not going anywhere soon. He mentioned something about giving fluids and checking levels, but we did not understand the terminology. He said a specimen of fluid looked milky and the differential seemed abnormal and a pressure measurement was high. Was this supposed to mean something to us? He talked so fast, and no matter whether you know the lingo or not, when it’s a loved one it’s hard to concentrate.

Another hour went by. I stared at the receptionist, but she would not let me catch her eye. Sometime later, another man came out to meet with us. He wore a clean uniform and looked less harried. He said he was a Specialist in this kind of problem. What kind of problem was unclear to me. He never told us his name.

He started with the good news. He told us that Bluebonnet was responding now, that her balance was good, though her joints were worn out and that she had no gross motor abnormalities. It could be a disk problem, but probably not. This all seemed like good news. But then came the kicker; he had heard something strange during his evaluation. It was an odd rumbling sound and the Specialist wanted another opinion. He wanted the Expert.

By now we had accepted the fact that we were not going anywhere. We had been absorbed into the system, a fixture in the waiting room. Another set of pale faces was now illuminated by the television screen, searching for information, hoping for good news, but not expecting it. The coffee was starting to seem not that bad.

When the Expert came out he was friendly and invited us to watch while he made his comprehensive evaluation. He seemed thorough and competent. He did not ask us any questions; perhaps his colleagues had filled him in. Bluebonnet was not going to be doing any talking, that was obvious. The Expert’s nonchalant demeanor evaporated as he pulled his hand out from beneath her, his finger covered in something black and tarry. He suggested more testing and hooked her up to an erratically beeping monitor. He told us that his evaluation might take a while, and perhaps we should leave. He would call us when he had a better picture of what was going on. We sadly trudged home.

When we returned the next day we met with the Expert again. He said he had found the problem. Bluebonnet needed her valve replaced. As best I could understand it, there were two problems: The valve would not open completely so flow was obstructed, and the valve would not close completely either. I put my head on my wife’s more stoic shoulder and began to cry. We were not ready to make this kind of decision; Bluebonnet seemed too old for a procedure this aggressive.

We reminisced about the good times and the bad. We considered the cost and risks. There was no guarantee that a valve replacement would do the trick. A time comes in existence when the good memories can outweigh common sense. In the end, however, I had them remove her from the monitors. I drove her home, not knowing what to expect.

The next month was fairly quiet. I made sure she was turned over as much as possible. There were no problems, but she barely went out. It seemed like she was missing her usual spark. One warm Sunday, with much trepidation, I took her shopping. Half way to the mall she started to cough, then shook uncontrollably. I looked frantically around; what would I do if she died right in the street? I was in luck however, there was a small facility right on the corner and I nervously pulled into the entrance.

It was a small, private place. A few friends had gone there and were pleased with the results. It was run by an efficient young woman who immediately helped us. She ran the facility on her own—no big corporation telling her what to do and monitoring her bottom line. She listened to the whole story, and checked out Bluebonnet thoroughly. She patted Bluebonnet affectionately; you could tell she cared. She smiled as she told us that the new valve would last for years. It was not the valve at all, only bad gas.

We had several more years with her, and then she was gone. But we never forgot our time with our 1969 Cadillac convertible, Bluebonnet.

Rust in peace. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Jacques Cartier

Jacques Cartier was in Newfoundland with his men in 1534, when the following occurred: “In December we understood the pestilence had come to the people of Stadacona … whereupon we charged them neither to come near our Fort, nor our ships. The said unknowen sickness began to spread itselfe amongst us after the strangest sort that ever was eyther heard of or seene, insomuch as some did lose all their strength, and could not stand on their feete, then their legges did swell. Others had all their skins spotted with spots of blood of a purple colour; then it did ascend up to ther ankels, knees, and thighs. Their mouth became stincking, their gummes so rotten, that all the flesh did fall off.”

What was the diagnosis and with what was it treated? Can you make the diagnosis based on the information provided? If so, e-mail your diagnosis to Physician Editor Jamie Newman at newman.james@mayo.edu. The deadline is Wednesday, July 5. We’ll publish the winner’s response in a future issue of The Hospitalist. TH

Jacques Cartier

Jacques Cartier was in Newfoundland with his men in 1534, when the following occurred: “In December we understood the pestilence had come to the people of Stadacona … whereupon we charged them neither to come near our Fort, nor our ships. The said unknowen sickness began to spread itselfe amongst us after the strangest sort that ever was eyther heard of or seene, insomuch as some did lose all their strength, and could not stand on their feete, then their legges did swell. Others had all their skins spotted with spots of blood of a purple colour; then it did ascend up to ther ankels, knees, and thighs. Their mouth became stincking, their gummes so rotten, that all the flesh did fall off.”

What was the diagnosis and with what was it treated? Can you make the diagnosis based on the information provided? If so, e-mail your diagnosis to Physician Editor Jamie Newman at newman.james@mayo.edu. The deadline is Wednesday, July 5. We’ll publish the winner’s response in a future issue of The Hospitalist. TH

Jacques Cartier

Jacques Cartier was in Newfoundland with his men in 1534, when the following occurred: “In December we understood the pestilence had come to the people of Stadacona … whereupon we charged them neither to come near our Fort, nor our ships. The said unknowen sickness began to spread itselfe amongst us after the strangest sort that ever was eyther heard of or seene, insomuch as some did lose all their strength, and could not stand on their feete, then their legges did swell. Others had all their skins spotted with spots of blood of a purple colour; then it did ascend up to ther ankels, knees, and thighs. Their mouth became stincking, their gummes so rotten, that all the flesh did fall off.”

What was the diagnosis and with what was it treated? Can you make the diagnosis based on the information provided? If so, e-mail your diagnosis to Physician Editor Jamie Newman at newman.james@mayo.edu. The deadline is Wednesday, July 5. We’ll publish the winner’s response in a future issue of The Hospitalist. TH

Beep, beep, beep, beep ... ,” the pager sounded. “What time is it?” asked Gregor S. His alarm clock flashed 7:42 a.m. He stumbled across the small apartment, grabbed a warm diet cola out of the grocery sack he had forgotten to unload in last night’s sleep-deprived state. The chicken was ruined, the bologna dubious. The whole bag ditched, save the six-pack.

Gregor went down the stairs two at a time. Mrs. Q with the arthritic boxer in 3G barely let him by, grumbling to herself about young folks today. No time for false pleasantries. He was late again. This would be the third time this month: his first month on staff as a hospitalist. He barely made the 7:52 bus, and was on ward 7 in a quarter of an hour.

At work—more Dr. S than Gregor—he hunted for an open computer. There were three on the ward. The head nurse hovered over a keyboard. Her shoulders were hunched and her body language said “Do not disturb.” Charting vitals or checking her stocks, it did not much matter. She was an immovable object, and he was no irresistible force.

The second keyboard was occupied by Heinrich W, the pharmacist. Dr. S had had a confrontation with the prickly pharmacist over an abbreviation two weeks ago and since then not a word had been spoken between them. Resigned, he approached the third keyboard.

Computer \JFSRVQ289476 was the worst in the entire hospital. The G key stuck and files seem to mysteriously disappear, but Dr. S had no other choice.

He tried to type in his password GREGORS/Hospital but the G button kept on sticking. He shook the keyboard and was ready to punch the monitor. He looked across the ward. The head nurse had left her computer. He got up to move there, but suddenly the G key became unfrozen and Dr. S typed the R and E, but the second G stuck again. He turned to move, but now a surgery resident had logged on to the other computer.

Amazingly, the G key yielded to Dr. S’ heartfelt entreaties, and Gregor signed on. His pager went off at that moment. Text message: Meeting with Committee R at 8:30, Mason Hall room 339. What was this all about? Committee R? What was Committee R? And where was Mason Hall? It was already 8:45 and he had not seen a patient yet. He could not reach the phone from his current position, so he left his seat and crossed the nurses’ station. He called his secretary, but only got her voice mail. He returned to the computer, but it had signed him off. His pager beeped for extension 5-44899. That was too many digits. All the hospital extensions had 5 digits.

He asked the ward clerk where Mason Hall was. She stared at him, chewing her gum and eyeing him like he was a giant cockroach. He turned to the pharmacist who had been watching the exchange, but he quickly turned his head back to the screen and doggedly ignored Dr. S.

Finally the head nurse came by. “Where is Mason Hall?” he pleaded with her. She shook her head at him. What kind of question was this? Why did he want to know where Mason Hall was? He told her about committee R.

“Go outside and look at the name of this building,” she snorted. This is Mason Hall. Dr. S shook his head; he’d never heard it called by that name. The pager again: Need admit orders for Mr. D. Who was this patient? He had heard of no admissions to his service today.

Dr. S ran down the stairs—no time to wait for the elevator. The staircase door on 3 was locked. He ran back up to 4, and that one was locked, too. He headed down the stairs. At the bottom a fire door was posted “Do Not Exit. Alarm Will Sound.” He pushed through. There was no alarm, and he found himself standing outside on the back of the building by the loading dock. His pager went off. The text message: Mr. D Needs Lab Orders. Mr. D? Who was this patient?

He made his way to the front of the building, sweating despite the cold temperature. His pager again alerted 67763—a number he recognized: the lab. The lab tech told him that “Mr. L’s K was 6.1.”

“Would the doctor please repeat this?” the tech asked. Dr. S tried to keep his temper. He had heard the result; why should he repeat it? It was policy per the tech. At too loud a voice he shouted, “Mr. L’s K is 6.1” and slammed the phone down in its cradle. He looked up and saw a crowd staring at him, including a small man with a notebook who peered at his ID badge and took notes. It was probably a HIPAA spy.

The lobby was crowded with families waiting for the one slow elevator. He would not risk the stairs again. He squeezed in between an oversize grandmother and a woman with three small but loud children. The doors began to close. Across the hall a man with packages was heading toward the elevator. “Let the doors close,” he prayed silently, “I couldn’t be any later.”

But the grandmother pressed the “door open” button. Floors 1 and 3 were pushed. The man was coming toward the doors. “Hurry up!” Dr. S pleaded to himself.

The man dropped his packages and then slowly picked them up. He walked to the doors and stood there. “I’m going down,” he said. The doors closed. On floor 1 the mother got off and a nurse got on. The nurse stared sullenly at Dr. S and then pressed the button for floor 2.

When the doors opened on 3, Dr. S nearly jumped off the elevator. He hustled down the hallway. Where was room 339? He followed the numbers 311, 313 down the long hallway. At the end of the hall was room 337. There was no room 339. His pager went off again Need orders for CT for Mr. D.

Finally he was back on the ward, logged in on his least favorite computer. On the other hand Mrs. J who had recently had an MI was doing better. He looked at her vitals, her labs. This was the way it was supposed to work. He wanted to start an ACE inhibitor. It was part of the protocol, but she had told him that ACE inhibitors had caused a cough in the past.

He pulled up her allergy list, NKDA. He put in the order for an ARB. A screen popped up: PATIENT POST-MI CONSIDER ACEI. He knew this, but had to use an ARB. He tried to put in the order again, but the pop-up returned. He pulled up the allergy list, and clicked “Update.” He tried to put in “ACEI-induced cough.” The system would not accept it. Then he tried “lisinopril-induced cough.” Again, didn’t work.

After four more attempts he gave up. He would order the ACEI, and if she coughed they would have to change it. He wrote the order to start low-dose ACEI. A screen popped up: Patient intolerant of ACEIs. Consider ARB. His pager went off again: Mr. D’s family waiting for results.

Dr. S checked his e-mail. There was a reminder not to miss his meeting with Committee R. There was a request from Nigeria from the deposed monarch’s widow for help regaining a vast sum of money, if he would only supply his bank account number; there was also an ad for “VIaGRow.” He searched the hospital database for Committee R, but before he could read the selection his pager went off again for extension 788988.

He called the hospital operator. The phone rang but no one picked up. His pager went off again: Sign discharge summary Mr. D.

The shift was finally over. Dr. S trudged down the hallway. At the nurses’ station there was a beautiful bouquet of flowers. The smell of anaerobes and melena was briefly replaced by the floral scent. As he walked off, the head nurse called to him. “Those are for you,” she mumbled.

“For me?” he wondered. At least someone appreciated his efforts. The annoyances and frustrations of the day seemed to melt away. He read the card: “Thanks for your excellent care. Mr. D and Family.” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Beep, beep, beep, beep ... ,” the pager sounded. “What time is it?” asked Gregor S. His alarm clock flashed 7:42 a.m. He stumbled across the small apartment, grabbed a warm diet cola out of the grocery sack he had forgotten to unload in last night’s sleep-deprived state. The chicken was ruined, the bologna dubious. The whole bag ditched, save the six-pack.

Gregor went down the stairs two at a time. Mrs. Q with the arthritic boxer in 3G barely let him by, grumbling to herself about young folks today. No time for false pleasantries. He was late again. This would be the third time this month: his first month on staff as a hospitalist. He barely made the 7:52 bus, and was on ward 7 in a quarter of an hour.

At work—more Dr. S than Gregor—he hunted for an open computer. There were three on the ward. The head nurse hovered over a keyboard. Her shoulders were hunched and her body language said “Do not disturb.” Charting vitals or checking her stocks, it did not much matter. She was an immovable object, and he was no irresistible force.

The second keyboard was occupied by Heinrich W, the pharmacist. Dr. S had had a confrontation with the prickly pharmacist over an abbreviation two weeks ago and since then not a word had been spoken between them. Resigned, he approached the third keyboard.

Computer \JFSRVQ289476 was the worst in the entire hospital. The G key stuck and files seem to mysteriously disappear, but Dr. S had no other choice.

He tried to type in his password GREGORS/Hospital but the G button kept on sticking. He shook the keyboard and was ready to punch the monitor. He looked across the ward. The head nurse had left her computer. He got up to move there, but suddenly the G key became unfrozen and Dr. S typed the R and E, but the second G stuck again. He turned to move, but now a surgery resident had logged on to the other computer.

Amazingly, the G key yielded to Dr. S’ heartfelt entreaties, and Gregor signed on. His pager went off at that moment. Text message: Meeting with Committee R at 8:30, Mason Hall room 339. What was this all about? Committee R? What was Committee R? And where was Mason Hall? It was already 8:45 and he had not seen a patient yet. He could not reach the phone from his current position, so he left his seat and crossed the nurses’ station. He called his secretary, but only got her voice mail. He returned to the computer, but it had signed him off. His pager beeped for extension 5-44899. That was too many digits. All the hospital extensions had 5 digits.

He asked the ward clerk where Mason Hall was. She stared at him, chewing her gum and eyeing him like he was a giant cockroach. He turned to the pharmacist who had been watching the exchange, but he quickly turned his head back to the screen and doggedly ignored Dr. S.

Finally the head nurse came by. “Where is Mason Hall?” he pleaded with her. She shook her head at him. What kind of question was this? Why did he want to know where Mason Hall was? He told her about committee R.

“Go outside and look at the name of this building,” she snorted. This is Mason Hall. Dr. S shook his head; he’d never heard it called by that name. The pager again: Need admit orders for Mr. D. Who was this patient? He had heard of no admissions to his service today.

Dr. S ran down the stairs—no time to wait for the elevator. The staircase door on 3 was locked. He ran back up to 4, and that one was locked, too. He headed down the stairs. At the bottom a fire door was posted “Do Not Exit. Alarm Will Sound.” He pushed through. There was no alarm, and he found himself standing outside on the back of the building by the loading dock. His pager went off. The text message: Mr. D Needs Lab Orders. Mr. D? Who was this patient?

He made his way to the front of the building, sweating despite the cold temperature. His pager again alerted 67763—a number he recognized: the lab. The lab tech told him that “Mr. L’s K was 6.1.”

“Would the doctor please repeat this?” the tech asked. Dr. S tried to keep his temper. He had heard the result; why should he repeat it? It was policy per the tech. At too loud a voice he shouted, “Mr. L’s K is 6.1” and slammed the phone down in its cradle. He looked up and saw a crowd staring at him, including a small man with a notebook who peered at his ID badge and took notes. It was probably a HIPAA spy.

The lobby was crowded with families waiting for the one slow elevator. He would not risk the stairs again. He squeezed in between an oversize grandmother and a woman with three small but loud children. The doors began to close. Across the hall a man with packages was heading toward the elevator. “Let the doors close,” he prayed silently, “I couldn’t be any later.”

But the grandmother pressed the “door open” button. Floors 1 and 3 were pushed. The man was coming toward the doors. “Hurry up!” Dr. S pleaded to himself.

The man dropped his packages and then slowly picked them up. He walked to the doors and stood there. “I’m going down,” he said. The doors closed. On floor 1 the mother got off and a nurse got on. The nurse stared sullenly at Dr. S and then pressed the button for floor 2.

When the doors opened on 3, Dr. S nearly jumped off the elevator. He hustled down the hallway. Where was room 339? He followed the numbers 311, 313 down the long hallway. At the end of the hall was room 337. There was no room 339. His pager went off again Need orders for CT for Mr. D.

Finally he was back on the ward, logged in on his least favorite computer. On the other hand Mrs. J who had recently had an MI was doing better. He looked at her vitals, her labs. This was the way it was supposed to work. He wanted to start an ACE inhibitor. It was part of the protocol, but she had told him that ACE inhibitors had caused a cough in the past.

He pulled up her allergy list, NKDA. He put in the order for an ARB. A screen popped up: PATIENT POST-MI CONSIDER ACEI. He knew this, but had to use an ARB. He tried to put in the order again, but the pop-up returned. He pulled up the allergy list, and clicked “Update.” He tried to put in “ACEI-induced cough.” The system would not accept it. Then he tried “lisinopril-induced cough.” Again, didn’t work.

After four more attempts he gave up. He would order the ACEI, and if she coughed they would have to change it. He wrote the order to start low-dose ACEI. A screen popped up: Patient intolerant of ACEIs. Consider ARB. His pager went off again: Mr. D’s family waiting for results.

Dr. S checked his e-mail. There was a reminder not to miss his meeting with Committee R. There was a request from Nigeria from the deposed monarch’s widow for help regaining a vast sum of money, if he would only supply his bank account number; there was also an ad for “VIaGRow.” He searched the hospital database for Committee R, but before he could read the selection his pager went off again for extension 788988.

He called the hospital operator. The phone rang but no one picked up. His pager went off again: Sign discharge summary Mr. D.

The shift was finally over. Dr. S trudged down the hallway. At the nurses’ station there was a beautiful bouquet of flowers. The smell of anaerobes and melena was briefly replaced by the floral scent. As he walked off, the head nurse called to him. “Those are for you,” she mumbled.

“For me?” he wondered. At least someone appreciated his efforts. The annoyances and frustrations of the day seemed to melt away. He read the card: “Thanks for your excellent care. Mr. D and Family.” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

Beep, beep, beep, beep ... ,” the pager sounded. “What time is it?” asked Gregor S. His alarm clock flashed 7:42 a.m. He stumbled across the small apartment, grabbed a warm diet cola out of the grocery sack he had forgotten to unload in last night’s sleep-deprived state. The chicken was ruined, the bologna dubious. The whole bag ditched, save the six-pack.

Gregor went down the stairs two at a time. Mrs. Q with the arthritic boxer in 3G barely let him by, grumbling to herself about young folks today. No time for false pleasantries. He was late again. This would be the third time this month: his first month on staff as a hospitalist. He barely made the 7:52 bus, and was on ward 7 in a quarter of an hour.

At work—more Dr. S than Gregor—he hunted for an open computer. There were three on the ward. The head nurse hovered over a keyboard. Her shoulders were hunched and her body language said “Do not disturb.” Charting vitals or checking her stocks, it did not much matter. She was an immovable object, and he was no irresistible force.

The second keyboard was occupied by Heinrich W, the pharmacist. Dr. S had had a confrontation with the prickly pharmacist over an abbreviation two weeks ago and since then not a word had been spoken between them. Resigned, he approached the third keyboard.

Computer \JFSRVQ289476 was the worst in the entire hospital. The G key stuck and files seem to mysteriously disappear, but Dr. S had no other choice.

He tried to type in his password GREGORS/Hospital but the G button kept on sticking. He shook the keyboard and was ready to punch the monitor. He looked across the ward. The head nurse had left her computer. He got up to move there, but suddenly the G key became unfrozen and Dr. S typed the R and E, but the second G stuck again. He turned to move, but now a surgery resident had logged on to the other computer.

Amazingly, the G key yielded to Dr. S’ heartfelt entreaties, and Gregor signed on. His pager went off at that moment. Text message: Meeting with Committee R at 8:30, Mason Hall room 339. What was this all about? Committee R? What was Committee R? And where was Mason Hall? It was already 8:45 and he had not seen a patient yet. He could not reach the phone from his current position, so he left his seat and crossed the nurses’ station. He called his secretary, but only got her voice mail. He returned to the computer, but it had signed him off. His pager beeped for extension 5-44899. That was too many digits. All the hospital extensions had 5 digits.

He asked the ward clerk where Mason Hall was. She stared at him, chewing her gum and eyeing him like he was a giant cockroach. He turned to the pharmacist who had been watching the exchange, but he quickly turned his head back to the screen and doggedly ignored Dr. S.

Finally the head nurse came by. “Where is Mason Hall?” he pleaded with her. She shook her head at him. What kind of question was this? Why did he want to know where Mason Hall was? He told her about committee R.

“Go outside and look at the name of this building,” she snorted. This is Mason Hall. Dr. S shook his head; he’d never heard it called by that name. The pager again: Need admit orders for Mr. D. Who was this patient? He had heard of no admissions to his service today.

Dr. S ran down the stairs—no time to wait for the elevator. The staircase door on 3 was locked. He ran back up to 4, and that one was locked, too. He headed down the stairs. At the bottom a fire door was posted “Do Not Exit. Alarm Will Sound.” He pushed through. There was no alarm, and he found himself standing outside on the back of the building by the loading dock. His pager went off. The text message: Mr. D Needs Lab Orders. Mr. D? Who was this patient?

He made his way to the front of the building, sweating despite the cold temperature. His pager again alerted 67763—a number he recognized: the lab. The lab tech told him that “Mr. L’s K was 6.1.”

“Would the doctor please repeat this?” the tech asked. Dr. S tried to keep his temper. He had heard the result; why should he repeat it? It was policy per the tech. At too loud a voice he shouted, “Mr. L’s K is 6.1” and slammed the phone down in its cradle. He looked up and saw a crowd staring at him, including a small man with a notebook who peered at his ID badge and took notes. It was probably a HIPAA spy.

The lobby was crowded with families waiting for the one slow elevator. He would not risk the stairs again. He squeezed in between an oversize grandmother and a woman with three small but loud children. The doors began to close. Across the hall a man with packages was heading toward the elevator. “Let the doors close,” he prayed silently, “I couldn’t be any later.”

But the grandmother pressed the “door open” button. Floors 1 and 3 were pushed. The man was coming toward the doors. “Hurry up!” Dr. S pleaded to himself.

The man dropped his packages and then slowly picked them up. He walked to the doors and stood there. “I’m going down,” he said. The doors closed. On floor 1 the mother got off and a nurse got on. The nurse stared sullenly at Dr. S and then pressed the button for floor 2.

When the doors opened on 3, Dr. S nearly jumped off the elevator. He hustled down the hallway. Where was room 339? He followed the numbers 311, 313 down the long hallway. At the end of the hall was room 337. There was no room 339. His pager went off again Need orders for CT for Mr. D.

Finally he was back on the ward, logged in on his least favorite computer. On the other hand Mrs. J who had recently had an MI was doing better. He looked at her vitals, her labs. This was the way it was supposed to work. He wanted to start an ACE inhibitor. It was part of the protocol, but she had told him that ACE inhibitors had caused a cough in the past.

He pulled up her allergy list, NKDA. He put in the order for an ARB. A screen popped up: PATIENT POST-MI CONSIDER ACEI. He knew this, but had to use an ARB. He tried to put in the order again, but the pop-up returned. He pulled up the allergy list, and clicked “Update.” He tried to put in “ACEI-induced cough.” The system would not accept it. Then he tried “lisinopril-induced cough.” Again, didn’t work.

After four more attempts he gave up. He would order the ACEI, and if she coughed they would have to change it. He wrote the order to start low-dose ACEI. A screen popped up: Patient intolerant of ACEIs. Consider ARB. His pager went off again: Mr. D’s family waiting for results.

Dr. S checked his e-mail. There was a reminder not to miss his meeting with Committee R. There was a request from Nigeria from the deposed monarch’s widow for help regaining a vast sum of money, if he would only supply his bank account number; there was also an ad for “VIaGRow.” He searched the hospital database for Committee R, but before he could read the selection his pager went off again for extension 788988.

He called the hospital operator. The phone rang but no one picked up. His pager went off again: Sign discharge summary Mr. D.

The shift was finally over. Dr. S trudged down the hallway. At the nurses’ station there was a beautiful bouquet of flowers. The smell of anaerobes and melena was briefly replaced by the floral scent. As he walked off, the head nurse called to him. “Those are for you,” she mumbled.

“For me?” he wondered. At least someone appreciated his efforts. The annoyances and frustrations of the day seemed to melt away. He read the card: “Thanks for your excellent care. Mr. D and Family.” TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

We are proud to practice medicine in the modern era: the 21st-century heirs to Hippocrates. Along the way we have abandoned a materia medica of bizarre and unusual therapies like mummy powder and eye of newt. Our pharmaceuticals are lined up in bottles and bags with clearly marked expiration dates. It’s a far cry from the witches in Macbeth, standing around the fire chanting:

Round about the cauldron go;

In the poison’d entrails throw.

Toad, that under cold stone

Days and nights has thirty-one

Swelter’d venom sleeping got,

Boil thou first i’ the charmed pot.

Double, double toil and trouble;

Fire burn and cauldron bubble.

Or have things really changed? We would shake our heads at the remedies of Shakespeare’s son-in-law, Dr. John Hall, who used spider webs, poultry larynx, and animal excreta as part of his materia medica. But wait: Perhaps we should think twice before condemning him. Perhaps we are less different then we think. We just use similar products that have been sanitized.

Some modern medicines retain their strong biotherapeutic flavor. The field of organotherapy led to the extraction of active elements from the glands of mammals and eventually insulin, thyroid extract, growth hormone, testosterone, and adrenaline. The modern forms of these drugs are just a few steps removed from their origins, but somehow don’t strike one as unusual. Read on to see how we use such non-mammalian biotherapeutic exotica as lizard spit, salmon sperm, and leech saliva as part of the most modern pharmaceutical armamentarium.

Lizards

How unlikely would it seem, but all too true, that the newest weapon in the fight against diabetes is derived from lizard spit? The lizards in question are Heloderma horridum and Heloderma suspectum (aka the Mexican beaded lizard and the Gila monster).

This strange tale begins in the Bronx, N.Y., not renowned (aside from the Bronx Zoo) as a home for Sonoran lizards. Cockroaches and rats may be the dominant fauna there. Dr. John Eng, an endocrinologist, was hunting for new hormones. In the venom of the beaded lizard he discovered a vasoactive hormone he named exendin-3. In the venom of the Gila monster he found the less vasoactive exendin-4, which seemed to have an interesting effect on beta cells.

Dr. John Eng eventually patented exendin-4, and now we have the newest drug on the market for the treatment of diabetes. The first of class of incretin mimetics, synthetic exendin-4, is also known as exanatide and marketed as Byetta. Administered as a twice-daily injection, exanatide stimulates beta cells, via a specific receptor, to secrete insulin in a glucose-dependent fashion, suppresses glucagon overproduction, slows gastric emptying, and improves satiety. The net result is that most patients experience improvement of glucose control and weight loss. The most common side effects are nausea, which tends to be moderate, self limited, and a result of hypoglycemia. As with any new drug, side effects may still be determined over time. As of yet there have been no reports of reptilian metamorphosis

Salmon

The sperm of salmon is worth mentioning here as a bridge between diabetes and the treatment of coagulation disorders. An important step in the biotherapy of insulin depended on salmon sperm. Salmon sperm contains protamines, which are small arginine-rich nuclear proteins that stabilize DNA. Salmon sperm was used because it is more easily obtained than some mammalian alternatives.

When we write prescriptions for NPH insulin, how often do we contemplate what those initials represent? The acronym stands for neutral protamine Hagedorn. In 1923 Hans Christian Hagedorn (a Danish physician, 1888-1971) and August Steenberg Krogh (a Nobel-prize winning physiologist, 1874-1949) obtained the rights from Sir Frederick Grant Banting (1891-1941) and Charles Best (1899-1941), who had first isolated insulin, and formed a company called Nordisk Insulinlaboratorium to produce insulin for Scandinavians. Krogh’s wife, Marie, was diabetic.

Ten years later Hagedorn and Jensen discovered that injection of insulin would have a prolonged effect if mixed with protamine-rich salmon sperm. The necessity of a pH of 7 for activation made the handling of insulin difficult. Zinc was added to the mix as a stabilizer. By 1946, an easier-to-use crystallized form was developed, and it was marketed by 1950 as NPH insulin.

When a patient is overdosed with heparin, excessive bleeding can be a problem. Protamine sulfate is a valuable medication used for reversal of heparin. Protamine is a strongly basic substance that combines with the strongly acidic heparin to form a stable complex. The protamine-heparin complex is not an anticoagulant; protamine causes a dissociation of the heparin-antithrombin III complex, resulting in loss of heparin’s anticoagulant activity. Given too quickly it may cause hypotension or anaphylaxis and may cause allergic reactions to patients with fish hypersensitivity.

Leeches

From the anticoagulant effect of salmon sperm, we move to the world of Annelida. More than any other creature, the leech stands out as the epitome of biotherapy. Its name alone, Hirudo medicinalis, emphasizes its medical nature. Used by many ancient societies, the leech reached its zenith in mid-19th century France. Leeches were the fashion, women’s dresses were decorated with faux leeches, and cosmetics were applied to give that “healthy pale look” sometimes attained by being bled with leeches.

In 1833 more than 40 million leeches were imported into France. However, the leech’s days were numbered. The biggest blow was when Pierre Louis made his name as the father of medical statistics by proving leeches led to a worse outcome in treating pneumonia. The death of the leech was the birth of evidence-based medicine.

But all is not lost for the leech lover. The use of the leech as an anticoagulant was recognized in 1884. In its modern chemical form, recombinant leech saliva marketed under names such as lepirudin, is indicated for coronary thrombolysis, unstable angina hemodialysis, heparin-induced thrombocytopenia, and DVT prophylaxis. Recombinant hirudin, a man-made chemical similar to leech saliva, is manufactured in large quantities and is much easier to obtain than “milking” leeches. The mechanism of action is direct inhibition of thrombin. Leeches are making a comeback in the treatment of skin grafts, however. A mechanical leech has also been designed.

The Future

The argument for the protection of our planet’s biodiversity could not be more obvious. A new treatment for diabetes comes from Gila monsters. What novel substances lurk in the ever-shrinking rain forests? Whether from lizard or leech, the day of biotherapy is not yet done. Despite all this, I’m not cornering the market on synthetic eye of newt. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

We are proud to practice medicine in the modern era: the 21st-century heirs to Hippocrates. Along the way we have abandoned a materia medica of bizarre and unusual therapies like mummy powder and eye of newt. Our pharmaceuticals are lined up in bottles and bags with clearly marked expiration dates. It’s a far cry from the witches in Macbeth, standing around the fire chanting:

Round about the cauldron go;

In the poison’d entrails throw.

Toad, that under cold stone

Days and nights has thirty-one

Swelter’d venom sleeping got,

Boil thou first i’ the charmed pot.

Double, double toil and trouble;

Fire burn and cauldron bubble.

Or have things really changed? We would shake our heads at the remedies of Shakespeare’s son-in-law, Dr. John Hall, who used spider webs, poultry larynx, and animal excreta as part of his materia medica. But wait: Perhaps we should think twice before condemning him. Perhaps we are less different then we think. We just use similar products that have been sanitized.

Some modern medicines retain their strong biotherapeutic flavor. The field of organotherapy led to the extraction of active elements from the glands of mammals and eventually insulin, thyroid extract, growth hormone, testosterone, and adrenaline. The modern forms of these drugs are just a few steps removed from their origins, but somehow don’t strike one as unusual. Read on to see how we use such non-mammalian biotherapeutic exotica as lizard spit, salmon sperm, and leech saliva as part of the most modern pharmaceutical armamentarium.

Lizards

How unlikely would it seem, but all too true, that the newest weapon in the fight against diabetes is derived from lizard spit? The lizards in question are Heloderma horridum and Heloderma suspectum (aka the Mexican beaded lizard and the Gila monster).

This strange tale begins in the Bronx, N.Y., not renowned (aside from the Bronx Zoo) as a home for Sonoran lizards. Cockroaches and rats may be the dominant fauna there. Dr. John Eng, an endocrinologist, was hunting for new hormones. In the venom of the beaded lizard he discovered a vasoactive hormone he named exendin-3. In the venom of the Gila monster he found the less vasoactive exendin-4, which seemed to have an interesting effect on beta cells.

Dr. John Eng eventually patented exendin-4, and now we have the newest drug on the market for the treatment of diabetes. The first of class of incretin mimetics, synthetic exendin-4, is also known as exanatide and marketed as Byetta. Administered as a twice-daily injection, exanatide stimulates beta cells, via a specific receptor, to secrete insulin in a glucose-dependent fashion, suppresses glucagon overproduction, slows gastric emptying, and improves satiety. The net result is that most patients experience improvement of glucose control and weight loss. The most common side effects are nausea, which tends to be moderate, self limited, and a result of hypoglycemia. As with any new drug, side effects may still be determined over time. As of yet there have been no reports of reptilian metamorphosis

Salmon

The sperm of salmon is worth mentioning here as a bridge between diabetes and the treatment of coagulation disorders. An important step in the biotherapy of insulin depended on salmon sperm. Salmon sperm contains protamines, which are small arginine-rich nuclear proteins that stabilize DNA. Salmon sperm was used because it is more easily obtained than some mammalian alternatives.

When we write prescriptions for NPH insulin, how often do we contemplate what those initials represent? The acronym stands for neutral protamine Hagedorn. In 1923 Hans Christian Hagedorn (a Danish physician, 1888-1971) and August Steenberg Krogh (a Nobel-prize winning physiologist, 1874-1949) obtained the rights from Sir Frederick Grant Banting (1891-1941) and Charles Best (1899-1941), who had first isolated insulin, and formed a company called Nordisk Insulinlaboratorium to produce insulin for Scandinavians. Krogh’s wife, Marie, was diabetic.

Ten years later Hagedorn and Jensen discovered that injection of insulin would have a prolonged effect if mixed with protamine-rich salmon sperm. The necessity of a pH of 7 for activation made the handling of insulin difficult. Zinc was added to the mix as a stabilizer. By 1946, an easier-to-use crystallized form was developed, and it was marketed by 1950 as NPH insulin.

When a patient is overdosed with heparin, excessive bleeding can be a problem. Protamine sulfate is a valuable medication used for reversal of heparin. Protamine is a strongly basic substance that combines with the strongly acidic heparin to form a stable complex. The protamine-heparin complex is not an anticoagulant; protamine causes a dissociation of the heparin-antithrombin III complex, resulting in loss of heparin’s anticoagulant activity. Given too quickly it may cause hypotension or anaphylaxis and may cause allergic reactions to patients with fish hypersensitivity.

Leeches

From the anticoagulant effect of salmon sperm, we move to the world of Annelida. More than any other creature, the leech stands out as the epitome of biotherapy. Its name alone, Hirudo medicinalis, emphasizes its medical nature. Used by many ancient societies, the leech reached its zenith in mid-19th century France. Leeches were the fashion, women’s dresses were decorated with faux leeches, and cosmetics were applied to give that “healthy pale look” sometimes attained by being bled with leeches.

In 1833 more than 40 million leeches were imported into France. However, the leech’s days were numbered. The biggest blow was when Pierre Louis made his name as the father of medical statistics by proving leeches led to a worse outcome in treating pneumonia. The death of the leech was the birth of evidence-based medicine.

But all is not lost for the leech lover. The use of the leech as an anticoagulant was recognized in 1884. In its modern chemical form, recombinant leech saliva marketed under names such as lepirudin, is indicated for coronary thrombolysis, unstable angina hemodialysis, heparin-induced thrombocytopenia, and DVT prophylaxis. Recombinant hirudin, a man-made chemical similar to leech saliva, is manufactured in large quantities and is much easier to obtain than “milking” leeches. The mechanism of action is direct inhibition of thrombin. Leeches are making a comeback in the treatment of skin grafts, however. A mechanical leech has also been designed.

The Future

The argument for the protection of our planet’s biodiversity could not be more obvious. A new treatment for diabetes comes from Gila monsters. What novel substances lurk in the ever-shrinking rain forests? Whether from lizard or leech, the day of biotherapy is not yet done. Despite all this, I’m not cornering the market on synthetic eye of newt. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

We are proud to practice medicine in the modern era: the 21st-century heirs to Hippocrates. Along the way we have abandoned a materia medica of bizarre and unusual therapies like mummy powder and eye of newt. Our pharmaceuticals are lined up in bottles and bags with clearly marked expiration dates. It’s a far cry from the witches in Macbeth, standing around the fire chanting:

Round about the cauldron go;

In the poison’d entrails throw.

Toad, that under cold stone

Days and nights has thirty-one

Swelter’d venom sleeping got,

Boil thou first i’ the charmed pot.

Double, double toil and trouble;

Fire burn and cauldron bubble.

Or have things really changed? We would shake our heads at the remedies of Shakespeare’s son-in-law, Dr. John Hall, who used spider webs, poultry larynx, and animal excreta as part of his materia medica. But wait: Perhaps we should think twice before condemning him. Perhaps we are less different then we think. We just use similar products that have been sanitized.

Some modern medicines retain their strong biotherapeutic flavor. The field of organotherapy led to the extraction of active elements from the glands of mammals and eventually insulin, thyroid extract, growth hormone, testosterone, and adrenaline. The modern forms of these drugs are just a few steps removed from their origins, but somehow don’t strike one as unusual. Read on to see how we use such non-mammalian biotherapeutic exotica as lizard spit, salmon sperm, and leech saliva as part of the most modern pharmaceutical armamentarium.

Lizards

How unlikely would it seem, but all too true, that the newest weapon in the fight against diabetes is derived from lizard spit? The lizards in question are Heloderma horridum and Heloderma suspectum (aka the Mexican beaded lizard and the Gila monster).

This strange tale begins in the Bronx, N.Y., not renowned (aside from the Bronx Zoo) as a home for Sonoran lizards. Cockroaches and rats may be the dominant fauna there. Dr. John Eng, an endocrinologist, was hunting for new hormones. In the venom of the beaded lizard he discovered a vasoactive hormone he named exendin-3. In the venom of the Gila monster he found the less vasoactive exendin-4, which seemed to have an interesting effect on beta cells.

Dr. John Eng eventually patented exendin-4, and now we have the newest drug on the market for the treatment of diabetes. The first of class of incretin mimetics, synthetic exendin-4, is also known as exanatide and marketed as Byetta. Administered as a twice-daily injection, exanatide stimulates beta cells, via a specific receptor, to secrete insulin in a glucose-dependent fashion, suppresses glucagon overproduction, slows gastric emptying, and improves satiety. The net result is that most patients experience improvement of glucose control and weight loss. The most common side effects are nausea, which tends to be moderate, self limited, and a result of hypoglycemia. As with any new drug, side effects may still be determined over time. As of yet there have been no reports of reptilian metamorphosis

Salmon

The sperm of salmon is worth mentioning here as a bridge between diabetes and the treatment of coagulation disorders. An important step in the biotherapy of insulin depended on salmon sperm. Salmon sperm contains protamines, which are small arginine-rich nuclear proteins that stabilize DNA. Salmon sperm was used because it is more easily obtained than some mammalian alternatives.

When we write prescriptions for NPH insulin, how often do we contemplate what those initials represent? The acronym stands for neutral protamine Hagedorn. In 1923 Hans Christian Hagedorn (a Danish physician, 1888-1971) and August Steenberg Krogh (a Nobel-prize winning physiologist, 1874-1949) obtained the rights from Sir Frederick Grant Banting (1891-1941) and Charles Best (1899-1941), who had first isolated insulin, and formed a company called Nordisk Insulinlaboratorium to produce insulin for Scandinavians. Krogh’s wife, Marie, was diabetic.

Ten years later Hagedorn and Jensen discovered that injection of insulin would have a prolonged effect if mixed with protamine-rich salmon sperm. The necessity of a pH of 7 for activation made the handling of insulin difficult. Zinc was added to the mix as a stabilizer. By 1946, an easier-to-use crystallized form was developed, and it was marketed by 1950 as NPH insulin.

When a patient is overdosed with heparin, excessive bleeding can be a problem. Protamine sulfate is a valuable medication used for reversal of heparin. Protamine is a strongly basic substance that combines with the strongly acidic heparin to form a stable complex. The protamine-heparin complex is not an anticoagulant; protamine causes a dissociation of the heparin-antithrombin III complex, resulting in loss of heparin’s anticoagulant activity. Given too quickly it may cause hypotension or anaphylaxis and may cause allergic reactions to patients with fish hypersensitivity.

Leeches

From the anticoagulant effect of salmon sperm, we move to the world of Annelida. More than any other creature, the leech stands out as the epitome of biotherapy. Its name alone, Hirudo medicinalis, emphasizes its medical nature. Used by many ancient societies, the leech reached its zenith in mid-19th century France. Leeches were the fashion, women’s dresses were decorated with faux leeches, and cosmetics were applied to give that “healthy pale look” sometimes attained by being bled with leeches.

In 1833 more than 40 million leeches were imported into France. However, the leech’s days were numbered. The biggest blow was when Pierre Louis made his name as the father of medical statistics by proving leeches led to a worse outcome in treating pneumonia. The death of the leech was the birth of evidence-based medicine.

But all is not lost for the leech lover. The use of the leech as an anticoagulant was recognized in 1884. In its modern chemical form, recombinant leech saliva marketed under names such as lepirudin, is indicated for coronary thrombolysis, unstable angina hemodialysis, heparin-induced thrombocytopenia, and DVT prophylaxis. Recombinant hirudin, a man-made chemical similar to leech saliva, is manufactured in large quantities and is much easier to obtain than “milking” leeches. The mechanism of action is direct inhibition of thrombin. Leeches are making a comeback in the treatment of skin grafts, however. A mechanical leech has also been designed.

The Future

The argument for the protection of our planet’s biodiversity could not be more obvious. A new treatment for diabetes comes from Gila monsters. What novel substances lurk in the ever-shrinking rain forests? Whether from lizard or leech, the day of biotherapy is not yet done. Despite all this, I’m not cornering the market on synthetic eye of newt. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine, Rochester, Minn.

It was the best of care. It was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others.

It was a slow day when Charles Darnay hit the admission office of Tellson General Hospital. Lucie sat at the terminal, glad for the distraction. She entered his information: DOB 04/21/29/Dr. Defarge/RTKA/Iodine Allergy/Regular Diet/Semi-Private/Regular Diet. Lucie was unsuccessfully trying to place a red seven on a black nine when the phone rang with a direct admit: Darren Charles/Dr. Mannette/DVT/NKDA/ Private/Diabetic Diet.

Darren Charles was not happy to be hospitalized. The CEO of an international fast food chain, he had been flying back from a business trip to London when his leg started to ache. He went to the emergency department where a right femoral vein thrombosis was observed on ultrasound. With a serum glucose of 380, he was incarcerated. The mattress was hard, the pillows starchy, and the cable selection poor. He knew this wasn’t a hotel, but he expected better service. He was tired of finger sticks, blood draws, and IVs already.

Inside Charles Darnay’s right knee joint, cartilage rubbed against cartilage. It was a wheelchair or surgery. He was adopted and a bachelor and the thought of a long lonely rehab left him cold. Dr. Defarge made it sound like it would be a breeze.

Syd Carton was the first physician’s assistant to work at Tellson General. She loved her job and had become very efficient over the last three years. She had started as an orthopedic PA, but switched to Dr. Mannette’s general medicine service to get a wider variety of cases. She took Mr. Darnay’s history. DVT post-airplane flight, with diabetes poorly controlled and dietary noncompliance. His glycohemoglobin was 12. He was high maintenance; she could live without taking care of VIPs.

Jerry Cruncher, the orthopedic intern on Dr. Defarge’s service, was fried. He’d been up all night on the graveyard shift, and it was now 1 p.m. His wife would not tolerate him coming home late again. She was likely to become a whistle blower and sink the whole residency program if he went over his allotted hours again. He loved orthopedics, but working for the infamous Dr. Defarge was a challenge. She was a great surgeon and sewed beautifully, but was mythically unpleasant. The slightest medical problem with a patient and she would bellow, “Off of my service.” It had better happen that way or it would be Intern Cruncher’s head. At any rate he was almost done—just an order or two to write and he’d be in his nice warm bed, with his nice warm wife.

PA Carton received a stat page. Mr. Charles’ oxygen saturation had dropped acutely, and he was complaining of shortness of breath. A fragment of thrombus had broken off from the expanding mass of platelets and protein in his leg and had gone for a wild ride through his circulatory system. A larger strand of thrombus fluttered precariously in the current of his femoral venous flow. Why did the VIPs always have complications?

PA Carton checked Mr. Charles’ PTT, therapeutic. His INR was coming up nicely with warfarin, but it sounded like he’d flipped a clot. She checked his vital signs: He was moderately tachycardic, but not hypotensive. His O2 sat was 84, and only came up to 91 with 4 liters nasal cannula oxygen. She ordered an EKG, troponin levels, and a CT angio. His renal function was normal, but he was on metformin. She held that drug, and called the radiologist. It took a bit of persuasion, but they would do the procedure that day.

Mr. Darnay’s right leg begun to swell. He had missed his physical therapy because it was Saturday and the pain medications made him lazy. His right popliteal vein began to fill with clot, and slowly spread proximally. Mr. Darnay’s nurse, Janice Lorry, would never have gone in his room if she hadn’t had a hankering for a Snicker’s bar, which she took from the bowl he kept to encourage visitors. She was surprised to see him looking uncomfortable; he asked for more pain medication. Something seemed wrong. She checked his oxygen saturation, 88 on room air; it had been 94 earlier that shift. She paged the intern on call.

The radiology resident sat in his office. It was a Saturday, and now he had to call in his technician and hang around to read the CT image. He had tried to put PA Carton off, but she was persistent and played the VIP card. When it was negative he was going to give her an earful.

Intern Cruncher was smiling. He was ready to check out; his wife was waiting. Connubial bliss and deep REM was all he could think of. He reached for the phone as his pager went off. It was that nurse on 14 West that drove him crazy. She said Dr. Defarge’s patient was hypoxic. He looked at his watch. He told her to encourage the use of the incentive spirometer; that it was probably post-operative atelectasis. He rolled his pager over, checked out, and went home.

Transportation was notified that they were ready for Mr. Charles in radiology. Kurt Rorcher from transportation had another patient to bring to the whirlpool, and they were short staffed on the weekend. When he finished with this first patient he would head up to 14 West, although he might have to stop by admissions and check out Lucie on the way.

Jarvis Lorry glanced over the terminal where he was polishing up a complex discharge summary. He’d been a hospitalist for two years now and enjoyed the flexibility of hours—and especially being around his wife, Nurse Lorry. However he recognized the look on her face; she was angry about something. He toyed with idea of sneaking down the back stairs, but then she spotted him. She wanted him to take a look at a patient for her. He knew better then to say no.

It was one of Dr. Defarge’s orthopedic patients, Mr. Darnay. He was hypoxic with a swollen leg. In Dr. Lorry’s mind every ortho patient with hypoxia had a PE until proven otherwise. He called radiology immediately. As expected on the weekend the reception was cool, but the tech was already there. He noted the patient’s iodine allergy and ordered a dose of Solu-Medrol.

The transportation aide went to the nurses’ station. They were ready for Mr. Darnay to get a CT angio. Nurse Lorry was amazed at how quickly it happened; her husband could sure get some action going. She helped load Mr. Darnay onto the stretcher. As soon as the transportation aide Torcher got down there they told him there was another patient to get on 14 West. Too busy for a Sunday. He might have to call in sick tomorrow if this kept up.

As Darren Charles made his way down to radiology on the second stretcher, Charles Darnay was getting contrast for his CAT scan. When Mr. Charles arrived he was given a dose of Solu-Medrol, which had been meant for Mr. Darnay. It would not be long until his glucose started to skyrocket.

Dr. Lorry ran down to radiology when he heard the code called. He never missed a chance to use his ACLS skills. He was happy to see PA Carton already running the code. It was Dr. Lorry’s patient, Mr. Darnay, in anaphylactic shock. The radiologist was fuming. Why hadn’t Mr. Darnay been premedicated? Dr. Lorry knew he had written that order.

When the dust cleared, Darnay was stabilized, and in fact, he did not have a pulmonary embolism. It looked like post-operative atelectasis after all. He did have a deep venous thrombosis in his leg.

PA Carton stood by the radiologist as he read the film on her VIP patient, Darren Charles. It would be later that night when his glucose inexplicably hit 500. The radiologist glared at her. What was with these people constantly ordering CT angios on a weekend? Did they know the cost and manpower involved?

PA Carton looked at the radiologist, whose sneer changed to surprise as he looked at the massive saddle embolism. He turned to her and said, “This is a far, far larger clot then I have ever seen before.”

It was the best of care; it was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

It was the best of care. It was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others.

It was a slow day when Charles Darnay hit the admission office of Tellson General Hospital. Lucie sat at the terminal, glad for the distraction. She entered his information: DOB 04/21/29/Dr. Defarge/RTKA/Iodine Allergy/Regular Diet/Semi-Private/Regular Diet. Lucie was unsuccessfully trying to place a red seven on a black nine when the phone rang with a direct admit: Darren Charles/Dr. Mannette/DVT/NKDA/ Private/Diabetic Diet.

Darren Charles was not happy to be hospitalized. The CEO of an international fast food chain, he had been flying back from a business trip to London when his leg started to ache. He went to the emergency department where a right femoral vein thrombosis was observed on ultrasound. With a serum glucose of 380, he was incarcerated. The mattress was hard, the pillows starchy, and the cable selection poor. He knew this wasn’t a hotel, but he expected better service. He was tired of finger sticks, blood draws, and IVs already.

Inside Charles Darnay’s right knee joint, cartilage rubbed against cartilage. It was a wheelchair or surgery. He was adopted and a bachelor and the thought of a long lonely rehab left him cold. Dr. Defarge made it sound like it would be a breeze.

Syd Carton was the first physician’s assistant to work at Tellson General. She loved her job and had become very efficient over the last three years. She had started as an orthopedic PA, but switched to Dr. Mannette’s general medicine service to get a wider variety of cases. She took Mr. Darnay’s history. DVT post-airplane flight, with diabetes poorly controlled and dietary noncompliance. His glycohemoglobin was 12. He was high maintenance; she could live without taking care of VIPs.

Jerry Cruncher, the orthopedic intern on Dr. Defarge’s service, was fried. He’d been up all night on the graveyard shift, and it was now 1 p.m. His wife would not tolerate him coming home late again. She was likely to become a whistle blower and sink the whole residency program if he went over his allotted hours again. He loved orthopedics, but working for the infamous Dr. Defarge was a challenge. She was a great surgeon and sewed beautifully, but was mythically unpleasant. The slightest medical problem with a patient and she would bellow, “Off of my service.” It had better happen that way or it would be Intern Cruncher’s head. At any rate he was almost done—just an order or two to write and he’d be in his nice warm bed, with his nice warm wife.

PA Carton received a stat page. Mr. Charles’ oxygen saturation had dropped acutely, and he was complaining of shortness of breath. A fragment of thrombus had broken off from the expanding mass of platelets and protein in his leg and had gone for a wild ride through his circulatory system. A larger strand of thrombus fluttered precariously in the current of his femoral venous flow. Why did the VIPs always have complications?

PA Carton checked Mr. Charles’ PTT, therapeutic. His INR was coming up nicely with warfarin, but it sounded like he’d flipped a clot. She checked his vital signs: He was moderately tachycardic, but not hypotensive. His O2 sat was 84, and only came up to 91 with 4 liters nasal cannula oxygen. She ordered an EKG, troponin levels, and a CT angio. His renal function was normal, but he was on metformin. She held that drug, and called the radiologist. It took a bit of persuasion, but they would do the procedure that day.

Mr. Darnay’s right leg begun to swell. He had missed his physical therapy because it was Saturday and the pain medications made him lazy. His right popliteal vein began to fill with clot, and slowly spread proximally. Mr. Darnay’s nurse, Janice Lorry, would never have gone in his room if she hadn’t had a hankering for a Snicker’s bar, which she took from the bowl he kept to encourage visitors. She was surprised to see him looking uncomfortable; he asked for more pain medication. Something seemed wrong. She checked his oxygen saturation, 88 on room air; it had been 94 earlier that shift. She paged the intern on call.

The radiology resident sat in his office. It was a Saturday, and now he had to call in his technician and hang around to read the CT image. He had tried to put PA Carton off, but she was persistent and played the VIP card. When it was negative he was going to give her an earful.

Intern Cruncher was smiling. He was ready to check out; his wife was waiting. Connubial bliss and deep REM was all he could think of. He reached for the phone as his pager went off. It was that nurse on 14 West that drove him crazy. She said Dr. Defarge’s patient was hypoxic. He looked at his watch. He told her to encourage the use of the incentive spirometer; that it was probably post-operative atelectasis. He rolled his pager over, checked out, and went home.

Transportation was notified that they were ready for Mr. Charles in radiology. Kurt Rorcher from transportation had another patient to bring to the whirlpool, and they were short staffed on the weekend. When he finished with this first patient he would head up to 14 West, although he might have to stop by admissions and check out Lucie on the way.

Jarvis Lorry glanced over the terminal where he was polishing up a complex discharge summary. He’d been a hospitalist for two years now and enjoyed the flexibility of hours—and especially being around his wife, Nurse Lorry. However he recognized the look on her face; she was angry about something. He toyed with idea of sneaking down the back stairs, but then she spotted him. She wanted him to take a look at a patient for her. He knew better then to say no.

It was one of Dr. Defarge’s orthopedic patients, Mr. Darnay. He was hypoxic with a swollen leg. In Dr. Lorry’s mind every ortho patient with hypoxia had a PE until proven otherwise. He called radiology immediately. As expected on the weekend the reception was cool, but the tech was already there. He noted the patient’s iodine allergy and ordered a dose of Solu-Medrol.

The transportation aide went to the nurses’ station. They were ready for Mr. Darnay to get a CT angio. Nurse Lorry was amazed at how quickly it happened; her husband could sure get some action going. She helped load Mr. Darnay onto the stretcher. As soon as the transportation aide Torcher got down there they told him there was another patient to get on 14 West. Too busy for a Sunday. He might have to call in sick tomorrow if this kept up.

As Darren Charles made his way down to radiology on the second stretcher, Charles Darnay was getting contrast for his CAT scan. When Mr. Charles arrived he was given a dose of Solu-Medrol, which had been meant for Mr. Darnay. It would not be long until his glucose started to skyrocket.

Dr. Lorry ran down to radiology when he heard the code called. He never missed a chance to use his ACLS skills. He was happy to see PA Carton already running the code. It was Dr. Lorry’s patient, Mr. Darnay, in anaphylactic shock. The radiologist was fuming. Why hadn’t Mr. Darnay been premedicated? Dr. Lorry knew he had written that order.

When the dust cleared, Darnay was stabilized, and in fact, he did not have a pulmonary embolism. It looked like post-operative atelectasis after all. He did have a deep venous thrombosis in his leg.

PA Carton stood by the radiologist as he read the film on her VIP patient, Darren Charles. It would be later that night when his glucose inexplicably hit 500. The radiologist glared at her. What was with these people constantly ordering CT angios on a weekend? Did they know the cost and manpower involved?

PA Carton looked at the radiologist, whose sneer changed to surprise as he looked at the massive saddle embolism. He turned to her and said, “This is a far, far larger clot then I have ever seen before.”

It was the best of care; it was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

It was the best of care. It was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others.

It was a slow day when Charles Darnay hit the admission office of Tellson General Hospital. Lucie sat at the terminal, glad for the distraction. She entered his information: DOB 04/21/29/Dr. Defarge/RTKA/Iodine Allergy/Regular Diet/Semi-Private/Regular Diet. Lucie was unsuccessfully trying to place a red seven on a black nine when the phone rang with a direct admit: Darren Charles/Dr. Mannette/DVT/NKDA/ Private/Diabetic Diet.

Darren Charles was not happy to be hospitalized. The CEO of an international fast food chain, he had been flying back from a business trip to London when his leg started to ache. He went to the emergency department where a right femoral vein thrombosis was observed on ultrasound. With a serum glucose of 380, he was incarcerated. The mattress was hard, the pillows starchy, and the cable selection poor. He knew this wasn’t a hotel, but he expected better service. He was tired of finger sticks, blood draws, and IVs already.

Inside Charles Darnay’s right knee joint, cartilage rubbed against cartilage. It was a wheelchair or surgery. He was adopted and a bachelor and the thought of a long lonely rehab left him cold. Dr. Defarge made it sound like it would be a breeze.

Syd Carton was the first physician’s assistant to work at Tellson General. She loved her job and had become very efficient over the last three years. She had started as an orthopedic PA, but switched to Dr. Mannette’s general medicine service to get a wider variety of cases. She took Mr. Darnay’s history. DVT post-airplane flight, with diabetes poorly controlled and dietary noncompliance. His glycohemoglobin was 12. He was high maintenance; she could live without taking care of VIPs.

Jerry Cruncher, the orthopedic intern on Dr. Defarge’s service, was fried. He’d been up all night on the graveyard shift, and it was now 1 p.m. His wife would not tolerate him coming home late again. She was likely to become a whistle blower and sink the whole residency program if he went over his allotted hours again. He loved orthopedics, but working for the infamous Dr. Defarge was a challenge. She was a great surgeon and sewed beautifully, but was mythically unpleasant. The slightest medical problem with a patient and she would bellow, “Off of my service.” It had better happen that way or it would be Intern Cruncher’s head. At any rate he was almost done—just an order or two to write and he’d be in his nice warm bed, with his nice warm wife.

PA Carton received a stat page. Mr. Charles’ oxygen saturation had dropped acutely, and he was complaining of shortness of breath. A fragment of thrombus had broken off from the expanding mass of platelets and protein in his leg and had gone for a wild ride through his circulatory system. A larger strand of thrombus fluttered precariously in the current of his femoral venous flow. Why did the VIPs always have complications?

PA Carton checked Mr. Charles’ PTT, therapeutic. His INR was coming up nicely with warfarin, but it sounded like he’d flipped a clot. She checked his vital signs: He was moderately tachycardic, but not hypotensive. His O2 sat was 84, and only came up to 91 with 4 liters nasal cannula oxygen. She ordered an EKG, troponin levels, and a CT angio. His renal function was normal, but he was on metformin. She held that drug, and called the radiologist. It took a bit of persuasion, but they would do the procedure that day.

Mr. Darnay’s right leg begun to swell. He had missed his physical therapy because it was Saturday and the pain medications made him lazy. His right popliteal vein began to fill with clot, and slowly spread proximally. Mr. Darnay’s nurse, Janice Lorry, would never have gone in his room if she hadn’t had a hankering for a Snicker’s bar, which she took from the bowl he kept to encourage visitors. She was surprised to see him looking uncomfortable; he asked for more pain medication. Something seemed wrong. She checked his oxygen saturation, 88 on room air; it had been 94 earlier that shift. She paged the intern on call.

The radiology resident sat in his office. It was a Saturday, and now he had to call in his technician and hang around to read the CT image. He had tried to put PA Carton off, but she was persistent and played the VIP card. When it was negative he was going to give her an earful.

Intern Cruncher was smiling. He was ready to check out; his wife was waiting. Connubial bliss and deep REM was all he could think of. He reached for the phone as his pager went off. It was that nurse on 14 West that drove him crazy. She said Dr. Defarge’s patient was hypoxic. He looked at his watch. He told her to encourage the use of the incentive spirometer; that it was probably post-operative atelectasis. He rolled his pager over, checked out, and went home.

Transportation was notified that they were ready for Mr. Charles in radiology. Kurt Rorcher from transportation had another patient to bring to the whirlpool, and they were short staffed on the weekend. When he finished with this first patient he would head up to 14 West, although he might have to stop by admissions and check out Lucie on the way.

Jarvis Lorry glanced over the terminal where he was polishing up a complex discharge summary. He’d been a hospitalist for two years now and enjoyed the flexibility of hours—and especially being around his wife, Nurse Lorry. However he recognized the look on her face; she was angry about something. He toyed with idea of sneaking down the back stairs, but then she spotted him. She wanted him to take a look at a patient for her. He knew better then to say no.

It was one of Dr. Defarge’s orthopedic patients, Mr. Darnay. He was hypoxic with a swollen leg. In Dr. Lorry’s mind every ortho patient with hypoxia had a PE until proven otherwise. He called radiology immediately. As expected on the weekend the reception was cool, but the tech was already there. He noted the patient’s iodine allergy and ordered a dose of Solu-Medrol.

The transportation aide went to the nurses’ station. They were ready for Mr. Darnay to get a CT angio. Nurse Lorry was amazed at how quickly it happened; her husband could sure get some action going. She helped load Mr. Darnay onto the stretcher. As soon as the transportation aide Torcher got down there they told him there was another patient to get on 14 West. Too busy for a Sunday. He might have to call in sick tomorrow if this kept up.

As Darren Charles made his way down to radiology on the second stretcher, Charles Darnay was getting contrast for his CAT scan. When Mr. Charles arrived he was given a dose of Solu-Medrol, which had been meant for Mr. Darnay. It would not be long until his glucose started to skyrocket.

Dr. Lorry ran down to radiology when he heard the code called. He never missed a chance to use his ACLS skills. He was happy to see PA Carton already running the code. It was Dr. Lorry’s patient, Mr. Darnay, in anaphylactic shock. The radiologist was fuming. Why hadn’t Mr. Darnay been premedicated? Dr. Lorry knew he had written that order.

When the dust cleared, Darnay was stabilized, and in fact, he did not have a pulmonary embolism. It looked like post-operative atelectasis after all. He did have a deep venous thrombosis in his leg.

PA Carton stood by the radiologist as he read the film on her VIP patient, Darren Charles. It would be later that night when his glucose inexplicably hit 500. The radiologist glared at her. What was with these people constantly ordering CT angios on a weekend? Did they know the cost and manpower involved?

PA Carton looked at the radiologist, whose sneer changed to surprise as he looked at the massive saddle embolism. He turned to her and said, “This is a far, far larger clot then I have ever seen before.”

It was the best of care; it was the worst of care. It was acts of wisdom; it was acts of foolishness. It was an epoch of evidence; it was an epoch of anecdotes. The patients were full code; they were DNR. It was the summer of safety and the winter of sentinel events. In short it was a hospital so like all others. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Junior Moleray rubbed his large hand against the jet-black stubble on his square jaw. His feet were on his desk, and a dead pint of Old Croup Whisky was in the dumpster. It was quiet in the Moleray detective agency. Too quiet.

Moleray specialized in medical insurance fraud. It had been a week since he had solved the last case. A cagey bird had been collecting disability payments on five different accounts. Moleray caught up with him on a double black diamond run at Jackson Hole. Case solved. It had been too easy.

Junior thought about how he’d gotten into the detective racket. It was an improbably sad story. He’d been a detective on the Philadelphia police force and quit to become a medical student—the second doctor in the family.

His older brother, Maurie, had just finished an internal medicine residency and had signed with a clinic in Punxatawney—an outpatient internal medicine and pain clinic. Things were great for Maurie those the first two weeks. He was still getting his feet wet when his boss, Dr. Rock, went on vacation and disappeared while climbing in Malta. Shortly thereafter Rock’s widow showed up at the clinic with legal papers in hand. She offered to sell the entire practice for $10,000 cash just to be done with it. It was a beautiful office and a busy practice. Dr. Rock’s misfortune was Maurie’s stroke of luck. The deal was closed in 24 hours.

A week later, moving men came for the furniture (it was all rented and payment was overdue). Then the building manager evicted Maurie because the rent was also unpaid. Within two weeks he was accused of Medicare and Medicaid fraud and prescription peddling and named as a codefendant on six separate malpractice cases. The malpractice premiums hadn’t been paid in months.

Mrs. Rock was nowhere to be found. Maurie had been framed. His license was suspended. His debt was magnificent. His career in tatters.

Junior got to his brother’s house just in time. He found Maurie knotting ties together into a noose.

Junior quit medical school to track down the wife. After months, he found Mrs. Rock living in a shotgun shack in St. Bernard Parish, La. It didn’t look like the home of a rich widow. When he saw Mrs. Rock, his draw dropped. She was a tall drink of water, and he wanted to be the straw. Later he couldn’t remember what her face looked like. She invited him in.

“Come on in, honey” was the last thing he heard as he stepped into the room. He woke up hours later in an empty room with an occipital goose egg. There was nothing left except some half filled out forms in a precise handwriting. It was a cold trail that he swore he’d pick up again one day.

The ringing of the phone was a welcome relief.

“Moleray, it’s your dime,” Junior barked into the receiver.

“Hey Mole,” came an annoyingly familiar voice on the phone, “I got a hot one for you.”

It was Benny “the Weasel” Rabinowitz from the Mutual International Reinsurance Corporation.

“We’ve got a hospital that just submitted some numbers that are hard to believe, perfect numbers,” said Rabinowitz. “Unless we figure out their scam, we are going to have to fork over a cool million in pay-for-performance bonus fees. I smell a rat.”

“What’s the matter, Weasel, don’t your handlers at the Mutt want to pay the piper?” Junior retorted. He never trusted these big companies, even if the clients were defrauding them. The companies were none too innocent themselves. He took the case. It beat boredom.

The hospital was a rickety old building on South Main. It didn’t seem like the type of facility that would have perfect utilization numbers, but looks can be deceiving.

The medical records office was in the basement. A grumpy woman directed him to a pile of charts and disappeared. Junior spent the next six hours sitting in the cramped cubicle, sipping lukewarm, weak coffee and marveling at the perfect records. They were all written by the same physician with the perfect handwriting. There was something familiar about the writing, but Junior couldn’t make the connection.

The records were meticulous. Every patient with an MI had been given an ace inhibitor, a beta-blocker, aspirin, and a statin. But every patient was identical; the EKGs identical; the lab values identical—even the vitals were the same. Something was very wrong with these charts. By day’s end Junior was ready to go back to his cheesy motel room and make some phone calls. He had lifted some phone numbers from the charts. (Junior didn’t let a little thing like confidentiality stand in his way.) He tried to call several patients, but every single one of them had a disconnected phone.

The next morning Junior returned to the record room and knocked on the door. There was a different clerk today. A lilting voice said, “Come on in, honey.”

Junior started to get chills up and down his spine. He knew that voice … from somewhere. He felt her brush against his back. The smell of jasmine filled the air as she place a cup of coffee on the desk before him. As he finished off the foul morning brew it came to him. He knew her voice and her handwriting.

He stood quickly and turned toward her, but his head began to swim. Suddenly she was joined by a man whose photo he had seen before. It was Dr. Rock and his “wife.” Junior took a step toward them and then hit the ground, drugged into oblivion.

Fluorescent lights. Movement though a hallway. Junior found himself strapped on a gurney. He heard the orderly talking, maybe to a nurse.

“Is this Mr. Johnson?” asked the nurse. She checked his arm band; the ID was correct.

“He doesn’t say much does he?” the orderly commented.

“He’s going for resection of a huge brain mass,” the nurse replied.

Junior wondered who they were talking about as his stretcher was wheeled into the operating room. He felt the IV go into his hand. They checked his arm band again: “This is Hugo Johnson, birth date Oct. 5, 1957? OK.” They started to put the mask over his face, and Junior summoned all his strength and whispered, “Not me.”

The anesthesiologist shook his head, ”Sorry I know you’re scared but these things happen to everyone. You’ll be fine, Hugo.”

Junior tried again: “Not Hugo.”

The anesthesiologist nodded again, “I know we all feel immortal, but anyone—even you—can get sick.”

The mask came toward Junior again. He knew this was his last chance before his skull was cut open and his brain dissected in a hunt for a tumor that was not there.

Summoning his last reserve of energy, he yelled, “Sentinel event.” Everyone in the room stopped cold.

Junior sat in his office, his feet on his desk, and a newly deceased pint of Old Croup in the dumpster. He looked at his check from the Mutual for $25,000. He was ready for his next case. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Junior Moleray rubbed his large hand against the jet-black stubble on his square jaw. His feet were on his desk, and a dead pint of Old Croup Whisky was in the dumpster. It was quiet in the Moleray detective agency. Too quiet.

Moleray specialized in medical insurance fraud. It had been a week since he had solved the last case. A cagey bird had been collecting disability payments on five different accounts. Moleray caught up with him on a double black diamond run at Jackson Hole. Case solved. It had been too easy.

Junior thought about how he’d gotten into the detective racket. It was an improbably sad story. He’d been a detective on the Philadelphia police force and quit to become a medical student—the second doctor in the family.

His older brother, Maurie, had just finished an internal medicine residency and had signed with a clinic in Punxatawney—an outpatient internal medicine and pain clinic. Things were great for Maurie those the first two weeks. He was still getting his feet wet when his boss, Dr. Rock, went on vacation and disappeared while climbing in Malta. Shortly thereafter Rock’s widow showed up at the clinic with legal papers in hand. She offered to sell the entire practice for $10,000 cash just to be done with it. It was a beautiful office and a busy practice. Dr. Rock’s misfortune was Maurie’s stroke of luck. The deal was closed in 24 hours.

A week later, moving men came for the furniture (it was all rented and payment was overdue). Then the building manager evicted Maurie because the rent was also unpaid. Within two weeks he was accused of Medicare and Medicaid fraud and prescription peddling and named as a codefendant on six separate malpractice cases. The malpractice premiums hadn’t been paid in months.

Mrs. Rock was nowhere to be found. Maurie had been framed. His license was suspended. His debt was magnificent. His career in tatters.

Junior got to his brother’s house just in time. He found Maurie knotting ties together into a noose.

Junior quit medical school to track down the wife. After months, he found Mrs. Rock living in a shotgun shack in St. Bernard Parish, La. It didn’t look like the home of a rich widow. When he saw Mrs. Rock, his draw dropped. She was a tall drink of water, and he wanted to be the straw. Later he couldn’t remember what her face looked like. She invited him in.

“Come on in, honey” was the last thing he heard as he stepped into the room. He woke up hours later in an empty room with an occipital goose egg. There was nothing left except some half filled out forms in a precise handwriting. It was a cold trail that he swore he’d pick up again one day.

The ringing of the phone was a welcome relief.

“Moleray, it’s your dime,” Junior barked into the receiver.

“Hey Mole,” came an annoyingly familiar voice on the phone, “I got a hot one for you.”

It was Benny “the Weasel” Rabinowitz from the Mutual International Reinsurance Corporation.

“We’ve got a hospital that just submitted some numbers that are hard to believe, perfect numbers,” said Rabinowitz. “Unless we figure out their scam, we are going to have to fork over a cool million in pay-for-performance bonus fees. I smell a rat.”

“What’s the matter, Weasel, don’t your handlers at the Mutt want to pay the piper?” Junior retorted. He never trusted these big companies, even if the clients were defrauding them. The companies were none too innocent themselves. He took the case. It beat boredom.

The hospital was a rickety old building on South Main. It didn’t seem like the type of facility that would have perfect utilization numbers, but looks can be deceiving.

The medical records office was in the basement. A grumpy woman directed him to a pile of charts and disappeared. Junior spent the next six hours sitting in the cramped cubicle, sipping lukewarm, weak coffee and marveling at the perfect records. They were all written by the same physician with the perfect handwriting. There was something familiar about the writing, but Junior couldn’t make the connection.

The records were meticulous. Every patient with an MI had been given an ace inhibitor, a beta-blocker, aspirin, and a statin. But every patient was identical; the EKGs identical; the lab values identical—even the vitals were the same. Something was very wrong with these charts. By day’s end Junior was ready to go back to his cheesy motel room and make some phone calls. He had lifted some phone numbers from the charts. (Junior didn’t let a little thing like confidentiality stand in his way.) He tried to call several patients, but every single one of them had a disconnected phone.

The next morning Junior returned to the record room and knocked on the door. There was a different clerk today. A lilting voice said, “Come on in, honey.”

Junior started to get chills up and down his spine. He knew that voice … from somewhere. He felt her brush against his back. The smell of jasmine filled the air as she place a cup of coffee on the desk before him. As he finished off the foul morning brew it came to him. He knew her voice and her handwriting.

He stood quickly and turned toward her, but his head began to swim. Suddenly she was joined by a man whose photo he had seen before. It was Dr. Rock and his “wife.” Junior took a step toward them and then hit the ground, drugged into oblivion.

Fluorescent lights. Movement though a hallway. Junior found himself strapped on a gurney. He heard the orderly talking, maybe to a nurse.

“Is this Mr. Johnson?” asked the nurse. She checked his arm band; the ID was correct.

“He doesn’t say much does he?” the orderly commented.

“He’s going for resection of a huge brain mass,” the nurse replied.

Junior wondered who they were talking about as his stretcher was wheeled into the operating room. He felt the IV go into his hand. They checked his arm band again: “This is Hugo Johnson, birth date Oct. 5, 1957? OK.” They started to put the mask over his face, and Junior summoned all his strength and whispered, “Not me.”

The anesthesiologist shook his head, ”Sorry I know you’re scared but these things happen to everyone. You’ll be fine, Hugo.”

Junior tried again: “Not Hugo.”

The anesthesiologist nodded again, “I know we all feel immortal, but anyone—even you—can get sick.”

The mask came toward Junior again. He knew this was his last chance before his skull was cut open and his brain dissected in a hunt for a tumor that was not there.

Summoning his last reserve of energy, he yelled, “Sentinel event.” Everyone in the room stopped cold.

Junior sat in his office, his feet on his desk, and a newly deceased pint of Old Croup in the dumpster. He looked at his check from the Mutual for $25,000. He was ready for his next case. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Junior Moleray rubbed his large hand against the jet-black stubble on his square jaw. His feet were on his desk, and a dead pint of Old Croup Whisky was in the dumpster. It was quiet in the Moleray detective agency. Too quiet.

Moleray specialized in medical insurance fraud. It had been a week since he had solved the last case. A cagey bird had been collecting disability payments on five different accounts. Moleray caught up with him on a double black diamond run at Jackson Hole. Case solved. It had been too easy.

Junior thought about how he’d gotten into the detective racket. It was an improbably sad story. He’d been a detective on the Philadelphia police force and quit to become a medical student—the second doctor in the family.

His older brother, Maurie, had just finished an internal medicine residency and had signed with a clinic in Punxatawney—an outpatient internal medicine and pain clinic. Things were great for Maurie those the first two weeks. He was still getting his feet wet when his boss, Dr. Rock, went on vacation and disappeared while climbing in Malta. Shortly thereafter Rock’s widow showed up at the clinic with legal papers in hand. She offered to sell the entire practice for $10,000 cash just to be done with it. It was a beautiful office and a busy practice. Dr. Rock’s misfortune was Maurie’s stroke of luck. The deal was closed in 24 hours.

A week later, moving men came for the furniture (it was all rented and payment was overdue). Then the building manager evicted Maurie because the rent was also unpaid. Within two weeks he was accused of Medicare and Medicaid fraud and prescription peddling and named as a codefendant on six separate malpractice cases. The malpractice premiums hadn’t been paid in months.

Mrs. Rock was nowhere to be found. Maurie had been framed. His license was suspended. His debt was magnificent. His career in tatters.

Junior got to his brother’s house just in time. He found Maurie knotting ties together into a noose.

Junior quit medical school to track down the wife. After months, he found Mrs. Rock living in a shotgun shack in St. Bernard Parish, La. It didn’t look like the home of a rich widow. When he saw Mrs. Rock, his draw dropped. She was a tall drink of water, and he wanted to be the straw. Later he couldn’t remember what her face looked like. She invited him in.

“Come on in, honey” was the last thing he heard as he stepped into the room. He woke up hours later in an empty room with an occipital goose egg. There was nothing left except some half filled out forms in a precise handwriting. It was a cold trail that he swore he’d pick up again one day.

The ringing of the phone was a welcome relief.

“Moleray, it’s your dime,” Junior barked into the receiver.

“Hey Mole,” came an annoyingly familiar voice on the phone, “I got a hot one for you.”

It was Benny “the Weasel” Rabinowitz from the Mutual International Reinsurance Corporation.

“We’ve got a hospital that just submitted some numbers that are hard to believe, perfect numbers,” said Rabinowitz. “Unless we figure out their scam, we are going to have to fork over a cool million in pay-for-performance bonus fees. I smell a rat.”

“What’s the matter, Weasel, don’t your handlers at the Mutt want to pay the piper?” Junior retorted. He never trusted these big companies, even if the clients were defrauding them. The companies were none too innocent themselves. He took the case. It beat boredom.

The hospital was a rickety old building on South Main. It didn’t seem like the type of facility that would have perfect utilization numbers, but looks can be deceiving.

The medical records office was in the basement. A grumpy woman directed him to a pile of charts and disappeared. Junior spent the next six hours sitting in the cramped cubicle, sipping lukewarm, weak coffee and marveling at the perfect records. They were all written by the same physician with the perfect handwriting. There was something familiar about the writing, but Junior couldn’t make the connection.

The records were meticulous. Every patient with an MI had been given an ace inhibitor, a beta-blocker, aspirin, and a statin. But every patient was identical; the EKGs identical; the lab values identical—even the vitals were the same. Something was very wrong with these charts. By day’s end Junior was ready to go back to his cheesy motel room and make some phone calls. He had lifted some phone numbers from the charts. (Junior didn’t let a little thing like confidentiality stand in his way.) He tried to call several patients, but every single one of them had a disconnected phone.

The next morning Junior returned to the record room and knocked on the door. There was a different clerk today. A lilting voice said, “Come on in, honey.”

Junior started to get chills up and down his spine. He knew that voice … from somewhere. He felt her brush against his back. The smell of jasmine filled the air as she place a cup of coffee on the desk before him. As he finished off the foul morning brew it came to him. He knew her voice and her handwriting.

He stood quickly and turned toward her, but his head began to swim. Suddenly she was joined by a man whose photo he had seen before. It was Dr. Rock and his “wife.” Junior took a step toward them and then hit the ground, drugged into oblivion.

Fluorescent lights. Movement though a hallway. Junior found himself strapped on a gurney. He heard the orderly talking, maybe to a nurse.

“Is this Mr. Johnson?” asked the nurse. She checked his arm band; the ID was correct.

“He doesn’t say much does he?” the orderly commented.

“He’s going for resection of a huge brain mass,” the nurse replied.

Junior wondered who they were talking about as his stretcher was wheeled into the operating room. He felt the IV go into his hand. They checked his arm band again: “This is Hugo Johnson, birth date Oct. 5, 1957? OK.” They started to put the mask over his face, and Junior summoned all his strength and whispered, “Not me.”

The anesthesiologist shook his head, ”Sorry I know you’re scared but these things happen to everyone. You’ll be fine, Hugo.”

Junior tried again: “Not Hugo.”

The anesthesiologist nodded again, “I know we all feel immortal, but anyone—even you—can get sick.”

The mask came toward Junior again. He knew this was his last chance before his skull was cut open and his brain dissected in a hunt for a tumor that was not there.

Summoning his last reserve of energy, he yelled, “Sentinel event.” Everyone in the room stopped cold.

Junior sat in his office, his feet on his desk, and a newly deceased pint of Old Croup in the dumpster. He looked at his check from the Mutual for $25,000. He was ready for his next case. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Chapter 1: Loomings

Call me Dr. Ishmael. Some years ago—never mind how long precisely—having little or no money in my purse and nothing particular to interest me, I thought I would go to medical school. I wanted to feel an enlarged spleen and learn the circulation.

Chapter 2: A Bosom Friend

It was the evening before the start of a long rotation, and I had to find quarters. I had been assigned to share a call room with another student. It was late and I dimmed the lights and fell into a disturbed sleep. Suddenly the lights flashed on, and a sight unlike any I had imagined came before my bleary eyes. It was a huge man, covered in tattoos, with strange piercings and wires sticking from his ears.

“Nizetameetya,” he mumbled. He pulled off his shirt, and I could see a large caduceus motif filled the canvas of his back.

“Watchaheerfaw?” he asked. It was some time before I could translate his strange island dialect. His name was Queequeg and he was from the island of Long. Before the sun had risen, we were best of friends. Better yet, we had been assigned to the same medicine service.

Chapter 3: The Hospital

A strange old building was the Pequod Hospital, an outreach of the Nantucket General Hospital. It was a hospital of the old school. The wooden floors were shiny with use and the walls a dim yellow. It had the distinct odor of disinfectant with a trace of stale urine; it smelled like a hospital. The spirits of patients lingered in the air.

Chapter 4: The Warning

As we entered the lobby, a student in a short white coat stumbled by us. Bedraggled, he was splattered with nameless filth. His name tag read “ELISA.”

“Doing a rotation are you? At the Pequod? You on Ahab’s team are you? It’s not too late to switch services. Not too late. Too late,” he said as he staggered off.

Chapter 5: Two Squires

We entered the ward and met an intern, Dr. Flask. A short, ruddy young fellow. Very pugnacious concerning scut. He was bent over a patient’s arm prodding for a vessel. He looked at Queequeg.

“Oh lord what have we here, are you a medical student or a freak show?” he barked. Queequeg pushed him aside, pulled a needle from a loaded pocket, and without hesitation plunged it into the patient’s arm, hitting the vein instantly. He turned toward Flask, who was now smiling broadly.

Several minutes later, a second intern named Dr. Stubb walked in. A mellow dude, neither serious nor intense. He was calm in a code; fearless in the face of an angry family. He constantly twirled a drug company pen, revolving endlessly around the fingers of his left hand. During rounds, while taking a history, perhaps while asleep, that ballpoint spun continually on a journey nowhere. It was hypnotizing.

Chapter 6: A Knight

I smelled him before I saw him. It was a scent of the islands, of roasted beans and cinnamon. It was Dr. Starbuck. He held the largest cup of coffee I had ever seen.

He caught my eye and rightly read my thoughts. “It’s a triple soy latte with a twist,” he said between sips. I never saw him without a cup in his hand. Lattes, espressos, cappuccinos—cold or scalding, frothy or black, Kona or Colombian—these were his passions. It was only about the divine essence of the bean that I saw him show his true emotions.

Chapter 7: Rounds

And so the strange rotation began to take shape. We headed down the long old ward, the patient’s beds in groups of two. For those of you who never rounded in these days gone by, not corrupted by the mighty powers of Microsoft, it was an odd sight. A mass of physicians huddled around a chart rack. From this rack were pulled clipboards: long wood or plastic holders with strange colored papers barely held in place, waiting to fall out and flutter to the floor, their normal order destroyed. The rack was our lifeboat, our master, and our servant. We went from room to room to see patients, discuss them, make a diagnostic plan. Then the resident turned to the interns and began to grill them. And Lord help the student who could not withstand the devious pimpage.

Knight Starbuck was no exception to this rule. He would scour the physiology and pharmacologic depths of our souls between sips of Jamaican roast. When we did not know, he would turn to Flask or Stubb. Stubb would generally answer, his pen incessantly turning.

Something felt wrong about this service, though. Some foreboding. Some hint of disaster to come. I realized then we were a ship without a rudder, dismasted without our leader, our attending physician. We heard footsteps coming our way. I could not say precisely how, but the air seemed to become charged, as if before a storm.

Chapter 8: Enter Ahab

Dr. Ahab strode upon the ward. His whole broad form was bronzed from some strange ailment or weeks at the beach. A large scar ran along the anterior part of his neck, white against the dark skin. A mark of some desperate wound or endarterectomy. But it was not this that left me speechless in his presence; it was his great white coat.

Each of us, except Queequeg who rejected such formalities, wore a white coat. Mine was short (in measure to my educational rank), filled to the brim with anything I thought might be of value. I was not one to be found wanting when an item was needed. The residents wore longer versions, their pockets stuffed with their own totems of power.

But Ahab’s white coat was of another dimension entirely. To call it pristine would fall short of its purity: It was incandescent. A wrinkle would have expired of loneliness. It was starched and unbending, like Dr. Ahab himself. It went nearly to the floor, the tops of his wing tips barely visible beneath. It was his armor, his shield, it was Ahab.

“Do you know what I’m looking for team?” he asked each of us in turn, as the hair rose on the back of my neck. “It’s evidence I’m looking for. And not just any, but Grade A-1 that we’ll be seeking”

Chapter 9: The Chase for Evidence

And so rounds began again. Each patient in their turn was prodded and poked. The medicines were reviewed; the care plan discussed. With each case Ahab became more agitated. He demanded proof that our therapies were supported by the literature. He worshipfully spoke of articles and references like they had a life of their own, a hierarchy of existence.

As we came to the last patient, Ahab began to pace nervously. It was Stubb’s turn to present.

“The next patient is a morbidly obese 74-year-old with a DVT and PE, on heparin. We are starting Coumadin now,” began Stubb.

Suddenly Ahab erupted: “Why is this patient in the hospital? Why isn’t he on LMWH and home already?”

“I thought he needed heparinization, and I’m concerned about hypoxia,” stammered Stubb.

“Aye, but what’s your evidence that inpatient is better than outpatient treatment? Can you drive blindfolded? Are your thoughts and concerns worth the wasted resources?” hissed Ahab.

The pen fell from Stubb’s hand and lay lifeless on the floor.

Suddenly the nurse ran from the patient’s room, calling a code. We rushed into the room. The patient was a huge man—a leviathan—his flesh an off-white in the fluorescent light. Flask jumped on his chest and began to pump; Stubb intubated and bagged, while Starbuck sipped his coffee. Queequeg plunged a needle into the patient’s femoral artery for a blood gas and a central line in his subclavian before I could move my feet. A small jet of blood streamed out while Queequeg positioned the tubing. The patient was resuscitated and wheeled to the ICU. I stood helplessly, thinking about evidence.

I then noticed that Ahab, who seemed shaken, was rooted to the floor. He stared at his own chest, a streak of clotted blood across his perfect white coat.

“Oh, lonely stats of death and life. Toward thee I strive, thou all-consuming data. From a cohort’s heart I randomize thee; to the last I graph with thee; for evidence sake I control my last study.” He stumbled from the room.

Chapter 10: Epilogue

I watched Ahab head to the elevator, his perfect coat tinged now with red. He waved to me three times, beckoning me to follow. But I leaned against the chart rack; it was solid. It kept me afloat. I stood there until the other team came by and joined them for their teaching rounds. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Chapter 1: Loomings

Call me Dr. Ishmael. Some years ago—never mind how long precisely—having little or no money in my purse and nothing particular to interest me, I thought I would go to medical school. I wanted to feel an enlarged spleen and learn the circulation.

Chapter 2: A Bosom Friend

It was the evening before the start of a long rotation, and I had to find quarters. I had been assigned to share a call room with another student. It was late and I dimmed the lights and fell into a disturbed sleep. Suddenly the lights flashed on, and a sight unlike any I had imagined came before my bleary eyes. It was a huge man, covered in tattoos, with strange piercings and wires sticking from his ears.

“Nizetameetya,” he mumbled. He pulled off his shirt, and I could see a large caduceus motif filled the canvas of his back.

“Watchaheerfaw?” he asked. It was some time before I could translate his strange island dialect. His name was Queequeg and he was from the island of Long. Before the sun had risen, we were best of friends. Better yet, we had been assigned to the same medicine service.

Chapter 3: The Hospital

A strange old building was the Pequod Hospital, an outreach of the Nantucket General Hospital. It was a hospital of the old school. The wooden floors were shiny with use and the walls a dim yellow. It had the distinct odor of disinfectant with a trace of stale urine; it smelled like a hospital. The spirits of patients lingered in the air.

Chapter 4: The Warning

As we entered the lobby, a student in a short white coat stumbled by us. Bedraggled, he was splattered with nameless filth. His name tag read “ELISA.”

“Doing a rotation are you? At the Pequod? You on Ahab’s team are you? It’s not too late to switch services. Not too late. Too late,” he said as he staggered off.

Chapter 5: Two Squires

We entered the ward and met an intern, Dr. Flask. A short, ruddy young fellow. Very pugnacious concerning scut. He was bent over a patient’s arm prodding for a vessel. He looked at Queequeg.

“Oh lord what have we here, are you a medical student or a freak show?” he barked. Queequeg pushed him aside, pulled a needle from a loaded pocket, and without hesitation plunged it into the patient’s arm, hitting the vein instantly. He turned toward Flask, who was now smiling broadly.

Several minutes later, a second intern named Dr. Stubb walked in. A mellow dude, neither serious nor intense. He was calm in a code; fearless in the face of an angry family. He constantly twirled a drug company pen, revolving endlessly around the fingers of his left hand. During rounds, while taking a history, perhaps while asleep, that ballpoint spun continually on a journey nowhere. It was hypnotizing.

Chapter 6: A Knight

I smelled him before I saw him. It was a scent of the islands, of roasted beans and cinnamon. It was Dr. Starbuck. He held the largest cup of coffee I had ever seen.

He caught my eye and rightly read my thoughts. “It’s a triple soy latte with a twist,” he said between sips. I never saw him without a cup in his hand. Lattes, espressos, cappuccinos—cold or scalding, frothy or black, Kona or Colombian—these were his passions. It was only about the divine essence of the bean that I saw him show his true emotions.

Chapter 7: Rounds

And so the strange rotation began to take shape. We headed down the long old ward, the patient’s beds in groups of two. For those of you who never rounded in these days gone by, not corrupted by the mighty powers of Microsoft, it was an odd sight. A mass of physicians huddled around a chart rack. From this rack were pulled clipboards: long wood or plastic holders with strange colored papers barely held in place, waiting to fall out and flutter to the floor, their normal order destroyed. The rack was our lifeboat, our master, and our servant. We went from room to room to see patients, discuss them, make a diagnostic plan. Then the resident turned to the interns and began to grill them. And Lord help the student who could not withstand the devious pimpage.

Knight Starbuck was no exception to this rule. He would scour the physiology and pharmacologic depths of our souls between sips of Jamaican roast. When we did not know, he would turn to Flask or Stubb. Stubb would generally answer, his pen incessantly turning.

Something felt wrong about this service, though. Some foreboding. Some hint of disaster to come. I realized then we were a ship without a rudder, dismasted without our leader, our attending physician. We heard footsteps coming our way. I could not say precisely how, but the air seemed to become charged, as if before a storm.

Chapter 8: Enter Ahab

Dr. Ahab strode upon the ward. His whole broad form was bronzed from some strange ailment or weeks at the beach. A large scar ran along the anterior part of his neck, white against the dark skin. A mark of some desperate wound or endarterectomy. But it was not this that left me speechless in his presence; it was his great white coat.

Each of us, except Queequeg who rejected such formalities, wore a white coat. Mine was short (in measure to my educational rank), filled to the brim with anything I thought might be of value. I was not one to be found wanting when an item was needed. The residents wore longer versions, their pockets stuffed with their own totems of power.

But Ahab’s white coat was of another dimension entirely. To call it pristine would fall short of its purity: It was incandescent. A wrinkle would have expired of loneliness. It was starched and unbending, like Dr. Ahab himself. It went nearly to the floor, the tops of his wing tips barely visible beneath. It was his armor, his shield, it was Ahab.

“Do you know what I’m looking for team?” he asked each of us in turn, as the hair rose on the back of my neck. “It’s evidence I’m looking for. And not just any, but Grade A-1 that we’ll be seeking”

Chapter 9: The Chase for Evidence

And so rounds began again. Each patient in their turn was prodded and poked. The medicines were reviewed; the care plan discussed. With each case Ahab became more agitated. He demanded proof that our therapies were supported by the literature. He worshipfully spoke of articles and references like they had a life of their own, a hierarchy of existence.

As we came to the last patient, Ahab began to pace nervously. It was Stubb’s turn to present.

“The next patient is a morbidly obese 74-year-old with a DVT and PE, on heparin. We are starting Coumadin now,” began Stubb.

Suddenly Ahab erupted: “Why is this patient in the hospital? Why isn’t he on LMWH and home already?”

“I thought he needed heparinization, and I’m concerned about hypoxia,” stammered Stubb.

“Aye, but what’s your evidence that inpatient is better than outpatient treatment? Can you drive blindfolded? Are your thoughts and concerns worth the wasted resources?” hissed Ahab.

The pen fell from Stubb’s hand and lay lifeless on the floor.

Suddenly the nurse ran from the patient’s room, calling a code. We rushed into the room. The patient was a huge man—a leviathan—his flesh an off-white in the fluorescent light. Flask jumped on his chest and began to pump; Stubb intubated and bagged, while Starbuck sipped his coffee. Queequeg plunged a needle into the patient’s femoral artery for a blood gas and a central line in his subclavian before I could move my feet. A small jet of blood streamed out while Queequeg positioned the tubing. The patient was resuscitated and wheeled to the ICU. I stood helplessly, thinking about evidence.

I then noticed that Ahab, who seemed shaken, was rooted to the floor. He stared at his own chest, a streak of clotted blood across his perfect white coat.

“Oh, lonely stats of death and life. Toward thee I strive, thou all-consuming data. From a cohort’s heart I randomize thee; to the last I graph with thee; for evidence sake I control my last study.” He stumbled from the room.

Chapter 10: Epilogue

I watched Ahab head to the elevator, his perfect coat tinged now with red. He waved to me three times, beckoning me to follow. But I leaned against the chart rack; it was solid. It kept me afloat. I stood there until the other team came by and joined them for their teaching rounds. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.

Chapter 1: Loomings

Call me Dr. Ishmael. Some years ago—never mind how long precisely—having little or no money in my purse and nothing particular to interest me, I thought I would go to medical school. I wanted to feel an enlarged spleen and learn the circulation.

Chapter 2: A Bosom Friend

It was the evening before the start of a long rotation, and I had to find quarters. I had been assigned to share a call room with another student. It was late and I dimmed the lights and fell into a disturbed sleep. Suddenly the lights flashed on, and a sight unlike any I had imagined came before my bleary eyes. It was a huge man, covered in tattoos, with strange piercings and wires sticking from his ears.

“Nizetameetya,” he mumbled. He pulled off his shirt, and I could see a large caduceus motif filled the canvas of his back.

“Watchaheerfaw?” he asked. It was some time before I could translate his strange island dialect. His name was Queequeg and he was from the island of Long. Before the sun had risen, we were best of friends. Better yet, we had been assigned to the same medicine service.

Chapter 3: The Hospital

A strange old building was the Pequod Hospital, an outreach of the Nantucket General Hospital. It was a hospital of the old school. The wooden floors were shiny with use and the walls a dim yellow. It had the distinct odor of disinfectant with a trace of stale urine; it smelled like a hospital. The spirits of patients lingered in the air.

Chapter 4: The Warning

As we entered the lobby, a student in a short white coat stumbled by us. Bedraggled, he was splattered with nameless filth. His name tag read “ELISA.”

“Doing a rotation are you? At the Pequod? You on Ahab’s team are you? It’s not too late to switch services. Not too late. Too late,” he said as he staggered off.

Chapter 5: Two Squires

We entered the ward and met an intern, Dr. Flask. A short, ruddy young fellow. Very pugnacious concerning scut. He was bent over a patient’s arm prodding for a vessel. He looked at Queequeg.

“Oh lord what have we here, are you a medical student or a freak show?” he barked. Queequeg pushed him aside, pulled a needle from a loaded pocket, and without hesitation plunged it into the patient’s arm, hitting the vein instantly. He turned toward Flask, who was now smiling broadly.

Several minutes later, a second intern named Dr. Stubb walked in. A mellow dude, neither serious nor intense. He was calm in a code; fearless in the face of an angry family. He constantly twirled a drug company pen, revolving endlessly around the fingers of his left hand. During rounds, while taking a history, perhaps while asleep, that ballpoint spun continually on a journey nowhere. It was hypnotizing.

Chapter 6: A Knight

I smelled him before I saw him. It was a scent of the islands, of roasted beans and cinnamon. It was Dr. Starbuck. He held the largest cup of coffee I had ever seen.

He caught my eye and rightly read my thoughts. “It’s a triple soy latte with a twist,” he said between sips. I never saw him without a cup in his hand. Lattes, espressos, cappuccinos—cold or scalding, frothy or black, Kona or Colombian—these were his passions. It was only about the divine essence of the bean that I saw him show his true emotions.

Chapter 7: Rounds

And so the strange rotation began to take shape. We headed down the long old ward, the patient’s beds in groups of two. For those of you who never rounded in these days gone by, not corrupted by the mighty powers of Microsoft, it was an odd sight. A mass of physicians huddled around a chart rack. From this rack were pulled clipboards: long wood or plastic holders with strange colored papers barely held in place, waiting to fall out and flutter to the floor, their normal order destroyed. The rack was our lifeboat, our master, and our servant. We went from room to room to see patients, discuss them, make a diagnostic plan. Then the resident turned to the interns and began to grill them. And Lord help the student who could not withstand the devious pimpage.

Knight Starbuck was no exception to this rule. He would scour the physiology and pharmacologic depths of our souls between sips of Jamaican roast. When we did not know, he would turn to Flask or Stubb. Stubb would generally answer, his pen incessantly turning.

Something felt wrong about this service, though. Some foreboding. Some hint of disaster to come. I realized then we were a ship without a rudder, dismasted without our leader, our attending physician. We heard footsteps coming our way. I could not say precisely how, but the air seemed to become charged, as if before a storm.

Chapter 8: Enter Ahab

Dr. Ahab strode upon the ward. His whole broad form was bronzed from some strange ailment or weeks at the beach. A large scar ran along the anterior part of his neck, white against the dark skin. A mark of some desperate wound or endarterectomy. But it was not this that left me speechless in his presence; it was his great white coat.

Each of us, except Queequeg who rejected such formalities, wore a white coat. Mine was short (in measure to my educational rank), filled to the brim with anything I thought might be of value. I was not one to be found wanting when an item was needed. The residents wore longer versions, their pockets stuffed with their own totems of power.

But Ahab’s white coat was of another dimension entirely. To call it pristine would fall short of its purity: It was incandescent. A wrinkle would have expired of loneliness. It was starched and unbending, like Dr. Ahab himself. It went nearly to the floor, the tops of his wing tips barely visible beneath. It was his armor, his shield, it was Ahab.

“Do you know what I’m looking for team?” he asked each of us in turn, as the hair rose on the back of my neck. “It’s evidence I’m looking for. And not just any, but Grade A-1 that we’ll be seeking”

Chapter 9: The Chase for Evidence

And so rounds began again. Each patient in their turn was prodded and poked. The medicines were reviewed; the care plan discussed. With each case Ahab became more agitated. He demanded proof that our therapies were supported by the literature. He worshipfully spoke of articles and references like they had a life of their own, a hierarchy of existence.

As we came to the last patient, Ahab began to pace nervously. It was Stubb’s turn to present.

“The next patient is a morbidly obese 74-year-old with a DVT and PE, on heparin. We are starting Coumadin now,” began Stubb.

Suddenly Ahab erupted: “Why is this patient in the hospital? Why isn’t he on LMWH and home already?”

“I thought he needed heparinization, and I’m concerned about hypoxia,” stammered Stubb.

“Aye, but what’s your evidence that inpatient is better than outpatient treatment? Can you drive blindfolded? Are your thoughts and concerns worth the wasted resources?” hissed Ahab.

The pen fell from Stubb’s hand and lay lifeless on the floor.

Suddenly the nurse ran from the patient’s room, calling a code. We rushed into the room. The patient was a huge man—a leviathan—his flesh an off-white in the fluorescent light. Flask jumped on his chest and began to pump; Stubb intubated and bagged, while Starbuck sipped his coffee. Queequeg plunged a needle into the patient’s femoral artery for a blood gas and a central line in his subclavian before I could move my feet. A small jet of blood streamed out while Queequeg positioned the tubing. The patient was resuscitated and wheeled to the ICU. I stood helplessly, thinking about evidence.

I then noticed that Ahab, who seemed shaken, was rooted to the floor. He stared at his own chest, a streak of clotted blood across his perfect white coat.

“Oh, lonely stats of death and life. Toward thee I strive, thou all-consuming data. From a cohort’s heart I randomize thee; to the last I graph with thee; for evidence sake I control my last study.” He stumbled from the room.

Chapter 10: Epilogue

I watched Ahab head to the elevator, his perfect coat tinged now with red. He waved to me three times, beckoning me to follow. But I leaned against the chart rack; it was solid. It kept me afloat. I stood there until the other team came by and joined them for their teaching rounds. TH

Jamie Newman, MD, FACP, is the physician editor of The Hospitalist, senior associate consultant, Hospital Internal Medicine, and assistant professor of internal medicine and medical history, Mayo Clinic College of Medicine at the Mayo Clinic College of Medicine, Rochester, Minn.