The Case of the Missing Hole...A Doctor Dalai Mystery

I'm on call tonight, and I've read about 200 studies since 8AM. Does wonders for the attitude. Imagine my joy (or lack thereof), when I received the following call from one of our hospitals:

"Uh, Dr. Dalai? This is Joe Tech from NorthSouth Hospital. I have another CT PA gram for you, and also a renal stone CT. Oh, and Dr. Feckless in the ER wants to know if we should scan a chest without or with contrast. Why does he want it? Well, he sees a hole in the lung on a chest X-ray, and he wants to scan it......"

Only the names have been changed to protect the innocent (ME!!!). The chest X-ray in question is anonymously reproduced below:

See the "hole"? It's in the region of the left axilla, and it is a bloody artifact caused by crossing of breast and arm shadows. Hole, indeed.

My response to Joe Tech was at first angry and then practical..."Is Dr. Feckless going to call in the surgeons based on the CT finding? No, don't repeat that....repeat the chest X-ray with the arms out of the way, and if the, ummm, hole is still there, THEN we'll do a CT." The repeat is found below. Voila! No hole!

This sad tale is wonderfully illustrative of how the ER thinks. Or doesn't as the case may be. The slightest twinge deserves the full court press. The slightest question is to be answered with a $1000 CT scan. In the middle of the night, of course. So, I have to get off my anti-self-referral bandwagon and get on my anti-scan-for-no-good-reason bandwagon. Hey, maybe they are the same bandwagon? Anyway, this knee-jerk ordering of a very expensive test is yet another reason imaging costs have skyrocketed out of sight. One of my partners very seriously states that the ER depends on us because we provide the diagnosis for them, because we have become so good at reading CT's, and because CT's have become so much better with multi-slice technique. Balderdash. The ER is just palming off their triage duties onto us. Order a scan of the affected area and see a few more victims while it's being done. And order scans on the new victims while we're at it.

This practice has got to stop, just as much as self-referral must be curbed. I keep backing into the conclusion that socialized medicine is going to do that for us, whether we like it or not. Hope I'm wrong. In the meantime, let me read the next 10 negative CT's.

SCAR Capitulates to Estonian Pressure!

Big news in the PACS world, folks! SCAR, the Society for Computer Applications in Medicine has changed its name to Siim. Now, in theory, this stands for the Society for Imaging Informatics in Medicine. However, Dalai, your intrepid reporter, did a little digging and discovered the following: The Prime Minister of Estonia is, you guessed it, Siim Kallas! Coincidence? I think not. Notice in the photo below how Mr. Kallas (the one on your left) is looking quite pleased with himself, having just convinced Mr. Bush to move SCAR, I mean SiiM, headquarters to Estonia. I will actually be in Estonia later this year (really!) and I will check this out personally.

In the meantime, if you go to http://www.siim.com, you will reach the site of a plastics manufacturer with these featured products:

Looks like they are in the PACS business, too! Do you sense any takeover plans? Hmmmmm?

United 93

Dalai's Note: David Beamer is the father of Todd Beamer, one of the heros of United Flight 93. His words are so eloquent and poignant, I have copied his statement from today's Wall Street Journal for the benefit of my readers. America needs to hear this, and we need to see this movie.

By DAVID BEAMER Wall Street Journal,April 27, 2006; Page A18

The calendar says it's April 25, 2006. At noon, my wife, Peggy, and I are walking around Battery Park -- near the Tribeca area -- in New York. It is our first time. The flowers are blooming; kids are fishing; people boarding the ferry to Ellis Island and the Statue of Liberty. Kids are laughing and noisy. The sun is shining. The vendors are hawking T-shirts, pretzels and some "designer" wares. And just up the street there is a hole in the skyline and in the ground.
In the park, there is a memorial with walls standing tall. Walls filled with so many names of those who gave their all in the Atlantic in World War II. How fitting that the names are here to honor those who gave their lives to enable this fun, this laughter -- on this sunny day. The sights and sounds of freedom continue.
Fast forward -- it is 10:30 p.m., April 25. We have just seen a movie premiere at the fifth annual Tribeca Film Festival. A film festival that has done so much to energize and revitalize the city, its people and especially the area that has that hole in the skyline and in the ground. This year the movie that had its worldwide premiere at the festival is titled "United 93." It is about the day when the hole in the skyline of New York was made -- the day when a hole was made in the side of the Pentagon near Washington, D.C. -- the day when a hole was made in a quiet mountain meadow in Pennsylvania. The day that our nation was attacked; the day when the war came home -- Sept. 11, 2001. The day our son Todd boarded United 93.
Paul Greengrass and Universal set out to tell the story of United Flight 93 on that terrible day in our nation's history. They set about the task of telling this story with a genuine intent to get it right -- the actions of those on board and honor their memory. Their extensive research included reaching out to all the families who had lost loved ones on United Flight 93 as the first casualties of this war. And Paul and his team got it right.
There are those who question the timing of this project and the painful memories it evokes. Clearly, the film portrays the reality of the attack on our homeland and its terrible consequences. Often we attend movies to escape reality and fantasize a bit. In this case and at this time, it is appropriate to get a dose of reality about this war and the real enemy we face. It is not too soon for this story to be told, seen and heard. But it is too soon for us to become complacent. It is too soon for us to think of this war in only national terms. We need to be mindful that this enemy, who made those holes in our landscape and caused the deaths of some 3,000 of our fellow free people, has a vision to personally kill or convert each and every one of us. This film reminds us that this war is personal. This enemy is on a fanatical mission to take away our lives and liberty -- the liberty that has been secured for us by those whose names are on those walls in Battery Park and so many other walls and stones throughout this nation. This enemy seeks to take away the free will that our Creator has endowed in us. Patrick Henry got it right some 231 years ago. Living without liberty is not living at all.
The passengers and crew of United 93 had the blessed opportunity to understand the nature of the attack and to launch a counterattack against the enemy. This was our first successful counterattack in our homeland in this new global war -- World War III.
This film further reminds us of the nature of the enemy we face. An enemy who will stop at nothing to achieve world domination and force a life devoid of freedom upon all. Their methods are inhumane and their targets are the innocent and unsuspecting. We call this conflict the "War on Terror." This film is a wake-up call. And although we abhor terrorism as a tactic, we are at war with a real enemy and it is personal.
There are those who would hope to escape the pain of war. Can't we just live and let live and pretend every thing is OK? Let's discuss, negotiate, reason together. The film accurately shows an enemy who will stop at nothing in a quest for control. This enemy does not seek our resources, our land or our materials, but rather to alter our very way of life.
I encourage my fellow Americans and free people everywhere to see "United 93."
Be reminded of our very real enemy. Be inspired by a true story of heroic actions taken by ordinary people with victorious consequences. Be thankful for each precious day of life with a loved one and make the most of it. Resolve to take the right action in the situations of life, whatever they may be. Resolve to give thanks and support to those men, women, leaders and commanders who to this day (1,687 days since Sept. 11, 2001) continue the counterattacks on our enemy and in so doing keep us safe and our freedoms intact.
May the taste of freedom for people of the Middle East hasten victory. The enemy we face does not have the word "surrender" in their dictionary. We must not have the word "retreat" in ours. We surely want our troops home as soon as possible. That said, they cannot come home in retreat. They must come home victoriously. Pray for them.

Happy Birthday, Dr. K!

Nobody escapes the Spanish Inquisition, or Doctor Dalai when he has photos!

Dr. K celebrated his 40th birthday by trucking into the hospital at 4AM to do a lumbar puncture on a 350 pound lady who wouldn't hold still. The day did improve significantly, and we had a chance to celebrate a little. Dr. K is an avid biker, occasionally riding all the way to the hospital from home. We thought he needed something a little snazzier......

8G SCAM! A Public Service Announcment from Doctor Dalai

From the "if it's too good to be true it probably isn't" department.....

I troll around eBay periodically, looking for bargains and whatnot. I stumbled across a listing for a "Sony Micro Vault 8GB USB Flash Drive," going for only about $40. I immediately bid on it. Fortunately, a kind soul informed me by email that Sony doesn't make any drives that large in that form-factor, and what I was bidding on was likely a fake. I was able to withdraw my bid in the nick of time. Yes, it would look like an 8GB drive to my computer, until I actually tried to write something to it and read it back. Then its real size of 64 MB would become apparent.

In the interests of Karma, I am passing this information on to my loyal readers. For more information, please see this notice on eBay.

This has been a public service announcement brought to you by Doctordalai.com. Thank you for your attention.

Happy Easter from Doctor Dalai!

I swear this has not been retouched save to eliminate the name of the store manager. I have always been one to promote good relations between peoples of all faiths. We purchased some Easter Chocolate for some friends, but we didn't realize until we left the store just how ecumenical our selection really was. I wonder if my friends will go for the ears first......

The X-Ray Man

It’s 2 AM on a Saturday
The regular crowd is all here
There’s an old man yelling out at me
With dementia he’s had for three years

He says, “Doc will you give me an enema?
You know where the barium goes
I got cramps and the trots
Which I didn’t have lots
When I had a younger man’s hose…”

Oh La La La De De Da
La La, De De Da Da Dum

Read us a film, You’re the X-Ray Man
Read us our film TONIGHT
‘Cause we’re all in the mood for a malady
And CT will make us alright

Now John down in Nukes is a friend of mine
He tries not to wake me ‘till 3
And he’s quick with his V/Q
And then he won’t seek you
Till the ER just won’t let him be
He says, “Doc, they just ordered another one”
“I tried not to do it till 10…
But the patient is dusky and comatose
And probably won’t live until then.

Oh La La La De De Da
La La, De De Da Da Dum

Read us a film, You’re the X-Ray Man
Read us our film TONIGHT
‘Cause we’re all in the mood for a malady
And CT will make us alright

Paul is our CT Technologist
Who scans like he’s been there for days
And he’s talking with Davy whose CR’s are wavy
But they all pass QC anyway.
And the ward-clerk is practicing medicine
As the waiting-room slowly gets mean
Yes, they’re sharing a drink they call Thunderbird
Which does wonders for liver and spleen

It’s a really slow night for a Saturday,
I’m 63 studies behind
It takes more than my best
To read neck, head, and chest
And abdomen, pelvis, and spine

And the PACS system smokes like a chimney
And the Dictaphone squawks in my ear
And I sit in my chair and stare off in the air
And say, “Man, what am I doin’ here?”

Oh La La La De De Da
La La, De De Da Da Dum

Read us a film, You’re the X-Ray Man
Read us our film TONIGHT
‘Cause we’re all in the mood for a malady
And CT will make us alright