Monday, December 30, 2013

Rash Actions in the ER

Today I am going to grumble just a little.  Working in the ER is interesting.  I can't complain about the wages.  I have good folks to work with and considerable flexibility in my scheduling.  I don't have to wear a suit and tie.  Ever.

But there are some ongoing annoyances and one big one is people who use the ER for things that should be seen in a clinic setting.

I am not talking about that uncomfortable kid with an ear ache at 2am on a Saturday.  I am talking about people turning up, sometimes also at 2am on a Saturday, with a rash they have had for weeks. Or months.  Occasionally for years.

Hear me now, with a few exceptions you should not go to the ER for a rash.

Reasonable exceptions:  widespread poison ivy.  Shingles.  Possible acute allergic reactions.  Rashes that are one component of a potentially bigger disease process - rashes that pop up with a high fever for instance.

But when somebody turns up with some vague spots of uncertain duration and expects me to A) diagnose it B) treat it, and C) give them a note to be off of work, that is inappropriate.

First of all it is not the sort of thing an ER does at all well.  Some of the useful things that could be done elsewhere such as fungal cultures, skin biopsies etc are difficult to impossible to do in an acute setting.  More importantly it is the kind of problem where having the same person see it before and after treatment is key....and doing follow up on a minor problem in the ER is nonsense.  You seldom even see the same doctor twice in a row.

Also I have to function with a computer system that generates prescriptions for me.  It does not even have most of the dermatologic preparations in there.  I have to laboriously free text it all in.  And it hangs up when you try to figure out doses.  "Apply a thin coating" is not in there.  It wants to know how many grams, or ampules, or inhalations or something.

So what you say, Tacitus MD can get a little grumpy when he is sleep deprived.  So sad.

But the real issue is that taking time for this kind of stuff keeps me out of the other rooms down the hall where there often are serious problems developing.  Many people who lack the insight on this epic level are also extremely demanding.  They want that prescription...NOW.  They want that note keeping them off of work for a week....NOW.  I can't show them the sick grandma down the hall who may be developing sepsis.

Although the patients are the immediate source of this problem they are not the entire issue.  Our healthcare system now discourages clinics from dealing with minor acute to sub acute problems.  They are paid best for chronic disease management.  They have to generate numbers that prove they have improved the blood pressure control or the diabetes control of their patient panel by a few percentage points in order to get the bonus money that is supposed to motivate them.  They are not especially interested in whether a person with eczema gets seen in a timely fashion.  Truth be told most of the folks who come in the door of the ER for an extremely minor issue have no intent whatsoever of paying a dime for the service.

Healthcare as a Right.  It is an interesting notion, and one that appeals to the "free stuff" crowd in particular.  But like all rights it can be abused.

Friday, December 27, 2013

Doctor, My Eyes...

In the ER you get all kinds of puzzles to solve.

The history is this:  A woman in her late 60s.  She tells me that while looking at her computer screen she developed a black spot in her central vision.  She looked away from the screen and then experienced a series of odd, glowing triangular shapes in both left and right visual fields, which slowly went over to just the left side, then faded away.

She also had a head ache and some chest pain, although on further questioning both these conditions seemed to have been present for weeks to months.


The patient did not seem to be in any distress.  In fact all her visual symptoms had resolved before her arrival in the ER, and the other symptoms seemed to be either ongoing or perhaps associated with a little anxiety after the visual symptoms.  She was concerned about retinal detachment.  She also suggested that the chest discomfort might be costochondritis.

Observation #1.
Patients who have diagnostic suggestions that specific often have a medical background. But that was not the case here.  In fact, I can generally detect active duty medical personnel at a range of 10 feet.  Retired doctors and nurses I can sense at roughly 50 feet.  The other possibility, as was the case here, is a person who looks a lot of stuff up on the internet.

Observation #2.
Since this involved both eyes there really could not be a local, one eye, problem like retinal detachment. It really had to be something central, in the vision processing areas of the brain.

Observation #3.
This being an ER after all, the words chest pain mean you get an EKG.  Should have been normal.  Totally was.

At this point with the patient cheerful and looking quite well I had to move on to other patients.  I sometimes do this when presented with a bit of a brain can process a few things on the back burner so to speak while doing other tasks.  Sometimes when you get back to the first patient in 10 or 15 minutes you have a theory.

My theory was that this might have been an atypical migraine.  It is very common to get bright geometric shapes as part of the "aura" or prelude to a migraine.  Sometimes the actual headache never turns up.  I tell patients it is sort of like singing the Star Spangled Banner and then not playing the ball game.  The other causes of transient, bilateral visual phenomena of this sort are much less common.  Seizure activity.  A concussion (no injury in this case).  And, er, well, not much else.

So I went back to the patient to put forward my theory.  She had something to tell me.

"I just remembered.  The internet site I was looking at when this all started was a collection of optical illusions!"

A new one for ER visit triggered by visual afterimages.

My job never wants for variety.

Wednesday, December 25, 2013

Merry Christmas 2013

Let's all take a day off from the Internet.

Enjoy your family.

I am anticipating gifts in keeping with my naughty/nice quotient for the year past.


Monday, December 23, 2013

Money - A Tale of Warning

My computer likes to tease me with financial ads.  They range from the laughable Nigerian Prince scams, to the almost as stupid peddlers of penny stocks.

Much of it has a rather alarmist tone to it, along the lines of Billionaire predicts Financial Ruin, which stocks will survive?

All rather nonsensical but to my surprise there is a solid etymological connection between "money" and "warning".

As with quite a few of my stories, it goes back to Rome.

The northern side of the Capitoline Hill was in deep antiquity the place where priests would read the auspices.  This word derives from auspex, which literally means one who looks at birds.  In early times the behaviour of flights of birds was felt to be predictive of the future.  Sometimes it was a favorable read, what we would call auspicious.  Sometimes not.

In 345 BC a certain Marcus Furius Camillus funded the construction on this site of a temple to Juno Moneta.  Things seem a bit muddled at this point.  Moneta might derive from monere which means "to warn".  This would be in keeping with the earlier use of the site.

Moneta could also derive from moneres, the Greek word meaning "alone, apart".  Juno was the wife/consort of Jupiter.  Together they were the highest figures in the Roman pantheon.  Juno being "the only one" for Jupiter sounds great in theory, and in this role she was the Protectress of marriage. Of course Roman gods were not particularly monogamous in this regard....various divine-mortal hybrids such as Hercules being the predictable result.

Another aspect of Roman history reinforces the "warning" aspect of Juno Moneres.  During the first Sack of Rome back in 387 BC a horde of Gauls had overrun the city.  A small band of stalwarts had fortified the Capitoline Hill and were holding out there.  A rugged path was still open for messengers to sneak out and make contact with Roman forces elsewhere.  The Gauls noticed one such messenger and planned a night attack that would approach the summit of the hill by this route.  Their plans were foiled when geese, kept in the temple of Juno, started honking and hissing in warning.

This is a reinforcement of the "warning" aspect of Juno Moneres (who presumably had a temple there prior to 345 BC) with a side helping of predictive bird behaviour.  Incidentally, the dogs who were supposed to be on duty did not bark.  For a very long time afterwards the Romans would have an annual parade where geese were honored and a few dogs were ceremonially crucified.

So where does money figure in to this tale of flapping and hissing omens, and of jilted monogamy?

Probably by accident.  Although Juno became associated with lots of things including the Protectress of funds, the establishment of the first Roman mint at the site of her temple on the Capitoline Hill was likely just a pragmatic recognition of it as a secure and defensible site.  Maybe thieves would be a little extra deterred by the mint being within the sacred precincts of a temple.

From this aspect of Juno Moneta we of course get the word money and all of its relatives.  And if like me you are pondering retirement and hoping that modern day thieves do not rig the stock market, well a few hissing geese would be ok in my book.

Friday, December 20, 2013

Helpful Escape Aid

My boring, high mileage little grey car had a nasty encounter with a patch of ice and a culvert a while back.  So I took the insurance check and bought....a different boring high mileage little grey car. 

I am still figuring out where all the buttons and gadgets are, and this morning I discovered a new feature:

This is obviously inside the trunk.  And if I understand it correctly it is a handle I can grab if I am locked in the trunk, possibly by hoodlums.  After pulling on the handle it appears-if things are to scale-that I will then be able to leap roughly six feet high and ten feet out in my first bound to freedom.

It's made of an interesting shade of plastic that I have in the past associated with "glow in the dark" objects.

Maybe I'll try it out.

Wednesday, December 18, 2013

Stone re-use in a modern "defensive" wall

On ancient and medieval sites you frequently run across older stones recycled into new construction. If you are a worker on anything other than a high profile palace or some such you are just going to use the stone that is easily at hand.  Hmm....lets pull a few off that tumbled down structure over there....

Often this results in the preservation of inscriptions that would otherwise be lost.  Particularly in the late Roman and post Roman era the builders probably had no clue what those scratchy lines on the stones even meant.

I have run across a few such stones when excavating at Vindolanda.  But it was a bit of a surprise to find the same thing going on with the flood control wall around a local creek.  Explanation at the end of the post.

A picturesque view on a very chilly day.

A real hodge-podge of material in this wall.  Polished granite for instance.

Closer to an explanation.  This slab has a depressed area chiseled out.  It looks as if some sort of plaque would have been mounted there.

Hiding under a flow of ice we find a date from the late 1800s.  The flood control wall seems to have been built in the 1920's or so.  The workers used whatever was at hand including left overs from a monument company that had gone out of business.  As the above tombstone has a birth date but no death date one wonders what happened.  Did the sick person unexpectedly rally and recover?  Did the carver screw up and get the first line wrong?  Did the company go out of business on the day this was being worked on?

Way down near ground level is a final tiny enigma.  Not a formal grave stone carving of course, but is it a very inconveniently placed bit of graffiti?  Or perhaps a workers mark from the monument company?

Monday, December 16, 2013

A Mystery Emperor...and his Pigeons

My occasional drinking pal MooseandHobbes gets to have more fun than most people.  In particular I am envious of her opportunities to work with the archaeology of the City of London.  Recently on her blog she posted an image of a very distressed coin that came up on the river bank next to the Tower of London.

The front was quite hopeless:

But as is often the case the reverse was tantalizingly close to legible:

photos courtesy of MooseandHobbes

Allowing for wear and tear, for potential mis-strikes, and for anomalous globs of oxidation, I made a tentative identification of it as being a coin from the usurper Magnus Maximus who held tenuous power over Britain and Gaul from 383 to 388 AD.  For a rationale of my pick, and for some amusing tales of MooseandHobbes as pop music fan girl, visit at MooseandHobbes.

This style of coin had a relatively brief run in Britain.  Constantine the Great reformed the chaos that had become Roman money circa 310 AD.  This style of cheap bronze small change, referred to by numismatists as an AE4, was created then.  And of course Roman currency would no longer have reached London much after 400 AD, when rampaging Goths and Vandals stepped up the assaults that eventually destroyed the Western Empire.  This "Barbarian Apocalypse" was probably to the ancient mind akin to our modern fears of a "Zombie Apocalypse".  Its most dramatic event was the Sack of Rome on August 24th, 410.

But after making a preliminary call of Magnus Maxiumus I find myself back pedaling a bit.  Because honestly, I think this is a closer match:

The placement of TOR in VICTORIA, the odd projection extending up and to the left from the figure's shoulder, the double line behind the figure....looks promising.  One small problem is that this is a coin of Arcadius who was Emperor of the East from 395 to 408.  And Constantinople is a very long ways from London.

But I do not consider this an insurmountable issue.  For those not conversant with the mess that is late Roman history, the last Emperor to hold unified power was Theodosius the Great from 379 to 395. Before his death he made his two sons associate rulers, Arcadius in the east in 383 and his younger brother Honorius in the west in 393.  These two kids were lousy Emperors.  Even recognizing the significant challenges that the Empire was facing, they were the Dumb and Dumber of ancient times. The above coin probably dates from the short time when Theodosius, Arcadius and Honorius were all living and holding office, hence the designation AUGGG, which refers to three Emperors.

Coins of Arcadius do turn up in Britain and Gaul, and from mint marks it is clear that they were made in places like modern day Trier and Lyon.  So coinage from the Eastern Emperor was circulated in the West and vice versa.

But I prefer to think of this as a coin issued under the aegis of Honorius, at that time the junior ruler of the West under his father's combined rule.

Honorius was an inept and indecisive monarch.  When the populace of the isolated province of Britannia desperately called for help he supposedly sent what is called The Rescript of Honorius, telling them they were on their own, and oh, good luck.  (some scholars have serious doubts on the authenticity of this btw).

When the Eternal City, Rome itself was sacked by villainous Goths in 410 Honorius was hiding elsewhere in Italy.  When the terrible news arrived he is said by Procopius to have been feeding his pigeons and only upset until it was made clear to him that it was the city that had been sacked, and that no harm had come to his favorite bird of the same name.  This tale also is considered dubious and by no lesser figure than the great if uncritical historian Gibbon. And Gibbon liked all manner of odd anecdotes. Still, it did inspire a nice painting by John Waterhouse...

So with no legible front I prefer to give our mystery coin over to Honorius. It seems fitting that one of the last coin issues to reach a dying Roman Britain should come from one of history's least vigorous sovereigns.  And in "Honor" of the event I present the Sesame Street re-enactment of the reign of Honorius....

As Rome was being sacked he was "Doin' the (coo! coo!) Pigeon!

Friday, December 13, 2013

Famous ER Quotes - Variations on "Sorry, No."

"Ma'am, I really don't think there are any bugs under the skin of your, er, well I really don't think sticking a needle in there to draw them out is a good idea."


"Sir, I am sympathetic.  But Viagra is generally prescribed by the clinic doctors.  And your list of medications is so long that I am concerned about drug interactions. has only been three weeks since your bypass surgery."


"Look.  We go back quite a ways.  I know you are dealing with some difficult issues.  But you do see how the results of your urine drug screen make it impossible for me to refill those missing prescriptions...."


"The closest tertiary care hospital is 30 minutes by air.  I promise that your member will get there alive.  Your preferred center is at least 90 minutes away.  He won't make it."


I did my medical training at the very tail end of the era where physicians were expected to be the final word in all health care matters.  Now with greater patient autonomy and considerably more bureaucracy that is not always so.  But the isomer of "the doctor is always right" is not "the patient (or in the last instance, the insurance company) is always right".  We need to remember the basic principle of "first do no harm".  Sometimes it has to just be shortened to "no".

Wednesday, December 11, 2013

Why a Duck?

Words interest me.  I am particularly fond of words that morph into several apparently contradictory meanings.  When this happens there is almost always a good story behind them, and in the case of today's tale, one that wends its way through several different languages.

Consider the word Canard.

Literally it is the French word for duck.  So how did we end up with the following:

Canard - a falsehood.  Usually given a bit of pomposity as a "Base Canard".

Canard - a set of small wings on the nose of an aircraft, or generally as an aircraft that has such an atypical configuration.

The aerodynamic sense of the word goes back to the earliest days of powered flight.

Behold the wondrous 1906 Santos-Dumont 14-bis.  This pioneering aircraft "might" have been the first functional heavier than air vehicle.  The dispute between this and the 1903 Wright Flyer seems to be about equally based on Gallic pride and on whether use of launch assistance such as a catapult comprises cheating.

Santos-Dumont remarkably was a Brazilian engineer working in France.  The peculiar design of the craft reflects its origins - it has elements of box kites combined with an engine used on early speedboats. The pilot steered it with a system of wires adapted from a system used on clocks in church towers.  One set attached to the shoulders of his flight suit.

The testing for the 14-bis was all improvisational.  Santos-Dumont first tried simply suspending it from one of his lighter than air inventions, a balloon unimaginatively named "14".  Bis is a French word that means roughly "extra" or "twin".  Since balloon 14 had trouble handling the extra weight Santos-Dumont switched to the high tech expedient of just building a big zip line to run it down. He had a donkey pull the aircraft to the top for test runs.

Ultimately he was able to make a few brief powered flights, sufficient to earn several established aeronautic awards and prizes.  As to the reason that this and similar craft derived from it were referred to as "Canard", well it sure looked like a duck to the average Frenchman of 1906.

This tradition continued for generations.  A 1932 experimental canard equipped aircraft from Focke-Wulf was nicknamed Ente, the German word for duck.  And check out this 1945 craft:

Before going on to create the highly capable line of MiG fighters the Mikoyan-Gurevich factory was tinkering around with various designs including the MiG-8, nicknamed Utka, the Russian word for duck.

So Canard as a term for a duck shaped aircraft makes a bit of sense, even if more recent versions have strayed a bit from the very duck-like 14-bis.  And Canard as a term for falsehood?

That goes back a bit further.  It seems to come from a French saying first documented in the 1850s, but probably going back much further.  Vendre des canards a moitie' means "to half sell a duck"  This refers to a business deal in which the intent is to swindle.  In this it is something along the lines of "selling someone the Brooklyn Bridge", or to the similar market place frauds of selling a pig in a poke with the inevitable denouement of letting the cat out of the bag!

Monday, December 9, 2013

Mercury Made Redundant

Although the subject matter of Detritus of Empire wanders far afield, the origins of this blog relate to archaeology.  Having been for a number of years now a volunteer excavator at the Vindolanda site on Hadrian's Wall I had tried various ways to keep the folks back home up to date on my adventures.  I started out quite modestly, just tapping out a group email each night.  I was writing from a 300 year old pub and using computers that seemed almost as ancient.

But of course technology has changed a great deal since then as has the ease with which information can be transmitted, well, anywhere.

If Mercury, the winged messenger of the gods, was still around he would by now have been laid off. Or as my British friends would have it: made redundant.

A generation ago archaeologists would do painstaking line drawings, take black and white photos that had to be sent to a lab to process, type up their reports by hand and bundle them off to a printing press.

Now in principle anybody with an average cell phone can in real time show an artifact being uncovered...and everyone on earth could watch it happen.  Distant alien civilizations too, one supposes, but they will have to wait a while for the signal to reach them.

This presents us with unprecedented opportunities.  And unexpected challenges.

For every person - paid or volunteer - who actually wields a trowel there must be hundreds, perhaps thousands of armchair enthusiasts.  In theory they can now follow a dig "virtually".  Age, health, geographic distance, job or family obligations....none of these are an impediment any longer.

I have tried when digging to transmit a bit of the flavor of this, as well as giving a few peeks into areas that do not usually get mentioned in popular archaeology.  What kind of fabric is used to cover the site at the end of the season?  What sort of stones are most prized by the guys doing wall consolidation? Can you really hear water running beneath the site after a heavy rain?  And is it from natural channels or from some Roman drainage ducts still functioning 18 centuries after their install?

It is the last sort of musing that can cause problems.

Those of us who blog about active digs are certainly not dummies.  We know not to crow about things like coin hoards that might attract middle of the night metal detector bandits.  We know that apparently significant findings such as new inscriptions are the proper business and privilege of the supervising archaeologists to report.  But on some level beyond that of common sense, the archaeology community seems uncomfortable with the newer, freer exchange of information.

Archaeology is the constant process of wondering what lies a few centimeters further down.  And I think the thing that gives our professional colleagues the most qualms is simply this:  premature speculation.

For good or ill, the internet is spontaneous. Rumors, celebrity gossip, political punditry, it goes on around the clock.

Archaeologists on the other hand work meticulously, one grain of sand at a time.  It may take them several seasons of work to decide whether a series of walls are from the 1st century or the 2nd...and they do not approve of brash whippersnappers who offer quick opinions.  (extra credit question:  do they disapprove more when said whippersnappers are wrong, or when they are right?).

So, blogging and archaeology.  The instantaneous meets the methodical.  Neither side is going to be in their comfort zone.  So which view will win out?  The one that looks to the future or the one that specializes in looking to the past?

Friday, December 6, 2013

An Eye that does not sleep

When the family of J.R.R. Tolkien sold the rights to The Lord of the Rings to the company that ended up making the (quite good really) movie trilogy there was a minor dust up.  Evidently down in the fine print of the contract was a provision that among the other merchandising rights signed away was permission to use the copyrighted material in advertising for gambling.  The deeply religious Professor Tolkien probably turned over in his grave a few times but the contract was signed and was in fact quite specific.

And they meant it too.

I am with the Professor on this one.  Vegas casinos are noisy places, inhabited not by cheerful hobbits but by dead eyed slaves (to their gambling addiction).  I realize that Frodo and company enjoyed a bit of pipe weed when they could get it, but I hardly think the foul stink of Marlboros would be at all the same to them.

No, casinos are no place for the Free Peoples of Middle Earth.  Orcs would manage there.  They would never have to see the sun. And they would constantly be under the watch of the Eye that Does Not Sleep....

"...a well-ordered and well-farmed countryside was their favorite haunt.  They do not and did not understand or like machines more complicated than a forge-bellows, a water-mill or a hand-loom..."

J.R.R. Tolkien "Concerning Hobbits"

Wednesday, December 4, 2013

Las Vegas - Out my window

Vegas is not exactly known for being a subtle, understated place.  They build things big and garish then knock them down to build something bigger and gaudier.

This is soon going to be the world's biggest Ferris Wheel.  It will make the London Eye look puny in comparion.  500 feet tall, when it opens sometime next year you will be able to take a slow 30 min turn on it, seeing glowing neon in all directions.

Here is the view from my hotel window.  For perspective I am on the 16th floor, and am not even near the halfway point of it.

Quite the view from my window.  And looking straight down I could see a couple of street people laying out on cardboard across the avenue from me. Most people pass them by without awareness.  I can't claim to be a "better" person than these marching fun-seekers....but when you are in town for a conference on ER medicine perhaps you can't help but see the side of society that others can look past.

Monday, December 2, 2013

Detritus of Las Vegas

Who knows maybe in some far distant future archaeologists - human or otherwise - will be trying to understand curious ruins from the early 21st century.  Written records will have long since vanished as all information after about 2020 will have been strictly digital and probably not sufficiently backed up. The enigmatic residue of documentation will be heavily skewed towards remarkable pictures of kittens, word fragments such as "LOL", and an encyclopedic body of data regarding the Kardashian family, evidently the ruling caste of this confusing era.

I suppose your average suburban neighborhood will be understandable, if only by repetition.  But what on earth will these hypothetical archaeologists make of Las Vegas?

Personally I think careers will be ruined and friendships severed over the controversy as to whether this in fact was actually the location of Paris.

I'd like to help out these scholars from the far future, so on a recent walk around Las Vegas I picked up various small bits of ephemera.  My only requirement was that the size and shape roughly conform to the famous Vindolanda Tablets that have opened such a personal window into antiquity.

I am pretty sure this does not advertise two for one drink specials

Ok, here we go, the cultural history of Las Vegas on small bits of cardboard:

Yes a product called Snus, that had a malodorous camel as its emblem.  It flat out told you that your teeth would probably fall out.  This could actually be sold.  But you had to knock the price down a bit and perhaps direct your marketing to folks who no longer had cause to worry about tooth loss...

This item will be a poser for them.  Were there actually non alcoholic beverages consumed in Las Paris?  But the dumps on the outskirts of town only contained millions of metric tons of Bud Lite bottles...

craft beer drinkers apparently being extinct by this point in history

Another extremely common artifact from the site are these colorful cards.  The exact commercial transaction being proposed here is not specified, nor is there any indication as to how a price of $47 was arrived at.  I am simply speculating here but one imagines that the slogan "What Happens in Vegas, stays in Vegas" does not apply to micro organisms.  Individuals who want to go for some kind of stupidity trifecta, take note, you can charge whatever this is on any major credit card for your wife or boss to notice.

note wedding ring.  worn at all times

These cards are handed out by shifty looking individuals out on the brightly lit Strip.  There are about two teams per block, more on the weekends.  They are for some reason always a man and a woman.

Vegas does take pride in a sort of free wheeling, uninhibited air.  But underneath it all is simply much that is seedy.  Wander away from the neon for just a hundred yards or so and you find beggars, homeless people, and sterile parking lots beyond which lie the darker and far more modest quarters where the actual workers of Las Vegas live.  Many of them come here with high hopes, with dreams of finding glory and riches at the blackjack table or on the stage.  My final artifact probably was dropped by one such soul, someone whose name I will redact.

A plasma donor card from back home.  I hope they found fame and fortune under the bright
lights.  I hope they did not have to sell anything more precious than blood.