The Bittersweet Life of Clara Bow

Clara Bow

For some reason I became fascinated by the actress Clara Bow. Like so many of the tangents I go off on, this one started with some clips on YouTube. Delving more deeply, I purchased some DVDs and read David Senn’s biography of Clara: Clara Bow, Runnin’ Wild. Clara’s life is both inspiring and sad—a glimpse into a Hollywood sodden with sexism long before the enlightenment of the #MeToo movement.

Clara was born in Brooklyn, New York in 1905. She was born into abject poverty. Her father Robert was a serial philanderer, constantly out of work. Her mother Sarah was mentally ill, probably schizophrenic. She was born in a rat and roach infested tenement, after her mother’s two previous pregancies had resulted in two dead children. Miraculously Clara survived her birth and grew up in the worst of environments: her father absent and her mother becoming more and more unstable and violent. Clara was a tomboy and learned to fend for herself by using her fists. At school she got good grades, but was bullied by classmates who made fun of her stammer. When she was nine years old a sad episode occurred. Her best friend was a little boy named Johnny. He lived in the same tenement and one day she heard him screaming her name. She ran to his room and found him on fire. She used a carpet to put out the fire but he died in her arms. Later in life directors were astounded that Clara could show emotion and cry at will for the camera. She told people that all she had to do was think about her childhood.

Clara’s one escape was the movies. She went to them as often as possible and read the movie magazines. She would imitate Mary Pickford in front of a mirror. In 1921 Motion Picture magazine announced a Fame and Fortune contest with a prize of a part in a motion picture. Over her mother’s objections she entered the contest. Entry required two photographs, and Clara couldn’t afford them. To her gratitude her father paid for the photographs. She had one dress, which she wore to all the try-outs. Photos of some of the contestants were published and when she saw the expensive clothes and jewelry some of them wore she knew her chances were not good. But, oddly enough, it was her acting ability that got her into the finals. She was a totally self-taught actor, but her natural abilities far out-shown her rivals. To her immense surprise and shock, she won the contest.

Sixteen year old Clara was as promised given a part in a movie shot locally on Long Island called Beyond the Rainbow. She invited her friends to the premiere only to be ridiculed by them. Her footage had been cut from the film! Worse, Clara’s mother, who was becoming more and more insane, was incensed that Clara wanted to become a film star. She screamed that Hollywood actresses were whores. Clara awoke one morning with her mother standing over her with a kitchen knife, saying it would be better if Clara were dead than for her to become an actress. Sarah Bow, prone to seizures, then lost consciousness. She died in an asylum shorly thereafter.

Clara had another chance in her second film, Down to the Sea in Ships. In this film she finally appeared on-screen and, although having a secondary role (which included a scene in which she indulges in some realistic fisticuffs—drawing on her tough upbringing), this time she  was definitely noticed by viewers and critics alike. Clara moved to Hollywood, and film after film came out, at least four a year. In short order she was the most sought-after star in Hollywood.  Despite her popularity and all the money she made for the studio,  her agent B.P. Schulberg ruthlessly exploited her. She was the most overworked and underpaid actor in Hollywood. She was also the most unorthodox actor in Hollywood.  She didn’t play the Hollywood games. Stars at the time signed “morality” clauses, and generally gave the impression of being morally upstanding, though in real life they were constantly sleeping around and having affairs. Clara had open liasons with various male stars and directors (including Gary Cooper and Victor Fleming, later the director of The Wizard of Oz) and so she regularly appeared in a bad light in the gossip magazines. Of course the men she went out with didn’t suffer the criticism she did! Clara was unmarried, and the men she went out with, with one exception (a doctor who was on the verge of divorce), were too. Yet since she was so open about her sex life she was widely condemned, generally by hypocrits who were engaging in the same activities, but lying about it.

Nevertheless Clara was loved by the movie-going public. She dyed her hair red with henna and when this fact leaked out, sales of henna went through the roof. Seeing her in the films that survive (about half of her silent films are lost due to neglect) it is no wonder. In her films she makes the other actors look like wooden robots. She is incredibly natural and alive. In her biggest hit, It, she plays a shop girl who has the mysterious quality “It.” In viewing the film, there is no doubt that Clara had “It,” both in the film and in real life. Her appearence is strangely modern. She looks like someone sent back in a time machine from our own time. Her acting is spontaneous and natural. Her face is incredibly expressive, which of course is essential in a silent film. As she is laughing uncontrollably while rolling around in the rotating barrel in Coney Island, it is impossible not to feel a connection with her. Audiences at the time certainly did.

She went through many engagements, but finally married an actor in cowboy movies, Rex Bell, who later became a Nevada politician, in 1932. By this time her short but bright career was already near its end. Her last film was released in 1933. She was only 28 years old. Plagued by scandals, defrauded by her best friend, denied her earned salary by the movie studio because of purported violation of her morality clause, Clara retired early in life. Adding to these factors, she did not like the “talkies”: she was spooked by the microphone over her head (she kept looking up at it, ruining takes) and her Brooklyn accent was criticized, though listening today it’s clear she could suppress it almost completely when needed. Moreover there was mounting evidence of mental illness. She would have outbreaks on the set. She became hypochondriacal. And so she retired forever from film and went to live on a Nevada ranch with her husband, Rex Bell.

Unfortunately, she seems to have inherited her mother’s schizophrenia. She had two children, but in time grew so unstable that her husband separated her from the children and she was institutionalized. Her psychiatric examination revealed more disquieting facts about her childhood.

Clara idolized her father, and supported him when she became a star. Yet it came out that he had repeatedly sexually abused her as a teenager. Her mother, who had repeated called Hollywood actresses whores had herself been a prostitute.

Clara lived out the rest of her life in isolation, accompanied only by a live-in nurse. She attempted suicide. Eventually she died in 1965 of a heart attack. She was alone, except for her nurse.

Today she survives in her films. She was beautiful, and a good and honest person. She personified the 1920’s “flapper” girl, but she was more complex than that. Her life was tragic, but for a brief moment in time her star shone as brightly as few others. It is sad that so many of films are lost, due to the unconscionable neglect of the film studios, who used copyright laws to prevent copies of these films to be made, while at the same time allowing the originals to rot in warehouses. Nevertheless through her films we can still, nearly a century later, get a glimpse of the phenomenon that was Clara Bow.

Hacking the QTc

Long QT, torsade de pointes

The QT interval—a measure of the duration of the overlapping action potentials from two billion ventricular muscle cells—has fascinated physiologists since the dawn of electocardiography.  Too long or too short, it can be a harbinger of ventricular arrhythmias and sudden death. Sensitive to electrolytes, drugs, and autonomic tone, susceptible to congenital ionic channel mutations, difficult to measure (which lead? where does it end? what about the U wave?), and markedly varying with heart rate—the QT interval is clinically important and, at the same time, elusive.  To distill the essence of the QT interval and separate out the volatile heart rate dependent components,  the corrected QT interval (QTc) was devised.   Succumbing like everything else to automation, the QTc has become just another number printed in the upper left corner of a digital electrocardiogram, along with the PR and QRS intervals, the QRS axis, and the patient ID. Lulled into complacency by its automatic generation via algorithm (despite the lurking disquiet engendered by the knowledge that the very same algorithm occasionally reads normal sinus rhythm during complete heart block), few bother to ask: Where does that number come from? What formula was used to derive it?  Is the corrected interval actually correct?

For those who care about such questions, the QT can be manually measured and the QTc calculated. Most use the hoary Bazett formula dating from 1920, relating the QT to the square root of the cardiac cycle length. Some are aware of a few other formulas: Fridericia, Hodges, or Framingham. There are many online and native app QTc calculators–in fact my apps EP Mobile and EP Calipers have built-in calculators for all four formulas. There seems to be little need for yet another QTc calculator app.  Nevertheless I have written one, EP QTc, and I should explain how that came about.

Formulas, formulæ

There are more QT corrective or predictive formulas in the medical literature than you might imagine—at least 40.   Rabkin et al. collected 31 of these formulas and worked out a standard nomenclature and classification scheme. Rabkin does not actually give the mathematical equations involved. In fact, nowhere are these formulas collected in a single source.  And what good are formulas if you can’t apply them?  On a whim I thought it would be interesting to write an app that would calculate the QTc using not just one or four formulas, but all the formulas given by Rabkin. The app would also provide details about each formula and statistics and graphs of the results.  I wasn’t sure who would be interested in such an app (probably no one), but at the same time I saw it as a simple project that might make QTc calculating more fun while putting this mass of QT correction literature into perspective. It turns out, it wasn’t such an easy matter.

Paywalls galore

Starting at the beginning, I looked up Bazett’s original article published in 1920. The only online source for the Bazett article is the Wiley Online library.  The site says the article was first published on October 27,  2006.  No, the article is from 1920, and this is a reprint of the original.   According to US copyright law, anything published before 1923 is in the public domain. I’m sorry, but reprinting an article that is in the public domain does not restart the copyright clock.  Nevertheless, the only way to get a digital copy of this historically important article is to pay an extortion fee of $38 to the wily racketeers at Wiley who have managed to kidnap this article and hold it hostage for almost a century.

What was true of Bazett was also true of the vast majority of the articles I was seeking.  The QT correction literature like most science is locked up behind paywalls.  Lacking institutional access and repelled by the idea of shelling out vast quantities of cash for papers many of which were in the public domain, I faced a major obstacle. Fortunately I enlisted some colleagues with digital library access to help liberate these publications, and I eventually managed to get nearly all the primary sources for the different QT formulas.  Beyond these paywalls, there were other lesser hurtles to leap over, but we’ll get to them later.  In the meantime, you may be asking…

What’s wrong with Bazett?

Most every QTc calculator uses the Bazett formula. Why not? It’s simple and can be solved with any device (slide rule or something more advanced perhaps) that does square roots. It was the first QTc formula developed. So why were 30 or more other investigators dissatisfied with Bazett and felt the need to develop their own formulas? What’s wrong with classic Bazett?

Reading the original Bazett article is interesting (though still not worth $38). We travel back to a simpler time when the ECG was relatively new, and the only leads were I, II, and III.  Bazett was interested in the dependence of the duration of mechanical systole on heart rate, and, lo, this particular interval on the ECG, the QT, seemed like a good surrogate to study this. Professor Bazett was able to gather a grand total of 39 healthy subjects, 20 men and 19 women, aged 14 to 53 (though one subject’s age is listed merely as “Boy”) and measure their heart rates and QT intervals.  In some cases individual values were given, in others averages of several values were used. Several  subjects were not his own, but data borrowed from Dr. Thomas Lewis. From this small selection of messy data points Bazett came up with what is still considered the gold standard QTc formula used today:

QTc = QT/√RR.

QTc or QTp?

Well, not exactly. Bazett and most of the early investigators did not create QTc formulas, i.e. formulas intended to give an idealized QT interval independent of heart rate. Bazett and his colleagues were interested in predicting what the QT interval should be at different heart rates. This is the QTp, the predicted QT interval.1 Bazett’s published formula was:

QT = K √RR where K = 0.37 for men and 0.40 for women with units in secs

Similarly the Fridericia formula, also published in 1920 was:

QT = 8.22 ∛RR with units in 0.01 sec

Yes, you read that right. The units are hundreds of seconds. Ugh.

As it turns out one can mathematically convert any QTp formula to a QTc formula, given the assumption that the QTc is independent of heart rate and the QTc equals the QTp at a heart rate of 60. The process is left as an exercise for the reader :).  Later authors took the Bazett, Friedericia and many other QTp formulas and converted them to clinically more useful QTc formulas.

In search of a better Bazett

No one was able to reproduce Bazett’s results. Many authors found that Bazett’s QTc formula tended to overcorrect the measured QT interval at high heart rates, and undercorrect it at low heart rates (e.g. see here). Certainly with such a low N and primitive methodology, Bazett may have mischaracterized the QT vs RR curve. Perhaps the exponent in the formula is not 0.5, or perhaps relating the QT to a power of the RR is not even the right kind of function to use.  The disturbing fact is that each group of investigators who has studied the relationship between the QT interval and heart rate has come up with a different formula.

Linear, power, logarithmic, exponential—oh my!

In reviewing the QT papers, including some studies using 10s of thousands of patients, it is remarkable how inconsistent the findings are with regard to the shape of the QT vs RR curve. Some authors find a straight line, with a linear function underpinning the relationship. Others find curvature at either end of the heart rate spectrum.  The resultant equations are sometimes logarithmic or exponential.

Rabkin uses a classification that I used in the EP QTc app.

ClassificationQTpQTc
linearQT = b + a*RR QTc = QT + a(1-RR)
rationalQT = b + a/RR QTc = QT + a(1/RR - 1)
powerQT = b RR^aQTc = QT/RR^a
logarithmicQT = b + a*ln(RR) QTc = QT - a*ln(RR)
exponentialQT = b + a*e^-RR QTc = QT + a*(e^-RR - 1/e)

(* = multiplication, ^ = raised to the power.  Table modified from Malik et al.)

This table also shows how each QTp formula can be converted to a QTc formula. Any QTp formula can be converted to a QTc formula, so theoretically there are as many QTc formulas as QTp formulas.  Rabkin lists many more QTp formulas than QTc formulas.  Evidently in many cases the conversion has not been considered worth the effort to do.

Typos and unit confusion

Back to the vicissitudes of creating the EP QTc app.  The tale of woe continues with multitudes of typographical errors in the sources and inconsistency of units in the formulas. Typos include mistranscribing formulas in secondary sources (e.g. reading 7 instead of 1 in a tiny exponent), rounding errors, and just plain poor proofreading. I will not mention specific sources, but these types of mistakes seem to be common in the medical literature.  Sure glad we’re paying those publishers all that money for quality control.

As to unit confusion, we already alluded to the use of 0.01 sec as the base unit in the Fridericia formula. Various authors use heart rate as opposed to cycle length in their formulas.  They are inversely related and the use of different terms makes it hard to compare formulas to each other.   Adding to the confusion is that formulas almost invariably use an RR interval measured in seconds, but then sometimes in the same formula require a QT in milliseconds.   Sometimes the units used for the dependent variables aren’t made clear.   Most authors also don’t seem to realize that the results of non-linear QTc formulas aren’t really in units of sec or msec. For example, Bazett QTc units are sec/√sec, i.e. √sec (or worse, msec/√sec).  To be fair, I sidestep this issue in the EP QTc app as well.  To my mind this unit confusion just emphasizes what an artificial thing a QTc is.

Nomenclature

Having obtained sources for all the formulas mentioned in Rabkin (and a few more), I applied Rabkin’s proposed nomenclature. This consists of a 6 letter code for each formula: the first 3 letters QTc or QTp, and the last three based on the first author’s last name. Thus Bazett’s QTc formula is QTcBZT. The Framingham study QTc formula, less well known by its first author (Sagie) is QTcFRM. There are some inconsistencies in the nomenclature which I have tried to correct. For example, Kligfield’s formula is given as QTpKLN in Rabkin, since Kligfield is misspelled as Klingfield. Oh well.

Sex and age

Some formulas differ depending on the sex or age of the subject, or both. The QT interval tends to increase with age and is longer in adult women. So some formulas require entering the age and/or sex. These formulas will simply refuse to give a result if these parameters aren’t present.

A tough question is how to apply QT formulas to subjects that don’t match the study population. I excluded formulas that were derived only from children. All of the study populations are predominantly based on adults, but in a few children were also included. Some studies used men only as subjects.  Is it reasonable to apply a formula derived from data from only men to a woman? In the EP QTc app I avoid such issues and leave it up to the user to deal with this question.

What is normal?

Here is another Pandora’s Box. Just as there are many QTc formulas, there are many papers dealing with establishing the normal QTc. Given syndromes of sudden death related to short QT intervals, both boundaries of normal need to be considered. I have gathered these papers together along with their QT interval cutoffs. These are often sex-specific, and sometimes gradations of abnormality are assigned, e.g. borderline and abnormal, or mildly, moderately, or severely prolonged. In the app the user can select from among these published criteria to define whether a result is normal or not.  In practical clinical use, the QTc interval is only one component in the risk scales needed to establish the diagnosis of long or short QT syndrome.

What about QTp intervals?

By definition a QTp interval is normal. Rabkin proposes that, since QTp formulas were derived from multiple different populations, QT intervals outside the range of all defined QTp intervals may be considered abnormal. I have implemented this algorithm in the EP QTc app. One objection to this approach is that QTp formulas (with some exceptions) give mean values for normal QT intervals.  Thus one would expect the range of normal QT intervals to be somewhat larger than the range of all possible QTp intervals. One should probably take this into account when interpreting the QT vs QTp interval statistics and graphs.

QT library and EP QTc app

All of the data on QTc and QTp formulas have been incorporated into a QTc library. This library is open source and free to use. It can be used with any iOS or macOS project. The library includes functions that make it easy to calculate the QTc or QTp by any formula, using any input (RR or heart rate, sec or msec). In addition information such as references and DOI links, notes, equations, and study populations can be easily assessed. For technical use of the QTc library see the README.

The EP QTc app was originally intended just as a demo app for the QTc library, but it has numerous features making it useful in its own right. Use it to calculate the QTc and QTp using 33 formulas. Graph and do statistics on the results. Copy the results to spreadsheet programs. Options to change precision, sort the results, use different QTc cutoffs from the literature and others are all available.  The source code is on GitHub, and I hope the app will soon be on the Apple App Store.

Finale

I’m not sure who will use the EP QTc app. Maybe no one. It is certainly overkill. If you just want an occasional Bazett QTc it may not be worth it. If you want to explore this minor corner of the literature further, it may interest you. At worst, you can at least impress your friends when you tell them the QTpMRR for your patient.

Some screenshots

Main calculator screen
QTc graph
Statistics screen
QTc results screen
Details screen
QTc limits screen
QT, QTp vs heart rate
Preferences screen
QTp graph

Cruises, Then and Now

The old Nieuw Amsterdam. Source: Public Domain, https://en.wikipedia.org/w/index.php?curid=11689010

[Author’s Note:  This post got completely garbled when I tried to transmit it to the server using the terrible shipboard internet service in the middle of the Pacific Ocean.  If you tried to read it before and gave up, convinced I had downed a few too many Bloody Marys, you might want to give it another shot.]

As I write this I am in the middle of the Pacific Ocean, just east of Hawaii, heading home on the final leg of a cruise on the Star Princess, 5 days from landfall. I am not an expert on cruising, as I found out during dinner conversations with other passengers, who casually admitted that this was their 20th cruise. Nevertheless I have bookended my life with cruises, starting out when I was a child, and ending up in my retirement. In between was work, and no time for chunks of vacation taking up more than a week of my time. But I do have fond albeit remote memories of those old ships and cruises, and would like to compare and contrast that era with today.

Back in the 50s, 60s, and 70s, I traveled transatlantically or cruised in the Carribean on the Homeric, the Nieuw Amsterdam, the Rotterdam, and the Queen Elizabeth II. The Nieuw Amsterdam was the ship I went on the most, going on two Carribean cruises in the 1960s and a transatlantic crossing around 1970, just before it was retired from service. It was a vessel built in the 1930s and is typical of the design of the older ships. Staterooms were below, with portholes, not balconies. The public areas of the ship were on the superstructure: the Promenade Deck, Sun Deck, Lido Deck, and the like. The dining room was located in the middle of the ship, without windows, at the center of gravity to minimize rocking and presumably broken plates. Over the dining area a string quartet played on a little balcony. The ship had a gray and white hull, with two yellow, green and white striped stacks. It was a beautiful ship–seaworthy and sleek in design, unlike the topheavy behemoths of today.

In the public areas were shops, lounges, a movie theater, and a dance floor. There was no continuous buffet as is de rigeur on current ships. Nevertheless there were little buffets around the ship and no lack of food. There was no lack of activities, sports, and entertainment. In what would be considered an environmental horror today, I remember my father driving golf balls off the deck of the ship in a competition to see who had the best golf swing.

There was an open deck on which you could circumnavigate the ship and get fresh air, and a similar deck below, the Promenade Deck, on which you could do the same while protected from the wind and cold by windows. On this deck were pingpong tables and places to sit and play card or board games. I remember on my first cruise circa 1960 all the crew and sailors were Dutch (this was the Holland-America line), but even by 5 years later the economics of cheap labor had replaced them with crew from Thailand and Indonesia. Today the crew stem mostly from the Philippines and Eastern Europe, though the officers on this particular ship are Italian for some reason.

In contrast to the sleek ships of yesteryear, today’s ships are squat and topheavy with row after row of balconies. I like having a balcony (I am sitting on it now, watching the waves go by), but the result is an ugly ship. Life on the modern cruise ship is centered around the buffet, which operates non-stop and is always filled with people. Eating, drinking, and more eating and drinking seem to be the major activities on board. Because of the design of the ship, there is no deck that you can walk all the way around in the open air, without climbing up and down stairways. There is no Promenade Deck in the traditional sense. However, despite these changes over the years, the ocean is still the same, magnificent and mysterious. It has a vast calming influence and makes it all worth while.

Of the different modern cruise lines I have been on, Princess, Royal Carribean, Celebrity, and Cunard, only Cunard makes an attempt to uphold the sailing traditions of old. My experience is based on their ship the Queen Mary 2 (QM2), on which I have made several transatlantic crossings since retiring. The ship has clean lines and a better design. There are balcony decks, but there is also a deck around which you can walk in a continuous circle in the open. The ship has a large, beautiful library with comfortable chairs that face windows overlooking the sea. The ship I am on now, the Star Princess, has a puny library with just a handful of books. The QM2 has a tasteful decor, with less kitsch than usual. Overall it feels more like a real ship than a floating hotel, or floating buffet.

Make no mistake, I’m not complaining (too much)! Being gently rocked by the silvery Pacific Ocean and listening to the white noise of the waves is akin to Paradise. So enough of this! Back to the buffet!

Cutting Down on Coffee

Not coffee

This morning as I write this, there is on my desk a steaming hot cup of fake coffee. The ingredients are roasted barley, roasted malt barley, roasted chicory, and roasted rye. This is the sort of stuff people drank as a coffee substitute during wartime rationing. It smells odd. It is hot and black and looks like coffee. It tastes kind of meh–not bad, not good.  It has a depression era vibe.

As someone whose very life energy used to be fueled by coffee, the transition from coffee to not-coffee was difficult. I drank at least 5 or 6 cups per day. When I was working as a physician I depended on it to keep going. I usually took it black, never added sugar, and completely eschewed Starbucks overwrought concoctions. I loved simple espresso based drinks, particularly Americanos, but, like a true addict, any bottom of the pot leftover coffee would do the trick. But then I was forced to go cold-turkey.

I was having some epigastric pains. The doctor told me to cut out coffee and spicy foods (that’s another saga). So I did.

The day after I quit coffee was filled with headaches and fatigue. The next day was a little better. By the third day I felt fine.

After quitting coffee and a course of omeprazole, my stomach felt better. I also felt pretty good energy-wise sans caffeine. So I cautiously reintroduced some coffee into my life.

I don’t drink it every day. When I do drink it I limit myself to one or two cups. Afterwards I feel a distinct “high” that I hadn’t really appreciated when I was a chronic imbiber. In the past I drank coffee just to feel normal. Doubtless I had built up a tolerance to it. If I didn’t drink it I felt bad.

Now when I don’t drink it I feel normal. When I do drink it I feel a burst of energy. But I don’t need to feel that way all the time. So most of the time I am drinking a coffee substitute or an herbal tea rather than coffee. It works for me.

Your mileage may vary.

The Death of Dr. Shock

Dr. Shock
By Source (WP:NFCC#4), Fair use, https://en.wikipedia.org/w/index.php?curid=38480846

The call came from one of my attendings at night during my cardiology fellowship. It had a touch of the black humor that medical persons don’t like to admit bubbles up to the surface from time to time.

“You know Dr. Shock, the guy on TV? He’s being transferred. He’s having a big infarct and is in cardiogenic shock.”

I was at home. I quickly pulled myself together and got into my car to drive to the hospital. During the drive I reflected on the call.

Of course I knew who Dr. Shock was. He was a staple on local Philadelphia UHF television. Back in the 1960s and 70s, before cable TV with its hundreds of channels, there was just broadcast TV. In Philadelphia I still remember the channels: 3 (NBC), 6 (ABC), 10 (CBS), and 12 (PBS). However, beyond this VHF set of channels there was also UHF TV. Instead of the usual rabbit-ears antenna, these channels used a circular antenna. They also tended to be fuzzy and staticky. The shows were low budget and local, but well worth watching after school as a kid growing up in the Philadelphia suburbs. Local TV personality Wee Willie Webber introduced me to Ultraman and 8th Man on his show. Sally Starr presented Popeye cartoons and Three Stooges shorts.  Dr. Shock hosted Horror Theater while prancing around in a Dracula get-up and presented old black and white monster movies. He was a funny, silly host, defusing the scariness of the movies in a tongue-in-cheek manner that later hosts, like Elivra, Mistress of the Dark, and Joel and Mike in Mystery Science Theater 3000 would come to perfect. So, yeah, I certainly knew who Dr. Shock was.

When I saw him in the hospital, I myself was shocked. This was a young looking man. Without his makeup, he didn’t at all resemble TV’s Dr. Shock. I found out his real name was Joseph Zawislak. He was just 42 years old. He was in the CCU with a big MI and low blood pressure. He shook my hand and was polite, dignified, and deferential. “Do what you can, Doc.” I had been directed by my attending to place a Swan-Ganz catheter.

This was 1979. I was a first year cardiology fellow. There wasn’t a whole lot we could do for someone in cardiogenic shock from a big myocardial infaction back then. It was the dawn of the thrombolytic and angioplasty age and those treatments were not readily available. Infact size limitation was all the rage, using nitrates, balloon pumps, and various magic potions. Practically speaking though, a large infarct with cardiogenic shock was usually a death sentence.

So it was that poor Dr. Shock arrested that night and couldn’t be resuscitated. Now, almost 40 years later, after so many forgotten patient interactions, I still remember him and that night clearly.

The End of Cardiostim

A few days ago I received an announcement by email that the Cardiostim meeting for 2018 has been cancelled. The Cardiostim website confirms this, and it looks like the meeting is gone for good.

Back in June, 2000, while still an academic electrophysiologist at the University of Colorado, I attended my first Cardiostim meeting in Nice, France. I loved it. The beautiful weather, the azure Mediterranean, the restaurants and cafés, and the charm of “Old Nice” were a relaxing break from work. The abstract presentations, poster sessions, and workshops were not too different from those of the Heart Rhythm Society back home, though obviously the European influence was greater. For good or ill, the lack of an FDA meant the Europeans got to play with new technology sooner than we did. Sure, industry was there in a large hall with all their exhibits, just like at HRS. But when they realized I was an American they didn’t really bother me. Their targets were the Europeans.

An electrophysiologist in Nice

The coffee, bread, and pastries were excellent.

Two years later, I brought a couple of my fellows with me back to Cardiostim. They presented a poster and a couple of abstracts. I went swimming out to the buoys off-shore. I ran a 5K sponsored by Biosense-Webster along the Promenade des Anglais. It was a great experience for the fellows and another enjoyable visit for me.

In 2003 I went into private practice with a large cardiology group in Kentucky. Nevertheless in 2004, and every two years after that (the meeting was biannual), I attended Cardiostim. Along the way I dumped HRS, tired of the conflict of interest between its mission to represent electrophysiologists and its industry support, whose goal was to expand device implantation by recruiting non-electrophysiologists to implant. And so Cardiostim became a biannual bright spot to look forward to during the drudgery of private practice.

The last Cardiostim I attended was in 2012. In 2014 I returned to Nice during Cardiostim, but I didn’t attend the meetings. I had retired from medicine. Nevertheless it was fun to see the city invaded one more time by the nerdy guys in their blue blazers (and women in equivalent uniforms) carrying their Cardiostim bags. It was clear the electrophysiologists were in town.

Cardiostim swag

In 2016 I didn’t visit during Cardiostim.   Later that year, in November,  I was in Villefranche-sur-mer, the town next door, at the Institut Français, pursuing my post-retirement goal of learning French. The Institut had fewer than their usual number of students that year. Enrollment had dropped after the terrorist truck attack in Nice on Bastille Day. That had occurred after Cardiostim. We visited Nice. Hundreds of hand-made memorials had been placed in a park adjacent to the Promenade des Anglais. The Promenade itself was in disarray. Areas of fencing and pavement were being repaired. New pylons were being put up, as an after-the-fact defence against a sickness that can’t be cured by putting up pylons. Nevertheless people were stretched out on the rocky beach as usual, joggers and cyclists plied the pavement, and business carried on as usual.  Although this attack had nothing to do with the end of Cardiostim (which was apparently due to Europace splitting off from them and lack of industry support), it seems like a sad coincidence that the meeting died after that vile attack.

So, goodbye Cardiostim.  Thanks for the memories.

Informal memorial to the Bastille Day victims
Nice on the Côte d’Azur
Cardiostim

Tips for using your cellphone

A cellphone

Congratulations on your purchase of a new cellphone! While this tiny rectangle of metal and glass may not look like much, you will soon find yourself drawn into its world  —  inexorably. So as not to become one of those zombie cellphone users you see around you, crashing their cars, walking off cliffs, and ruining friendships, we have some tips for you. What’s that? This is your 10th cellphone purchase? Well pay attention, sonny boy, you might learn something too.

Like all technologies, cellphones are neither good nor evil. It is how they are used that matters. True, there are certain technologies, like nuclear weapons and cellphones, for which finding good uses is a bit of a stretch. Nevertheless we will try.

  • Waste time more efficiently
    You’re stuck in the waiting room at the doctor’s office. Go ahead and use your cellphone. It’s got to be better than that tattered June 2010 edition of People Magazine.
  • Read good stuff
    Millions of books, articles, online courses, and other good stuff are available to read via your cellphone. Use it to learn. Avoid mindless social media and amateur videos. If you’re going to walk off a cliff, do it while reading Tolstoy instead of while perusing cat videos.
  • Push vs Pull
    Alexander Graham Bell’s telephone was the first disrupting — no, interrupting — technology created (thank you very much!), and the cellphone is a much more malignant interrupter. Not only is it already a telephone, liable to go off at any moment — and unlike an old-fashioned telephone you can’t go outside to escape it — but it will also cheerfully beep or ping or vibrate incessantly with so-called “push notifications.” You need to set limits. Who’s the boss here: you or the cellphone? Do you really need to be alerted to the astounding fact that so-and-so, someone you’ve forgotten about, has finally tweeted something after not tweeting for a long time? Push notifications are usually on by default, and need to be turned off for each app, which is a pain. Nevertheless it is worth the effort to do so. Short of North Korea declaring war on the US, these notifications can wait until you decide you want to check them.
  • Don’t be rude, there are other people out there
    Long ago, at the dawn of the cellphone age, I saw a woman at the train station seemingly talking to herself in the middle of a crowd of people. I thought she was schizophrenic, talking to an imaginery person. Now such a sight is common, and people share their end of a private conversation with abandon in the midst of a crowd of perfect strangers via their cellphone plus or minus some bluetooth accessory. Don’t do this.
  • Put it away
    Two people at a restaurant. Man and woman. A lovely couple. Ignoring each other while fully mesmerized by their cellphones. This scene is repeated everywhere thousands of times a day. Why? Even if the other person is more boring than a cat video, can’t you at least pretend to be a human being who still is interested in others of your species?

It is hoped that by following the guidelines above, you will remain a sane and productive cellphone user.

George Mines and the Impermanence of Knowledge

George Mines

It was a chilly Fall morning in Montreal. A Saturday, the campus of McGill University was quiet. Students, not much different in 1914 from those of today, were sleeping off their Friday night activities. A cleaning woman entered the Physiology Laboratory to dust the glassware and wash the floors. As she turned a corner she was startled to see a young dark-haired man, sitting in a chair. She recognized Professor Mines, the handsome English scientist whom she had often seen working in the laboratory at odd hours. He appeared to be sleeping. His shirt was open and a strange apparatus was strapped to his chest. Rubber tubing stretched from this apparatus to a table filled with equipment next to him. A smoked paper drum rotated slowly. The needle of the drum was motionless, then suddenly jumped. Startled, she let out a little gasp. “Professor, Professor,” she called out. “Are you alright?” She noted he looked very pale, deathly so. She touched his hand. It was cold.

She ran to get help. The police took Professor George Mines to the hospital. There he briefly regained consciousness, but not long enough for him to explain what had happened. He died later that day. He was 29 years old. During his brief life, he used animal models to describe the physiology of reentry in the heart. He described the mechanism of supraventricular tachycardia in Wolff-Parkinson-White Syndrome long before that syndrome was described. He used a telegraph key to deliver timed electrical shocks to rabbit hearts, inducing ventricular fibrillation which he described without the benefit of an electrocardiogram. He thus was the first to report the existence of the ventricular vulnerable period. Despite all this amazing work, much of what he discovered was little noted at the time, until “rediscovered” by later researchers.

It seems likely that he was the first to induce arrhythmias in a human, long before the field of clinical cardiac electrophysiology. Unfortunately that human was himself, and the result was his own death.

The published papers of George Mines are fascinating to read. His very primitive equipment by today’s standards was more than compensated for by his remarkable ingenuity and keen powers of observation and reasoning.  He described the relationships between conduction velocity and refractoriness in reentry, the existence of an excitable gap, and deduced the reentrant nature of ventricular fibrillation. In one memorable experiment he cut fibrillating tissue into larger and larger loops until he was left with just one circulating wavefront. Amazing stuff! What more would he have accomplished had his life not been cut short?

Back in the days before the Internet, I used to keep photocopies of medical articles in a file cabinet (actually several large file cabinets). In those days of academia I enjoyed going to the stacks of the medical library and randomly reading articles from old bound journals, some dating back to the 19th century.  I learned a lot.  One thing I learned was that science has a problem with collective amnesia.  Discoveries are often forgotten or ignored, only to be rediscovered years later.

Nowadays everything is online. Or is it? Recently I wanted to look up Bazett’s original article on correcting the QT interval for heart rate. It was published in Heart in 1920 (Bazett HC. (1920). “An analysis of the time-relations of electrocardiograms”. Heart (7): 353–370.) These old volumes of Heart have not been digitized and are not online. Such a famous article though is surely reprinted? Indeed it is, on the Wiley Online Library site. I can get a copy of the PDF for $38. Absurd! An article from 1920 costs $38!

Here we see the bitrot of science, the impermanence of knowledge. On the one hand, modern scientific research is largely hidden behind a paywall, so that the poor (in the financial sense) reader must rely on abstracts, news reports, online sites such as Medscape, and presentations at medical meetings to keep up-to-date, instead of a careful reading of research methods and results. On the other hand, our precious scientific heritage, the published papers of previous generations, remains largely undigitized, residing in the dusty stacks of libraries, increasingly ignored by newer generations to whom nothing matters if it is not online. There are some exceptions. The Journal of Physiology has digitized all of its content back to Volume 1 from 1878. But most publishers haven’t bothered doing this.

At least half of early films have been lost. Early TV archives, like those of Dr. Who were routinely destroyed or copied over, resulting in loss of these shows forever. The situation is not so dire with old scientific research. The libraries will remain for a long time, and paper has a good half-life. But the beautiful work of George Mines and those like him, the true pioneers of medicine, will remain largely obscure to future generations unless that work is available online.

Perhaps some portion of the $38 for a PDF copy of a 1920 article could go to that cause.

The Smartphone is an Essential Medical Instrument

The storage capacity of the human mind is amazing. One estimate of the size of the brain’s “RAM” is as high as  2.5 petabytes (a million gigabytes). The number is based on the total number of neurons in the brain and the total number of possible connections per neuron. I suspect it is an overestimate, given the vagaries and innate inefficiency of biological systems. Nevertheless the true figure is undoubtedly impressive. But not infinite.

There are well-documented feats of human memory and calculating prowess. Ancient Greeks could memorize and recite the epic poems of Homer. Indeed this was how the Iliad and the Odyssey were passed down for generations before the Greeks acquired writing. Savants can quickly perform cube roots of long integers or have memorized pi to over 20,000 decimal places. Musical prodigies like Mozart or geniuses like Einstein impress us with the capabilities of their brains. Yet for the average person who has trouble memorizing a shopping list, these stellar examples of mental fortitude provide little solace. The old myth that we are only using 10% of our brain capacity has been debunked . So unless you’re willing to believe the combination kelp-Ginkgo-biloba-blueberry supplement you heard about on the radio is really going to work, you are pretty well stuck with the brain and memory capacity you have right now. At least until things get worse as you get older.

While the brain’s capacity may increase due to evolutionary forces over the next few thousands years (or not, see the movie Idiocracy), the amount of information that it is required to hold is not constrained by such a slow process. According to one source , there are now over 50 million scientific publications, with about 2.5 million new articles published each year. There is a 4-5% increase in the number of publishing scientists per year. No one can absorb all this. The days of the “Renaissance Man” who could quote Bulwer-Lytton while relating the latest experimental data from Maxwell and then play a Bach fugue while giving a dissertation on Baroque counterpoint are long gone. So what’s a 21st century scientist (or physician) to do?

One thing we should not do is to attempt to memorize everything. It is important to off-load as much information from our brains as possible. Our brains need to be more like an index than a database. We need to know what information we are looking for and where to find it. Information that we use all the time is automatically memorized and we don’t have to look it up. But a lot of information that we don’t use frequently is better off external to our brains. As long as it is easily retrievable, it will be available. Better to look something up that we are unsure about, such as a drug dose, than hazard a guess and be wrong.

Fortunately we live in an era when we can implement this strategy very easily. We carry smartphones that are constantly connected to the Internet. All the data we need is at our fingertips and incredibly easy to look up. Similarly we can store data on these devices for later retrieval. This constant availability of information makes life easier for doctors and undoubtedly makes for better patient care because of decreased mistakes due to memory errors.

There are those who would argue that relying on these devices is a crutch, and any good doctor wouldn’t need them. What would happen if a doctor’s plane crash landed on some remote island, where there were no charging ports? How could that doctor function?

I think it’s time to put aside such nay-saying and embrace our digital assistants. These devices are our tools, as essential to modern medicine as ultrasounds, blood tests, and MRI scanners. Take away any of these tools, and doctors will be limited in what they can do. We should be proud of the impressive technology that allows us to carry powerful computers in our pockets, and we shouldn’t be ashamed to use them.

Notwithstanding the above, medical board certification is still old-school, rooted in that outmoded 19th century Renaissance Man philosophy that doctors should hold everything in their heads. Certainly some medical board questions are practical and test things all doctors should know. But thrown into the mix are a lot of obscure questions about obscure facts that may be difficult to regurgitate during a testing session, but would be easy to look up online in a few seconds in a real-world setting. So, do these tests actually test one’s abilities as a real-world practicing doctor armed with modern information technology or are they just a particularly arcane version of Trivial Pursuit?

I’ll leave the answer to this question as an exercise for the reader.

Trying Out Vim Using Emacs Evil Mode

After using the text editor Emacs for over 20 years, and after listening to debates on the merits of Emacs vs Vi/Vim  (henceforth in this post referred to as simply “Vim”) for at least as many years, I decided that I wanted to give Vim a try. To be fair, I had used Vim before, but, also to be fair, I had never tried to master it or given it a real chance. I knew enough Vim keybindings (the “hjkl” keys and “ZZ” to save and quit) to get by when editing a file via a remote terminal. But I had never taken the time to really learn Vim to the point that it would be an efficient text editor for me. And I certainly didn’t want to abandon Emacs, mostly because of Org mode  the best organizational tool there is, and Magit , the best Git interface there is. Nevertheless the constant key-chording of Emacs, which uses control key combinations for most editing tasks, continued to be awkward despite many years of practice. The question kept coming up: was using Vim a better way to edit text?

My initial resistance to Vim was not just because I liked Emacs. Vim is a modal text editor, so-called because entering text and editing text require changing modes. Moreover, the “Normal” mode in Vim is the text editing mode. To actually enter text, you use a keyboard command to switch to “Insert” mode. To return to Normal mode, you use the Escape key. So you use the Escape key a lot. On my Mac keyboard, the Escape key is located at the top corner of the keyboard, a tiny sliver of a key that is several inches away from my left pinky. New MacBooks don’t even have a dedicated Escape key anymore.

The modal concept caused problems in my prior limited use of Vim. I would constantly forget what mode I was in and start typing in the wrong mode, causing havoc to my text. But still, lots of people used Vim and liked it a lot.

So I started reading more about it. I bought Drew Neil’s book,  Practical Vim, and skimmed through it. Something he said in chapter 2 of the book I found attractive. To paraphrase him, text is to the writer as a painting is to a painter. A painter spends time studying his subject, mixing paints, selecting brushes, and so forth. Only a fraction of time is used to actually apply paint. Likewise a writer, or programmer, spends a lot of time thinking and editing rather than just putting text down on the screen.

While I suspect the analogy appeals more to my vanity, comparing writing to art, than is true (because I think both writers and painters probably spend most of their time applying words or paint to canvas), I think the theory is at least worth trying to put into practice. Editing is what turns mediocre writing into good writing, and what bit of writing wouldn’t benefit from more editing?

Beyond the theoretical, Drew’s book is chock full of examples in which Vim shines as a way to edit text rapidly with a minimum of keystrokes. I had used Emacs’ macros on occasion to do repetitive tasks, but it looked like Vim had the potential to really rev up my editing speed.

Enter Evil mode  for Emacs. Evil mode is an Emacs major mode that transforms Emacs into a Vim clone. You can edit text using Vim keybindings, and still have all other Emacs functionality available. In other words, the best of both worlds. I have been using it for about a week now, and I think it’s great.

It works fine out of the box, but some tweaking always helps. First off, I remapped my Caps Lock key to be the Escape key in my System Preferences. It’s right next door to the “A” key and makes changing modes (referred to as “States” in the Evil manual, since the word “mode” has its own meaning in Emacs) a snap.

Then I added some fixes so that cursor movement with the “hjkl” keys would respect visual lines instead of physical lines, since a lot of my writing uses Emacs word wrap mode. Here is what I inserted into my .emacs file:

;; play with evil mode
(use-package evil
:ensure t
:config
;; make it default, gulp!
(evil-mode 1)
;; Make movement keys work respect visual lines
(define-key evil-normal-state-map (kbd "<remap> <evil-next-line>") 'evil-next-visual-line)
(define-key evil-normal-state-map (kbd "<remap> <evil-previous-line>") 'evil-previous-visual-line)
(define-key evil-motion-state-map (kbd "<remap> <evil-next-line>") 'evil-next-visual-line)
(define-key evil-motion-state-map (kbd "<remap> <evil-previous-line>") 'evil-previous-visual-line)
;; Make horizontal movement cross lines
(setq-default evil-cross-lines t))

Finally, there are some unexpected niceties of Evil mode that makes it perfect for someone wanting to transition to Vim. First of all, it is pretty easy to tell what mode/state you are in because the cursor changes shape and the mode line has a little indicator like so: <N> that indicates the state.

Second, you can easily go back to Emacs keybindings at any time by pressing C-z. The state indicator indicates for Emacs mode. Press C-z again to return to Vim keybindings.

Third, while in Vim Insert mode, a lot of Emacs keybindings work! You can move around with C-f, C-b, M-f, M-b, etc.! So no need to constantly change modes if you don’t want to. I expect I will use this less as I get more used to “The Vim Way,” but it sure is helpful for learning.

Finally, many other Emacs keybindings work too. C-l centers the cursor in the page. I can use C-x C-s to save the file, as opposed to :w in Vim. Of course M-x commands all still work too. And C-g, the Emacs get of jail key, works as well.

So if you want to have the best of both worlds, and bring the editor wars to a peaceful settlement, Evil mode is the answer.

Here is a good talk on YouTube that also contributed to my decision to try Evil mode.