Many thanks to Barbara The Medical Quack.

Medical Quackadryl - talk to your blogger to see if this right for you…

This is fun and just down right silly. Cedra, a clinical research organization created something for fun, so why not, now I have my own drug.  If you have nothing better to do for a few moments, have a little fun.

You can go here to create your own.

[Image Credit]

In a related post a few days later, I answered some questions that had been raised in the comments on the first post.

About our citizens view of abortion. Specifically - Do they think it is ‘okay’?

After 35 years of legal ‘abortion on-demand in India’ (thank you Dr. Flea - the link obviously doesn’t work now. It was to a post by Flea where he linked to my post and used the phrase to describe the situation re. abortion in India) I think the answer is definitely yes. Most Indians think that abortion is ‘okay’. There are people who are anti-abortion (or pro-life in US terms) basically because of their religious beliefs - Catholics, Buddhists, Jains, Orthodox Hindus, etc….

What about Doctors?

Well, Doctors in India have been living in the same sociocultural environment for the past 35 years. So the answer would be that most Doctors in India have accepted ‘abortion on-demand’ as a way of life. I personally know of many obstetricians (especially those dealing with treatment of infertility) who refuse to perform abortions. I am sure there are a large number of such Doctors in India. But there are is a larger group of Doctors for whom an abortion is just another medical procedure - no ethical or moral strings attached.

Here are my conclusions from the first of the older posts.

Living in India I find the whole ‘abortion debate’ thing in the US funny. I’ll hasten to add that I agree totally with Dr. Flea ‘there’s nothing funny about the abortion debate at all’. The humor, if any, is black and is directed at the sad state of affairs in India.

It is surely a sign of a developed nation (I mean that in all the right senses) that a considerable amount of time and human effort is being spent to protect even the unborn child. To quote Rabindranath Tagore’s Gitanjali - ‘Into that heaven of freedom, my Father, let my country awake’.

That last paragraph sounds maudlin and ridiculous to me now. I do not now agree with what I wrote then. I seem to have been a bit more realistic and prescient in the second post.

Abortions can be legally performed in India by any registered medical practitioner in a legally licensed centre. The doctor need not be a specialist (ie, an ObGyn). There is a reason for this kind of an unregulated, ‘free-for-all’ kind of practice. The Government wants to reduce the incidence of illegal abortions - those done at unlicensed centres by untrained persons.

Why do people get illegal abortions performed in such a permissive legal environment? That brings me to the last and most difficult question: ‘is abortion viewed as a form of birth control’. My answer is yes. I will reiterate that the Government’s official line differs. I am sure many of my colleagues will agree with my view.

As a radiologist I have scanned many live and healthy-looking first & early second trimester foetuses that I knew where destined to die. I used to be disturbed… but I guess I’m no longer affected by it. These days, if I do think about it, I console myself with the thought that I am not the one doing the dirty deed. I know that sounds like escapism … but that’s how it stands….

There’s no definite conclusion to this post….

I don’t think there ever will be a definite conclusion to this issue…

That brings me to the purpose of the current post.

When I first read the news about the abortion that the Mehta’s wanted, I thought they had set a dangerous precedent. This is what I wrote then…

To my knowledge, this is the first instance of the judiciary being involved in a decision to abort, which has traditionally been the prerogative of the parents and the treating physicians here in India. I have my own reservations about abortions, especially when they are preformed for treatable congenital anomalies. I am afraid this might become a precedent which could pave the way for an acrimonious debate about abortion as is already seen in the US.

I was not too surprised by the court’s verdict and my personal opinion bears repeating…

My Opinion: Which a lot of medical types in India will share, is that the couple & their doctor made a mistake in approaching the court.

My fears about the acrimony and debate were confirmed in the following days. Everything that I have presented in this post is from blogs. I am sure there are even more vociferous debates on TV talk shows, which I have no way of knowing about as we do not watch TV in our house.

To make this more than a rehash of my own thoughts, I have included here some excerpts from bloggers who have written about this sad case.

Lekhni presents a great analysis in her post Abortion and the Niketa Mehta case, which got a mention in Desipundit. She has linked to other posts [by Mad Momma, Sowmya, Maami & Prerna; all mentioned below]. She raises some important points that are worth reading. I strongly recommend that you read her entire post. Here are a few snippets to whet your interest…

The foetus has a congenital heart defect that would require a permanent pace maker.  This may or may not disable the child for life depending on which version of the same hospital’s report you believe.

The treatment for the disease is expensive. The pacemaker costs Rs 1 lakh [INR 100,000 = US$ 2400] and would have to be changed every 5 years.

People with congenital heart disease and pacemakers don’t really suffer or are disabled, says a 35 year old man in India with a pacemaker since age 9.

The judges offered to have the government pay for the foetus’s lifetime expenses for the pacemaker.  The plaintiffs rejected the offer, saying they did not trust the Government. They seemed to fear that the Government would not deliver on its promise.

Jaslok Hospital in Mumbai has offered to bear the entire expenses for the delivery and post-natal care of the baby. It is not clear if the offer is for the baby’s entire life, though.

There are people willing to pay the expenses of the child, and there are always such a thing as fundraising, so the finance issue alone should not be a cause for aborting the foetus.  Is a child’s life just worth much less than Rs. 1 lakh, then?  If the parents are still not willing to bring up the child, they could always give it up for adoption.  I am sure there would be many (Indian and foreign) parents willing to adopt the child, or donors willing to pay for its medical expenses.

If we continue to take the position that the foetus is an independent legal entity (even though it cannot survive independent of its mother), then extending that argument, by requiring a mother to complete her pregnancy for a foetus she doesn’t want, we are forcing her to provide prenatal care (using her own body) which is not of her own choice, and for which she is obviously not being compensated either.  The question is, is that a fair and just law? Think about it, the only other persons whom the State forces to work without compensation are prisoners.

Lekhni’s final position on this is unequivocally pro-choice.

…the State has no right to force a woman to put all her energy and her life-blood into bearing a baby that she is strongly against carrying to term.  A woman should have the right to make the final decision on very part of her own body.

Here are some more voices from the new media.

Nita asks a pertinent question “Do we need a national debate on our abortion law?” and proves her point with a short comparative analysis of abortion laws around the world.

Our abortion law is a decent one. Sure, the law can and should improve, everything can be improved. I just wonder whether this subject is worthy of a “national debate.”

What’s a good time for you to abort?, Mad Momma asks in her thought-provoking post. She has  linked to some of the other blogs which have related posts.

I might support the court’s decision for a variety of reasons. But I support the parents for one simple reason. No child should have to be born into a home where it isnt wanted. No parent should have to rear a child they dont want because God knows its hard enough for me to rear the two I wanted so badly.

And oh - here’s a question. I wonder what the baby will think of all this debate if it does see the light of day and reads all this someday….

Maami on Abortion and the Indian Woman.

The niggling part is when a pro-abortion country that is grappling with unhealthy abortion practices chooses to put its foot down and turn holy and pro life in the most uncharitable way.

Mrs Mehta went to court hoping that her poor foetus will be spared the cruelty of being born with a congenital defect or moving around with a pacemaker or other life support. The judges have ruled that since there is not enough warning of mental instability or deformity, a congenital heart problem does not qualify for abortion. I can only see her photo with her face buried in her husband’s chest crying after the judge read out his verdict. She wants to know whether she should have just gone to a quack and not expected medical help in a legitimate manner from a civil society. No learned judge has answered her yet. I have also heard of the pro life argument that just as the disabled have a right to live with dignity and all choices within society so also a defective foetus must run its term and be allowed to birth because it has a right to live. It’s indeed a foolishly brave mother who exercises that choice.

Sowmya, who says she wrote this - Abortion at 25 weeks - after reading Maami’s post, is pro-life.

At 25 weeks, it is a child, not a fetus. Somehow addressing it as a fetus makes it a little impersonal and discussing abortion feels more comfortable.

I am not sure how grieving works. Is it more tolerable in an impersonal abortion of the fetus, than in the birth and loss of a child? What can one live with is a big question?

Though Prerna has titled her post Mercy Killing of a Foetus, she is very much pro-choice.

What should a mother do in case congenital heart defect is detected in her unborn child? Watch her child suffer in front of her eyes all her life. The trauma is unimaginable for somebody who hasn’t been through this or witnessed somebody else suffer through such misfortune. The other way is, she goes to her local doctor, and asks her to doctor the pregnancy records. There is a fair chance that she will find a few doctors who will be prepared to do so for various reasons. The doctor will certify that the foetus 19 weeks old and terminate the pregnancy legally.

Which mother would like her child to live on charity? I think the decision to abort in this case arises out of love for the unborn child and not because the parents don’t want to have a child. Watching your child suffer and lead an abnormal life is not easy. A lot of suffering is involved in bringing up an abnormal child. Society in India is not tolerant and encouraging to anyone with disabilities. It is easy to sermonise on morals, ethics and religion but practical life is different. When parents watch their child suffer while other children play merrily, they die a hundred deaths.

The flip side is that if the court ruled in the favour of the Mehtas, it could have been misused. Female foeticide is the cause of worry. But that is happening anyway. People and doctors involved in the gruesome act of female foeticide are doing it illegally and will continue doing so despite the law. Social transformation and political will, not law is required to cure this malaise [I agree emphatically].

Sree writes about her own threatened abortion [For the non-medical readers, 'threatened abortion' is an actual medical term]

I may not really know how it feels to have an abortion, the trauma women go through. The quick decision that need to be made about giving life or saving the baby by letting it go. But I can certainly feel. If I have to say something to a woman who has gone through such times in her life, I would say this: Thankfully you didn’t get to know that person. The tiny little soul who slept in your womb for a while and left peacefully. Maybe s/he understood why.

I’m not against abortion. A woman has every right to let go,if she really knows that she can only offer misery to her child and moreover to herself. One need to be happy oneself to make others happy. Let the reasons be sound.

Here is a hard hitting post from Emancipation of Eve.

As you change nations and boundaries, you realise that facets taken for granted in one country/place are alien to another. Even illegal. And then some facets don’t change.

Like abortion. Or the presumption that brave women have babies and bitches kill theirs. Or sluts.

If a woman is pregnant and lord forbid, she has a miscarriage or loses the baby, her support system will be around her. It was a mother who lost her baby. She is allowed to mourn the loss. But if a girl chooses to terminate the pregnancy, the reactions change. No one considers that she could perhaps mourn the loss too. After all, she chose to kill her baby, didn’t she?

A vehemently pro-life post, No right to kill by Anil Thakraney. I don’t agree with most of what he has written. I take particular exception to this statement…

Under no circumstances must technology be allowed to come in the way of Mother Nature. No matter how unhealthy the foetus is, NO ONE HAS THE RIGHT TO DECIDE ITS DESTINY, not even the parents. We have heard stories of abnormal children going on to to live perfectly healthy lives. The parents must use the high tech to HELP the child live a healthy life, rather than nip it in the bud.

I wonder how “high tech” would help in a case such as this [here is another related post with ultrasound images & links about holoprosencephaly at the end]. I just chose holoprosencephaly because I had blogged about it. I can come up with a bunch of other non-fatal anomalies that you wouldn’t wish upon even your worst enemies’ children.

KM philosophizes…

The concept of rights arises from the fact that man (by his nature) needs to act on his own independent judgement if he is to survive. Rights can only pertain to beings that have a purpose and the capacity to exercise judgement. The right to life is the right to act independently, free from physical force from other men. A fetus is not independent. It depends on the mother for its sustenance. It cannot exercise or even form judgement. It does not have a purpose. Judgement and purpose are concepts that depend on the capacity of choice. A fetus is incapable of choice.

The current law regarding abortion (like most of India’s laws) protects no ones rights. Neither the rights of the mother to her own body (as illustrated by this case) nor the alleged right of the fetus (since its life can be terminated in the case of a risk to the life of the mother).

Jo has a very balanced outlook, so he does not come to any conclusion, or is not able to take sides in this.

Finally Vatsap does some plain-speaking, that I find myself mostly in agreement with.

Mr. and Mrs. Mehta could have got the job done illegaly. They could have bribed some doctor to kill the foetus. There is nothing wrong if they don’t want a child with congenital heart disease.

The couple did NOT get the job done illegaly, like so many others in India do. The reasons for illegal child abortions are of course different. In most of the cases, the reason isn’t even close to being as genuine as this couple’s. Some of them don’t want a child merely because it’s a girl. Usually by the time you know the gender (gender disclosure is illegal at the first place), you have already crossed the legal limit of pregnancy (I guess that stands at 20 weeks).

Many thanks to Dr. A for putting a great sounding name for what we all do and for the shout-out about the Medical Microblog, which I guess is in it’s alpha/beta release stage. I created it on a whim when I saw the twitter-like Prologue theme at WordPress. Some of the stalwarts of New Media Medicine joined the experiment almost immediately. I sort of expected Berci, Walter, symtym or Dr.A to take over from there, because this sort of thing is right up their alley. In fact, Berci liked the idea so much that he blogged about it and used the same theme and created a Medicine 2.0 Microcarnival.

I guess the timing of the launch was wrong, what with Berci visiting the WHO HQ in Geneva; Dr.A appearing in his ABFP recertification exam; symtym appearing in his Bar exam and Walter preparing a major review article. Hopefully, they will have time to use the microblog after they finish the more important stuff in their lives.

There are a lot of medical bloggers who can already be described as microbloggers. By that I don’t mean the people who are on twitter, Pownce, Jaiku, friendfeed, Plurk, etc. I meant the medical bloggers who regularly post very short articles or provide links to other blogs or websites with interesting stuff. Prominent examples would include Kevin MD, Kidney Notes, Medical Quack and GruntDoc (of late).

Dr.A was being nice when he wrote “Vijay’s Medical Microblog,” but I don’t claim any ownership on the name or the microblog. It’s open to anyone who already writes about health related issues, i.e., the medical blogosphere as a whole. One issue with that blog is that it requires you to have an account at WordPress.com to become a co-author (you can opt to have only a username if you aren’t interested in having a WP blog). So if anyone is interested, please register at WP first and contact me or any of the other authors currently listed in the microblog so that we can get you in as a co-author.

** Incidentally, the post where Dr.A used ‘New Media Medicine‘ is a shout-out for the next episode (Show 42) of The Dr. Anonymous Show featuring my famous blog friend Theresa Chan as the guest (I am not being facetious when I say famous, you can see proof of her fame here, here & here).

Listen in live at 6:30 AM IST on Friday, August 1, 2008

(9 PM EST on Thursday, July 31 in Dr.A’s place in Ohio ).

Dr.A’s standard advice for first time Blog Talk Radio listeners:

Although it is not required to listen to the show, I encourage you to register on the BlogTalkRadio site prior to the show. I think it will make the process easier.

To get to my show site, click here (or on the button above). As show time gets closer, keep hitting “refresh” on your browser until you see the “Click to Listen” button. Then, of course, press the “Click to Listen” button.

You can also participate in the live chat room before, during, and after the show. Look for the “Chat Available” button in the upper right hand corner of the page. If you are registered with the BTR site, your registered name and picture will appear in the chat room.

You can also call into the show. The number is on my show site. I’ll be taking calls beginning at around the bottom of the hour. There is also a “Click To Talk” feature where you do not need a phone to call into the show - only a microphone headset. Hope these tips are helpful!

Coincidentally, I had a patient for Carotid arterial Doppler ultrasonography yesterday who had similar critical Internal Carotid stenoses on both sides. Here are the pictures.

Colour Doppler US image of the right Common Carotid arterial bifurcation with a large eccentric fibrofatty plaque. Severe aliasing and turbulence are seen at the stenotic segment.

The Spectral Doppler trace shows extremely high systolic and diastolic velocities (PSV 450cm/s & EDV240cm/s) in the stenotic segment with turbulence.

Colour Doppler US image of the left Internal Carotid arterial origin with a large eccentric calcified plaque. Severe aliasing and turbulence are seen at the stenotic segment.

The Spectral Doppler trace shows extremely high systolic and diastolic velocities (PSV >500 cm/s with aliasing & EDV 260 cm/s) in the stenotic segment with turbulence.

After seeing JSE Booth’s post, I was curious as to whether this patient had bruits. I was not curious motivated enough to go check that myself. I did what all senior doctors do. Called up our Family Medicine residents and gave them a spot test ‘to go find something interesting in the general examination of that particular patient.’ One of them called back a little later and told me the patient had a palpable thrill and an audible bruit on the right side. There wasn’t anything noticeable on the left side.

Suggested reading:

EG Grant, CB Benson, GL Moneta, AV Alexandrov, JD Baker, EI Bluth et al. Carotid Artery Stenosis: Gray-Scale and Doppler US Diagnosis – Society of Radiologists in Ultrasound Consensus Conference. Radiology 2003: 229:340-346. [read the full text of the article here]

I feel compelled to do this now. So here goes….

“The Big Read reckons that the average adult has only read 6 of the top 100 books they’ve printed.”

1) Bold: I have read.
2) Underline: Books I love.
3) Reprint this list in your own blog so we can try and track down these people who’ve read 6 and force books upon them

1 Pride and Prejudice - Jane Austen (I’ve read an abdridged version & I’ve seen the film).
2 The Lord of the Rings - JRR Tolkien
3 Jane Eyre - Charlotte Bronte
4 The Harry Potter Series - JK Rowling
5 To Kill a Mockingbird - Harper Lee
6 The Bible
7 Wuthering Heights - Emily Bronte (I’ve read an abdridged version).
8 Nineteen Eighty Four - George Orwell
9 His Dark Materials – Phillip Pullman
10 Great Expectations – Charles Dickens (I’ve read an abdridged version).
11 Little Women - Louisa M Alcott
12 Tess of the D’Urbervilles - Thomas Hardy
13 Catch 22 - Joseph Heller
14 The Complete works of Shakespeare (I’ve read The Merchant of Venice, Julius Caesar, Much Ado About Nothing, King Lear)
15 Rebecca - Daphne Du Maurier
16 The Hobbit – J.R.R. Tolkien
17 Birdsong – Sebastian Faulks
18 Catcher in the Rye - JD Salinger
19 The Time Traveler’s Wife
20 Middlemarch - George Eliot
21 Gone With The Wind - Margaret Mitchell
22 The Great Gatsby - F Scott Fitzgerald
23 Bleak House - Charles Dickens
24 War and Peace - Leo Tolstoy
25 The Hitch Hiker’s Guide to the Galaxy - Douglas Adams
26 Brideshead Revisited – Evelyn Waugh
27 Crime and Punishment - Fyodor Dostoyevsky
28 Grapes of Wrath - John Steinbeck
29 Alice in Wonderland - Lewis Carroll (I’ve read an abdridged version).
30 The Wind in the Willows - Kenneth Grahame
31 Anna Karenina - Leo Tolstoy
32 David Copperfield – Charles Dickens
33 Chronicles of Narnia - CS Lewis
34 Emma - Jane Austen
35 Persuasion - Jane Austen
36 The Lion, The Witch and The Wardrobe - CS Lewis
37 The Kite Runner - Khaled Hosseini
38 Captain Corelli’s Mandolin - Louis De Bernieres
39 Memoirs of a Geisha - Arthur Golden (I don’t think I completed this one)
40 Winnie the Pooh - AA Milne
41 Animal Farm - George Orwell
42 The Da Vinci Code - Dan Brown
43 One Hundred Years of Solitude - Gabriel Garcia Marquez (Started reading & did not complete it)
44 A Prayer for Owen Meaney - John Irving
45 The Woman in White - Wilkie Collins
46 Anne of Green Gables - LM Montgomery
47 Far From The Madding Crowd - Thomas Hardy
48 The Handmaid’s Tale - Margaret Atwood
49 Lord of the Flies – William Golding (I’ve read an abdridged version).
50 Atonement - Ian McEwan
51 Life of Pi - Yann Martel
52 Dune- Frank Herbert
53 Cold Comfort Farm - Stella Gibbons
54 Sense and Sensibility - Jane Austen
55 A Suitable Boy - Vikram Seth
56 The Shadow of the Wind - Carlos Ruiz Zafon
57 A Tale Of Two Cities - Charles Dickens (I’ve read an abdridged version).
59 The Curious Incident of the Dog in the Night-time - Mark Haddon
60 Love In The Time Of Cholera - Gabriel Garcia Marquez
61 Of Mice and Men - John Steinbeck
62 Lolita - Vladimir Nabokov
63 The Secret History - Donna Tartt
64 The Lovely Bones - Alice Sebold
65 Count of Monte Cristo - Alexandre Dumas (Did not complete it)
66 On The Road - Jack Kerouac
67 Jude the Obscure - Thomas Hardy
68 Bridget Jones’s Diary - Helen Fielding
69 Midnight’s Children - Salman Rushdie
70 Moby Dick – Herman Melville
71 Oliver Twist - Charles Dickens
72 Dracula - Bram Stoker
73 The Secret Garden - Frances Hodgson Burnett
74 Notes From A Small Island - Bill Bryson
75 Ulysses - James Joyce
76 The Bell Jar - Sylvia Plath
77 Swallows and Amazons
78 Germinal - Emile Zola
79 Vanity Fair - William Makepeace Thackeray
80 Possession - AS Byatt
81 A Christmas Carol - Charles Dickens
82 Cloud Atlas - David Mitchell
83 The Color Purple - Alice Walker
84 The Remains of the Day - Kazuo Ishiguro
85 Madame Bovary - Gustave Flaubert
86 A Fine Balance - Rohinton Mistry
87 Charlotte’s Web - EB White
88 The Five People You Meet In Heaven – Mitch Albom
89 Adventures of Sherlock Holmes - Sir Arthur Conan Doyle
90 The Faraway Tree Collection – Enid Blyton (One of the first complete collections that I read).
91 Heart of Darkness - Joseph Conrad
92 The Little Prince – Antoine de St. Exupery
93 The Wasp Factory – Iain Banks
94 Watership Down - Richard Adams
95 A Confederacy of Dunces – John Kennedy Toole
96 A Town like Alice- Nevil Shute
97 The Three Musketeers - Alexandre Dumas
98 Hamlet- William Shakespeare
99 Charlie and the Chocolate Factory - Roald Dahl
100 Les Miserables – Victor Hugo

I would suggest - in no particular order other than the first two, which I think are mandatory:

1. The collected works of P. G. Wodehouse.
2. The entire Discworld collection by Terry Pratchett.
3. A Short History of Nearly Everything by Bill Bryson.
4. Made in America by Bill Bryson.
5. The Last of the Mohicans by James Fenimore Cooper
6. All Quiet on the Western Front by Erich Maria Remarque.
7. The Collected Short Stories of Saki.
8. Malgudi Days by R.K. Narayan.
9. The Mandala of Sherlock Holmes by Jamyang Norbu.
10. The Godfather by Mario Puzo.

For those who do not have any idea about electrical engineering, here are the basic laws that would help (?!) in completing this exercise.

Kirchoff’s Current Law (KCL, also known as Kirchhoff’s first law, Kirchhoff’s point rule, Kirchhoff’s junction rule (or nodal rule), and Kirchhoff’s first rule), states…

At any point in an electrical circuit that does not represent a capacitor plate, the sum of currents flowing towards that point is equal to the sum of currents flowing away from that point.

Simplified, it reads thus…

At every node, the sum of all currents entering a node must equal zero.

and

Kirchoff’s Voltage Law (KVL, also known as Kirchhoff’s second law, Kirchhoff’s loop (or mesh) rule, and Kirchhoff’s second rule), which states…

The directed sum of the electrical potential differences around any closed circuit must be zero.

Here is the exercise….

Please apply Kirchoff’s Current and Voltage laws to the following figures….

Figure 1

Figure 2

[click the links to open the figures in new windows]

If you come up with the correct solution, I promise to make you the Power Minister when I become Prime Minister of India.

[Many thanks to my friend Shankar who sent this to me via email].

I came across this at Shadowfax’s blog. It’s a great story, which just happens to be about appendicitis & CT scan.

I recently cared for a young boy with abdominal pain. He was about six years old, and had pain in his lower abdomen for about 12 hours prior to coming to the ER. His parents, Ukranian immigrants, were really nice people. Their English could have been a little better, but we could understand one another perfectly with a little effort and we got along fine. They were among the nicest people I have had the pleasure of interacting with in the ER in a long time. They were reserved, polite, and deeply respectful towards me in a manner that struck me as almost old-fashioned, and they were very concerned about their son, their only child, who was in a lot of pain and had never been ill like this before.

I was almost certain that he had appendicitis, and after explaining this to the parents, I called the surgeon to see if we could just take him to the OR for a laparotomy. You may recall I’ve run into trouble with this sort of thing before, and the surgeon, the same surgeon as before, wouldn’t bite this time. In fairness, the story wasn’t quite perfect — the pain didn’t localize quite right, the white count wasn’t really high enough, etc — so she asked me to image the child to verify the diagnosis, which is reasonable.

Read the rest of the story at Movin’ Meat: Triggers.

I’m Honored to be the first Sixth Time Host, but more importantly to be the host of the 200th Edition of MedBlogs Grand Rounds.  Dr. Nick Genes deserves all the credit for starting (and maintaining) this wandering collection of links to the best of the MedBlogosphere (thanks, Nick!).

There were more than 40 submissions this week, and here they are in the order they were received, (with my ER Doc attention span review in parenthesis at the end of the link):

GruntDoc » MedBlogs Grand Rounds 4:44 The 200th Edition!.