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Hickey

Always start with an excuse. I have been ill for the last 10 days. I suspect I picked up an infection from the woman I slept with in Vegas.* I normally go through the day at warp 5 (I do not want to destroy space-time), but this illness has reduced my mental functioning in the evening to one-half impulse at best, with thoughts moving at the speed of a cold Oregon slug. So bear with me.

There can be an odd popularity to medicine. I see this in antibiotics usage. When a patient is admitted to the ICU with sepsis, while awaiting cultures you try and kill all the likely bacteria that may be trying to kill the patient. At any given time most doctors can only remember two antibiotics and the current popular duo is vancomycin and pipericillin/tazobactam. It is a reasonable choice, one of many combinations that would treat most patients with sepsis. I am not certain how this combination became so popular, although I have been told that the pipericillin/tazobactam reps have been very active at the Universities with medical students and residents. As the adage goes, “Give me a student until he is seven and I will give you the doctor.”

There are also popular trends in alternative medicine as well. Every now and then there is a flurry of mentions on the interwebs suggesting that a pseudo-medicine has become all the rage. Or maybe it is just the echo chamber that is the interwebs.

This week it is Oil Pulling Might Be The Next Big Thing — Or Not and What is cupping? Lena Dunham the latest celeb to try the ancient Chinese remedy for pain relief.

If oil pulling appears on the Huffington Post it must popular, although Dr. Novella is skeptical as to its efficacy. And just thinking of swishing oil in my mouth for 20 minutes or so gives me that gaggy feeling.

Cupping is not the protection I used for karate as a kid. Cupping is a technique where a vacuum is made in container and applied to the skin, and the vacuum sucks on the skin creating a welt. Basically cupping gives the patient a hickey without, usually, the mess and aggravation of making out.

Medicine has, for the most part, toughened me. I have learned not to scream or vomit when faced with the occasional surprise such as an unexpected squirt of pus up a tie or a jar filled to the brim with dried boogers. But the photos of cupping on the interwebs give me the wiggins. It doesn’t make me gaggy like oil pulling, but ick.

Cupping is one of the ancient therapies, used in Egypt, China, and Greece. Antiquity is always a reliable guide for health and life-style choices. I live in a pyramid with my terracotta army, tended by my slaves and planning the conquest of a city-state based on the entrails of a sacrificed goat. What was good enough for the ancients is good enough for me. Except for that whole “short life expectancy from infections” thing. It is an oddity of the appeal to antiquity in that it is mostly used to justify pseudo-medicines, but little else in life if you are not Amish. I can’t see anything in my personal or professional life that uses the methods of the ancients. I am certainly glad it is not used in the brewing of beer.

Cupping is like acupuncture in that at different times and places variations on the technique have evolved. There are a many forms of forms of cupping: dry, fire, retained, moving, flash, needles, medicinal and wet among others. In wet cupping they make a small incision in the area of suction to make sure that blood is drawn out to:

remove harmful substances and toxins from the body to promote healing.

That is like cleaning a swimming pool by taking out a cup of water.

Like acupuncture, there is no process for which it cannot be used. Except birth control. As best as can be determined, prevention of conception is not the strong suit of TCM. But it has been suggested that there are 1,001 diseases for which cupping can be of benefit (although they mention only 120).

Our results suggest that CT is currently prescribed for up to 120 diseases and disorders that are difficult to treat, including cutaneous (21.7%), musculoskeletal (15%), and central nervous system (13.3%) disorders.

There is no reason cupping should have any effect on any disease beyond the usual placebo effect and it would be difficult to do placebo controlled trials given the large hickeys induced by the procedure, although someone has devised a form of sham cupping. Given the dramatic changes to the skin from cupping, I would expect the technique to be a particularly powerful set of beer goggles. The more impressive the placebo, the more it will alter perception. And, like a good set of beer goggles:

majority of studies show potential benefit on pain conditions…that there is insufficient high-quality evidence to support the use of cupping therapy on relevant diseases….Existing trials are of small size and low methodological quality. Further high quality studies of larger sample size are needed to assess the effectiveness of cupping therapy.

More studies needed. They always say that, no matter how ridiculous the intervention. I would beg to differ. There is no reason to waste time and money on interventions with no reason to work. I would also expect, since cupping has no reality-based reason for efficacy, that it would have no significant effect on a process with a hard endpoint like hypertension. And it doesn’t.

Like most pseudo-medicine, cupping only shows efficacy in poorly-controlled trials and usually only for subjective endpoints.

Despite the large number of studies on cupping therapy, including the 62 new ones, there remains a lack of well-designed investigations [Shocking – Ed.]. Of the 135 RCTs included in this review, 84.44% were high risk of bias [What ! Ed.] . One issue is adherence to the Consolidated Standards of Reporting Trials (CONSORT) in which randomization methods should be clearly described and fully reported. Another issue is blinding, which continues to be a challenge for studies involving manual healing therapies, such as acupuncture, massage, and cupping therapy.

Reality also remains a challenge, but that is almost never considered in the discussion:

our study is based on a process that has no basis in anatomy and physiology and as such any likely efficacy can be accounted for by bias and poor study design. More research needs to be done.

I love the purported mechanism:

The mechanism of cupping therapy is not clear, but some researchers suggest that placement of cups on selected acupoints on the skin produces hyperemia or hemostasis, which results in a therapeutic effect.

Exactly how skin hypermia or hemostasis would have any effect beyond the local hickey is never explained, except in the context of mystical fiction:

Like acupuncture, cupping follows the lines of the meridians. There are five meridian lines on the back, and these are where the cups are usually placed. Using these points, cupping can help to align and relax qi, as well as target more specific maladies. By targeting the meridian channels, cupping strives to ‘open’ these channels – the paths through which life energy flows freely throughout the body, through all tissues and organs, thus providing a smoother and more free-flowing qi (life force).

When you look at the ginormous welts (not for the squeamish) on cupping patients you have to wonder just how select these points are. They must activate half a dozen acupoints with each cupping. Shouldn’t it set off a qi storm with so many acupoints being activated at once? Oh, wait, I’m sorry. For a moment I was considering the process as if it actually corresponded with reality.

I can see how cupping would be popular since it leaves a tell-tale mark that lets those around you know that you are one of the cognoscenti without the permanence of a tattoo. No one knows if you are getting acupuncture or reiki, but the hickey on the back is an instant attention-getter, the perfect pseudo-medical ‘look at me’ sign that advertises your subtle understanding of ancient Chinese wisdom. Seems perfect for Hollywood.

Or it might suggest you would be interested in helping move some money from Nigeria to the US to help out a poor widow whose husband left her a fortune.

And if you have been cupped perhaps there is a way to remove the embarrassing bruise.

Two notes.

April 12/13 I will be in Manchester at QED ostensibly to give a talk and participate in panel discussion. I am really there to see if there are any English beers better than those here in Beervana. I doubt it.

I have had issues with the Quackcast and iTunes RSS feeds. I think it is fixed. If you have been a listener but wonder where the podcast has gone, delete the feed and resubscribe.


*My wife was ill first and I suspect I got it from her. Get your mind out of the gutter.

Posted in: Acupuncture, Traditional Chinese Medicine

Leave a Comment (93) ↓

93 thoughts on “Hickey

  1. Windriven says:

    This stopped me dead in my tracks:

    “Despite the large number of studies on cupping therapy, including the 62 new ones, there remains a lack of well-designed investigations ”

    62 new studies on … cupping. Who pays for this crap? And after 62 new studies there still remains a lack of well-designed investigations?! 135 times – 62 of them recently – a funding group was either too stupid to recognize the methodological weaknesses of the proposed studies or were too lazy to care. Is the invisible hand checkbook of NCCAM at work here?

    ” I am really there to see if there are any English beers better than those here in Beervana.”

    There are. If not better, certainly as good. The Brits make fine ales and their IPAs* aren’t hopped to taste like Murphy’s Oil Soap – a moderation that I hope our local breweries will someday come to embrace. But they’re served at an insipid temperature and the variation from ale to ale is much less stark than what one would find in a 5 mile radius of the Pearl District.

    *Note to non-beeristas: IPAs – India Pale Ales – are more highly hopped than most other ales. This style dates to the Raj when the ales shipped to India were heavily hopped as a preservative. I’ve no idea whether hops are an effective preservative or not but like heavily spicing food in warm climates, with enough hops you couldn’t taste spoiled beer if it was green and gurgling. Here in the Pacific Northwest – where thermal spoilage of beer isn’t really an issue outside the three days of summer – brewmasters often follow the American rule: if a bit of something is good, three sh!tloads of it will be much better. Now locally brewed ales have the flavor profile of IPAs and IPAs have the flavor profile of tetrahydrofuran. They brag about it with names like Hop Monkey, Hop Czar, and Tricerahops (billed as a “double” IPA). There are even “triple” IPAs like Hopocalypse. Tastes like crap to my palate but it is wonderful for cleaning silver.

    1. Andrey Pavlov says:

      Here is where you and I part ways Windriven. I am a sucker for hop bombs. I’ve never actually tasted tetrahydrofuran because my ochem lab would have been displeased if I did (and maybe other reasons too).

      But IMHO one cannot put too much hops in a beer. Down from whence I come is a beer called Green Flash that makes such an IPA. Around here the Hopitoulas and the Mechahopzilla are amongst my favorites (odd… Hopitoulas is somehow recognized by my spell check but not Mechahopzilla….)

      For my lovely, any IPA is unpalatable. She says it tastes like perfume to her (another libation I’ve never tried). There have been some very mild IPA’s that she has tolerated but none for more than a sip or two.

      But it sounds like I need to wend my way to the PNW for some serious hops. Which should not be too big an ask now that my (future) brother-in-law is living in Redmond after getting a job at Microsoft.

      1. Windriven says:

        Yes Andrey, you and Crislip are both palate dead, I know. ;-)

        I’m sure you also know that half of what I write is just to be provocative. I love a good IPA in the heat of summer. In the colder months I prefer pale and red ales.

        But brewers should be faithful to the style of beer they are brewing. Pale ales have been around for a long time. The flavor profile is established. If you’re going to hop them like an IPA fine, just call them IPAs. And if you’re going to hop them into outerspace that’s fine too, just label them for what they are. It is really the “hops creep” that dismays me.

        Anyway, you’ll love the breweries here. Portland is to my mind (and palate) a far more sophisticated area for both food and beer. Seattle has lots of expensive, fru-fru places that deliver marginal experiences. You can literally get better food at any number of Portland area food trucks than you can at some of Seattle’s more reknowned restaurants. So be sure to save time for the Rose City.

        1. Andrey Pavlov says:

          Haha, and it seems Angora as well. I feel I am in good company!

          I understand what you mean about the creep. I can respect that.

          Portland is a place I have not been to, nor foresee a cause to in the immediate future. Hopefully there will be a conference up there that I can attend. I’ll make it a point to do so when I get the chance.

        2. Mark Crislip says:

          No no no no no. I have a sophisticated palate.

          As the brewmaster at Bridgeport said years ago, my favorite beer is the one I have in my hand. At least as long as it doesn’t have light in the title.

          1. Windriven says:

            My stock greeting when I go to a new brew pub or encounter a new server at an old one is to order a Coors Light – just to see how they handle it.

            Bridgeport as you doubtless know has stopped bottling Blue Heron. I haven’t been there in a while but I was told they might stop brewing it altogether. Too bad. My very favorite winter beer with food, perhaps because it was the very first local beer I tried when I moved to the PNW.

            Enjoy England. I was going to Portugal next month but I need to put a new roof on the house on the Oly Peninsula. How do you say ‘f*ck me’ in Portugese?

            1. weing says:

              How do you say ‘f*ck me’ in Portugese?
              Second person is “Foda se!” I don’t know if it makes sense in first person.

              1. Dennis Kovacich says:

                I don’t know about your request, Windriven, but my Portuguese relatives told me eons ago that “dull knife” in Portuguese is “faca mal.” It lets you say one thing in one language while sounding like something else in another. It’s the ultimate play on words!

      2. Angora Rabbit says:

        Windriven, we love and adore you. Apart from this teensy-weensy flaw. But I guess that means diversity gives Andrey and me more IPA, so it’s all good in the end. I have to say that Tricerahops is one of my all-time favs. Plus it gets bonus points for being named after a dinosaur. Had several lovely visits at Ninkasi last year whilst on sabbatical. :) And Santa puts Amarillos in my Xmas stocking. Santa is wonderful.

        1. Windriven says:

          I haven’t had the Amarillo – but I read some tasting reports on line and it sounds appealing. Funny the way different palates process – some of the reports note quite forward alcohol and bright citrus while others speak of subdued alcohol and absent citrus. Could be the age of the bottle. Anyway, I’m going to give it a try. But I’ll have to buy my own. Santa usually brings me Barolo.

          Or sometimes just the lump of coal.

        2. Angora Rabbit says:

          Whoops – maybe a misunderstanding? Amarillo is a hop variety. To me, it has a lot of floral topnotes and a hint of citrus. It has medium alpha-acids. in our house we use it for dry hopping, hence several ounces in the Xmas stocking.

          Sweetness was my first week in Corvallis, when they were celebrating Fresh Hopped beer week. Fascinating and quite an education. We have it here now in my area. Both Deschuettes (sp) and Rogue had five to seven of these going; it was really interesting to taste how each varietal changed.

          1. windriven says:

            “Whoops – maybe a misunderstanding? Amarillo is a hop variety.”

            Yes, a misunderstanding. There is an Amarillo beer as well. And shame of shames – I didn’t know about the Amarillo hops variety. Do they even use that in Budweiser?

      3. Greg says:

        She says it tastes like perfume to her (another libation I’ve never tried).

        If you’ve ever tried Earl Grey tea then you know what perfume tastes like – it’s flavored with bergamot, an ingredient also found in gin, the oil of which is used in perfumes.

        http://www.britannica.com/EBchecked/topic/61710/bergamot

        1. Windriven says:

          I’ve had some French beers that taste like Earl Grey brewed with club soda (how did they manage to keep the CO2?). Definitely not appealing.

          1. Calli Arcale says:

            Suddenly I am put in mind of the fictitious Old Frothingslosh. “A whale of an ale for the pale stale male: the foam is on the bottom.”

            1. Angora Rabbit says:

              I thought foam on the bottom was what happens when Guinness is poured the wrong way? :)

      4. Kultakutri says:

        I could pick wild hops by the river and I happen to run a hotel which includes a bar and I buy beer by keg but my, I hate it. They say this is a beer country and I’m much of an oddity but drinking something that tastes like bitter soap… well, whatevs. To each of their own.

        While perfume, on the other hand. These days, colognes are made of denatured alcohol. I could possibly drink some of those I make but I’d need to make some more potable stuff, not the usual 30 % of fragrant things, 70 % alcohol. But the other day, I ventured to Trentino and in the local grocery, stumbled upon a pine-flavoured chocolate. Pinus mugo flavoured white chocolate, to be exact. I could do without the green dye but the taste! Alas, the workshop doesn’t have an online store (we’re talking about Italy, after all) but I know where to get cocoa butter in bulk and a few pots are no biggie and the rest is alchemy and dirty kitchen. I only need to check for papers to my essential oils and see whether there’s something particularly poisonous – I hear tonka beans are a great flavouring but coumarin is somewhat carcinogenic.

        But, I’m that kid who harvested resins from the neighbourhood conifers to eat.

    2. Michael says:

      Bacteria in petri dishes find hops to be mildly to moderately annoying.

      Antiadherent and antibiofilm activity of Humulus lupulus L. derived products: new pharmacological properties.

      http://www.ncbi.nlm.nih.gov/pubmed/24175280

      1. Windriven says:

        Cool. Thanks for the citation.

        1. Windriven says:

          For s. aureus, no less. We don’t need no stinking beta-lactams! We’ve got Corona!!!

          1. Birdy says:

            I suspect Dr Crislip may have a new motto thanks to that, Windriven.

    3. Angora Rabbit says:

      “I am really there to see if there are any English beers better than those here in Beervana. I doubt it.”

      Two words: Black Sheep. It’s the successor to Old Peculiar after he sold OP and then decided he missed it. Kinda like Bully Hill Winery or the long-lamented Celis White. Though OP on draught is mighty fine.

      Before you leave, spend a little time at the CAMRA website (Campaign for Real Aile). You will obtain many fine recommendations on proper beer and ales across the pond. Just avoid pubs named “The (insert noun here) and Firkin.” That’s a chain. Oh, and some Brits seem to think that Rolling Rock is a beer.

      Trust me on this – trust in CAMRA as your guide.

    4. agitato says:

      “April 12/13 I will be in Manchester at QED ostensibly to give a talk and participate in panel discussion. I am really there to see if there are any English beers better than those here in Beervana. I doubt it.”
      A link for your trip:
      http://www.theguardian.com/travel/2013/oct/11/manchester-top-10-craft-beer-pubs

      “When you look at the ginormous welts (not for the squeamish) on cupping patients you have to wonder just how select these points are.”
      Absolutely not for the squeamish! Yuck!!! People voluntarily submit to this? There is no hope.

      1. Columbina says:

        Like the USA, the UK has undergone a bit of a renaisance in real ale and microbrewers of late. Unfortunately, most of the best ales still remain local and thus you will need a mancunian ale drinker to advise. Find a CAMRA pub and the locals / landlord will normally be happy to help.

        If you find yourself passing through the London area, I can recommend getting hold of any of the Meantime selection (they do a fine pale ale).

        Also increasingly common (at least around london where I am based) are micro gin distillaries, adding new twists to that traditional British drink, the G&T.

        Also @winddriven, if your beer is being served at an insipid temperature, I would be registering a complaint with the landlord!

    5. Frederick says:

      huum Irish stout, and english style brown beer. I’m a big fan of belgian style wihte and german heiffenwiser (also white). I’m lucky in Québec we have a lot a very good small Brewery, like a 2 right here in my region. Le trou du Diable, the make my Favorite Stout, La sang d’encre. Man that is good,

      Ah damn you all. I have assignments to do, now i only thinking about beer!

      Speaking of beer google, I will have to be Drunk as …. to let people cup me like those disgusting pictures.

  2. ca1879 says:

    Man, those Vegas bugs are tough. Apparently they infect you with Star Trek Fan Syndrome along with the tummy gurgles and sniffles.

    I don’t think the ebb and flow of the popularity of SCAM modes is surprising. Since there is no enduring benefit that drives anything beyond a certain ground level of belief, any given mode is popular only in proportion to the current level of media interest and promotion by advocates. Much like any other non-critical consumer good. For all the hand wringing we do, it really seems that this nonsense has no staying power and our ongoing task as scientific skeptics seems to be little more than counter-marketing.

  3. Alia says:

    Well, when I was a kid, my mother used to do cupping on me for colds and such. Fire cupping, which means you get a glass bowl, fire a wick dipped in alcohol, put the wick inside the bowl so that it sucks out air, and then put the bowl onto the skin. So it’s hot and pulling on skin at the same time.
    Anyway, this was used as an alternative for antibiotics and afterwards I had to stay in bed for two days straight (because, you know, if some cold air touched those hickeys, it would be a recipe for disaster). So of course, for colds it worked miracles (as with any other self-limiting illness). And since the alternative was intramuscular antibiotic shot (as a kid, I would throw up any orally given antibiotic) – I think I was better off with cupping.
    And this was a doctor-recommended treatment, performed by a qualified nurse (that is, my mom). But its tradishun, man, so it must work!

    1. The other Alia :) says:

      My parents used cupping too (this, and mustard patches on the chest). I’m pretty sure most Eastern Europeans did it for everything, starting with common cold and ending with pneumonia.

  4. Andrey Pavlov says:

    At any given time most doctors can only remember two antibiotics and the current popular duo is vancomycin and pipericillin/tazobactam.

    At my institution we use pip/tazo, vanc, and cipro. We all tend to agree the cipro is a useless add-on, but it was formalized as part of the protocol and since we are running a prospective trial, it sticks. But it is usually the first one we nix ASAP.

    But here is a funny story for you. I was rounding in the ICU and come up to one of my patients. An ornery old lady from the bayou who was a real (fun) kick in the pants. She’d broken her femur pretty badly in a fall. The ER doc admitted her as a severe sepsis/septic shock under our standardized protocol. Why? Because she met 2/4 SIRS and he decided she had a UTI. We all marveled at the admit. Anyways, inertia kept the abx going (as I’m sure you well know) and ortho was consulted to repair the femur. It was a late day admit and evening rounds, so we planned to just keep her overnight and then transfer her to a surgical floor for ortho in the morning.

    The next morning we are rounding, and I we come around the corner I tell a joke:

    “What’s the difference between a carpenter and an orthopod? The carpenter knows more than one antibiotic!”

    It got some yucks. Anyways, we get there and are actually surprised to see that ortho took her in for the repair overnight. We figured they would wait till the daytime. So we are going over all her orders and see that the pip/tazo, vanc, and cipro are still ordered. A bit annoyed we definitely tell the nurse to cancel them. Then she asks, “What about the cefazolin?”

    The what? Who the heck ordered cefazolin… especially when the patient is already on pip/tazo, vanc, and cipro?

    Turns out the orthopod ordered it.

    1. MadisonMD says:

      @Andrey,
      The relevant joke here is:
      What is orthopedic triple antibiotics? 3g Ancef
      Your ortho deserves to hear it after giving it–prob in standard postop order set.

      I enjoy your SIRS story as well. It turns out many onc patients on chemo who shows up at our ER get broad-spectrum antibiotics due to SIRS often without documented infection (or soft call-pneumia, pyuria, rash, diarrhea, etc.). They might have HR>90 d/t anemia (plus anxiety and possibly pain or dyspnea depending on why they showed up). Then they usually have either WBC12000 + bands due to dexamethasone and GCSF. It doesn’t seem like a good idea to give broad-spectrum antibiotics so readily given the rise of resistant bacteria and c.diff.

      Once or twice I have received the call to admit:
      Resident: “Do you want antibiotics?”
      Me: “No”
      Resident: “But patient has bands and meets SIRS”
      Me: “We’ll watch closely after admit.”
      Resident: “We already gave Vanco/Zosyn.”
      Me: “Oh”

      1. weing says:

        Definition of double blind study?
        Two orthopedists reading an ECG.

      2. Chris Hickie says:

        As a third year medical student I broke a finger (my middle finger). I couldn’t get in to be seen by the orthopedist for several days. I thought the fracture was well aligned, but it wasn’t, and by the time I was seen, the orthopedist could not realign it in the office. She sent in her resident to do a pre-op physical on me for an outpatient surgery to re-break the finger, followed by reduction and placement of pins to hold alignment. The resident listened with her stethoscope for 2 seconds at a spot about 1″ above the bottom of the sternum. I asked the resident if she was going to listen anywhere else. She said no and told me me where she had listened was the “orthopedic triple point” where she can hear breath, bowel and heart sounds all at one location. She then handed me the physical form and said “here, you’re a med student–do your own pre-op physical on yourself”.

        Those were the days.

        1. D Hocson says:

          And if you push hard enough when listening, you can get a stool sample.

      3. Andrey Pavlov says:

        Yes, I have seen similar such cases. From what I’ve seen it seems to be fueled by a fear of missing an infection and a lack of understanding of what SIRS actually means (and doesn’t mean). Inflammation is inflammation, whether it is from trauma or not. And other processes can induce similar cytokine changes to mimic it.

        And I’ll definitely remember your triple therapy. One of my really good friends in the year behind me is going to do ortho. He is an extremely smart guy though – knows his medicine extremely well. He will definitely be the smartest ortho in the program! LOL.

      4. PMoran says:

        Hey! Enough about the orthopods! I was going to let this go, but this one was practising a sound standard of care, instituting antibiotic prophylaxis during open joint surgery on someone who (to him) would have had no obvious reason to be on antibiotics beforehand.

        He, or his assistant, or (commonly) the anaesthetist, or whomever actually put pen to paper, should certainly have done more bleary-eyed checking of the entire medication sheet in the middle of the night before prescribing an additional antibiotic , but they are no more culpable than the person (or system) that started the unnecessary antibiotics without good reason in the first place or those who said “stop them all” without considering that there were reasons why this patient might be in need of some antibiotic cover.

        A far worse outcome could arise if there were not a well-entrenched routine of prescribing antibiotics in the manner being criticised herein.

        1. Andrey Pavlov says:

          First off, it is in jest. There are jokes about every specialty and every specialty (and every doctor) makes a really dumb error (usually, and hopefully, not one that actually really harms the patient, but worth laughing about amongst colleagues).

          That said, in this case, there really was no such mitigating factors. At our institution it is the orthopod who puts in the orders or verbally orders the anesthesiologist to do it (but that is discouraged, and in this case it was the orthopod that put in the order). And all of our records and orders are 100% electronic. No pen or paper. The meds are on the main screen and plastered all over the place, with the ability to look at them grouped by class.

          Yes, the patient shouldn’t have been on any antibiotics at all. And yes, that ER physician was appropriately educated after the fact. It is, after all, a learning institution. But it is equally justifiably a dumb move to add on cefazolin when pip/tazo and vanc are already running in. If it were because of bad med review that is probably even a worse offense. It was also quite likely that the ortho didn’t know the coverage of the other drugs and didn’t want to bother looking it up. Either way, particularly in light of the off-hand joke I had told leading up to the discovery, it was extremely funny.

          We all make bonehead moves. And we should be able to laugh about them while at the same time taking a lesson from it. Many times when I do or say something boneheaded if nobody else picks up on I make the joke about myself.

          And yes, you are absolutely right that in this circumstance a far worse outcome could happen. But anything being so entrenched is never a good thing. That’s why the patient got put on a sepsis protocol in the first place. That’s why people get so many needless blood transfusions. And that’s why it is appropriate to point it out as the failure that it is. Nothing wrong with doing it with some humor.

        2. MadisonMD says:

          Peter and Andrey,
          It strikes me how this is related to the usual post here about the report of 46-98,000 medication errors per year (neverminding that the survey is over a decade old and usually the numbers are inflated outrageously). This is an example of one medical error. Although not common, there could have been an adverse event (rash, interstitial nephritis, etc.) even if it was not likely to occur in this particular case. (and agreed, the culpability goes beyond the orthopod). Is it a big deal or no?

          I have seen a lot more effort in medication reconciliation in recent years and with electronic records it really is quite easy to look up medications.

    2. Dave says:

      I suspect the orthopod was following a surgical protocol for cefzol immediately before surgery and for three doses afterwards. Probably a case of algorithms overriding the thought process.

      1. Andrey Pavlov says:

        @dave:

        No doubt. But that’s the joke in and of itself. Bone broke. Must fix bone.

  5. jacobv says:

    Beers in the UK are different and my recommendation would be to enjoy them for what they are. And I’d just tell any server at a pub that you like real ale’s and hops and see what shows up!

    During my CPS investigation years I had a number of cases where a young child had been cupped and a school teacher or day care provider would freak out when they saw the marks. And the marks can look pretty bad but there is no pain involved and we now train CPS investigators to be aware of this type of practice. And all the cases I encountered involved first generation immigrant parent usually from South East Asia. And my only encounter with wet cupping was when Anthony Bourdain subjected himself to the practice on one of his shows, which was a disappointment because I generally like his shows.

    1. Calli Arcale says:

      I prefer Andrew Zimmern’s shows. He has on occasion indulged in some local traditional medicinal practices, but he’s always got a rather amused look on his face and it’s always seemed clear to me that it was more about being polite to his local hosts who want to show him everything that their region has to offer. And in some cases, getting treated by the local shaman seems to help get him access to their most authentic cuisine, because it’s a display of trust and respect for their beliefs.

      The key here is that “respect for beliefs” doesn’t mean “adoption of beliefs”. It just means not trying to embarrass them. You respect your elders, so that means you don’t bring up their horrible halitosis at the family Christmas dinner. ;-) You’re a guest in their house; you let them decide how to live their lives unless they explicitly ask you for your opinion on the subject. That’s what respecting someone’s beliefs means. It saddens me that for many, respecting someone’s belief means acting as if it is entirely legitimate in all contexts and never ever criticizing it. Because that’s just passive aggressive BS, really.

    2. Mal Adapted says:

      Here’s how to find the best beer/ale in the UK: go into the most nondescript pub that offers local product, and ask for their “best bitter”.

      I discovered that in a little Welsh village in 1994.

      1. Windriven says:

        Amen! When in a foreign country and if the bartender speaks a little English or I speak enough pidgin, I ask the barkeep what he’d be drinking.

        1. Mal Adapted says:

          Heh. In that Welsh pub, I did ask the locals sitting at the bar what they were drinking. They all said “best bitter”, so that’s what I had. It was astonishingly good.

          1. jacobv says:

            After a long hot walk on our honeymoon in Cornwall back in the 80’s I asked the bartender at a pub what the local drink was and he proudly said “Scrumpy cider, made by my mate”. So I ordered a pint and enjoyed it very much. I discovered after my first attempt to get up and leave the pub that the cider had ABV of 12-13%. I still like scrumpy style cider and even make it myself, however an Imperial pint of the stuff on an empty stomach after a long walk is not advised unless sitting is all you have planned for the rest of the afternoon.

      2. Windriven says:

        I was once in a bar in Denmark with a group of business people including the douche I worked for at that moment. His idea of life well-lived was a cheeseburger and a Bud while watching a Kentucky basketball game.

        So we’re in this bar and the guy orders an Amstel Light, mostly because he’d at least heard of it before. Not much later some Aussies came in and were quizzing the bartender on what to drink. They’re going through the beer list and one of them asks the barkeep about Amstel to which he responded “river piss.” My associate looked as if he’d swallowed a skunk. Me? I just smiled.

  6. Greg says:

    That is like cleaning a swimming pool by taking out a cup of water.

    LOL – great analogy!

    Seems perfect for Hollywood.

    Of course it is! Hollywood cares little about reality.

  7. Lytrigian says:

    Some sumo wrestlers use cupping to treat minor injuries or colds during a tournament, and from time to time one will step into the ring looking as if he’s been attacked by a particularly amorous giant squid.

    With 90% of any game being at least half mental, I suppose anything which makes them THINK they’re getting treatment would help, and honestly, they don’t have a sound alternative most of the time.

    Intravenous vitamins are popular too, but I understand that’s not too uncommon in Japan.

    1. Windriven says:

      “With 90% of any game being at least half mental”

      Yogi Berra?

      I love sumo. I was particularly fond of Akibono back in the day. Dumped TV some years ago so I don’t much get to watch it now. It isn’t popular in any local sports bars ;-)

      1. Lytrigian says:

        Yogi Berra?

        Maybe, maybe not. He didn’t say half the things he said.

        There aren’t a lot of Hawaiians or Samoans left in the sport. Akebono himself made a rather embarrassing go at MMA after he retired, but he recently returned as an unofficial coach at his old stable. The only other ones left I know of is Musashimaru, who took over the Musashigawa kabu and established a new stable not too long ago, along with his nephew as his first trainee.

        The Japan Sumo Association used to put out a free video stream during tournaments, but they recently started charging for it. There’s a YouTube channel that records and posts all the bouts though, and it’s still possible to watch it live for free if you know where to look.

        1. Windriven says:

          I didn’t't know about the MMA thing with Akebono. Very disturbing. I saw a video of his retirement ceremony where his topknot was removed. Chad Somethingorother- the mighty Akebono – wept. Glad I never saw the MMA thing. I thought he was going to open a stable but I recall there was some controversy as he was not a Japanese national. I vaguely recall that he renounced his US citizenship but as you know this was about 10 years ago now.

          Nice to encounter another sumo fan, especially in this rather unlikely venue. Musashimaru must be nearing the end of his career. I’ll make it a point to find a good sumo feed.

          1. Lytrigian says:

            From what I hear, Akebono was strapped for cash, and they waved a bunch of money under his nose. The problem was that MMA wasn’t any easier on his knees than sumo, and of course, sumo training doesn’t prepare you well for fights as long as you see in MMA.

            He did some pro wrestling for a while after that too.

            It’s now a well-established idea that you need to have Japanese citizenship to remain in sumo past your active career. Ozeki Kotooshu, a Bulgarian rikishi who just retired this past tournament, made sure to get his citizenship first, and he’ll be remaining as an oyakata. Typically a yokozuna can stay as an oyakata with no question, but Akebono was the first non-Japanese yokozuna so probably there had to be some discussion about it.

            There are usually a few tears shed at the danpatsu-shiki.

            Musashimaru is pretty far from retirement yet. He’s just past 40. Mandatory retirement isn’t until 65.

            And if you visit the Sumo Forum at sumoforum dot net you might find some good discussion and information. Don’t ask about a free stream outright, but you can locate it if you search.

            1. Windriven says:

              Thanks for the info. You are much better informed than I.

              The retirement ceremony was quite moving. Thanks for the info. There is a basho coming in May and I will follow it on the net.

  8. Mary Russell says:

    Regarding drug reps, we kicked our cohort out of the office a year ago and have been delighted with the extra time this affords us. Are some hospitals and residency programs starting to do away with drug rep meetings and lunches?

    1. Andrey Pavlov says:

      At my institution we haven’t had drug reps allowed for 2-3 years now. And if physicians want to hold a drug rep sponsored “journal club” on their own time, they are allowed to do so but it must be declared and it is limited to a certain number per year (I don’t know the exact details but it is something like that).

      Personally I think it is a good thing. I’ve been to drug rep lunches and dinners. In fact, one of the most expensive dinners I’ve ever had was on Pfizer’s tab. In my undergrad days I did some research in heart failure with a local hospital and they took us out for a celebratory dinner. Came out to around $1,500 a head and they covered the entire team, including me because the attending said I should come along. I went to a number of such events in my undergrad days. I’ve only been to 1 lunch and 2 journal club dinners during med school.

      To think that you would manage to be completely unbiased in regards to the drugs with these reps running around is ridiculous. My step father (a critical care pulmonologist) has fun taking photos of the reps. All of them are extremely attractive women. He laughs at the ploys they are using and then flips through his photo album to prove it.

  9. Thor says:

    Great to have another Crislip post and the ensuing comments! Perfectly appropriate (and entertaining) for a Friday. I think only he could engender such light-hearted, yet avid, enthusiasm about the (sub) topic. There certainly is as much passion on display about beer as there is about SBM. Oh, actually they are part and parcel: medicine (herbs), chemistry, bacteria, health-food, mental/emotional well-being, beneficial neurological changes.

    Re: TCM, about 26 years ago, I was given the option of receiving cupping or moxibustion as part of my treatment. I chose moxibustion. Unfortunately, the burning, red-hot end of the stick fell off on my back. (I know, my anecdote doesn’t mean it doesn’t work-ha.) I still carry the scar with me (but no one ever sees it because of its location). Maybe should have opted for the major hickey action instead.

    1. I do not recommend the technique to a novice. I’ve used a Tiger, warmer or an electric soldering iron to heat the points.

      I once saw a kid from Mexico whose family used a heated coin to try to heal an illness.

      A lady from Korea who had dozens of the scars at the points, she was oblivious to them, must have been a local was common treatment.

      Now I just use plain ole needles of various types because of Gunn’s protocols.

      1. WilliamLawrenceUtridge says:

        I do not recommend the technique to a novice. I’ve used a Tiger, warmer or an electric soldering iron to heat the points.

        As opposed to real doctors who don’t recommend it at all.

        Between your needles and now apparently a soldering iron, you come across less as a credulous doctor (the former, very much so, the latter not at all) and more like discount torturer. What’s next, dental drils?

        1. Calli Arcale says:

          A soldering iron???

          Seriously?

          I hope it was a new one, and not one that had ever actually been used for soldering. Would you like some Sn/Pb in your acupuncture, sir?

          And here, I thought the worst hazard with solder was the risk of tin whiskers.

          1. Windriven says:

            “And here, I thought the worst hazard with solder was the risk of tin whiskers.”

            1. They would go nicely with his tinfoil hat;

            2. They could explain the defective reasoning. Perhaps tin whiskers have bridged the three neurons in his rational thinking unit.

          2. Chris says:

            Yikes!

            The soldering ironI used was for stained glass, much bigger than the one hubby used for electrical work. The issue would be the lead vaporizing when solder the came (the lead u-tubes that surround the individual pieces of glass).

            1. Windriven says:

              It’s probably OK Chris. I’m pretty sure no one would have explained the ‘plugging it in’ part. I’m sure IR is counting on the inductive energy of pulsing, throbbing qi to produce the heat. Feel the POW-ahhhhh!

        2. Gee, no imagination at all! Sad froma a group of so call free thinking scientist.
          Improvise especially when the building is non-smoking … Mugwort produced smoke, though some types are smokeless. … stupid!!!!! :)

          The iron is new and fresh so no solder or lead … stupid!!!! :)

          Hey guys are you learning and doing any homework or are you just being … silly and stupid!!!!!! :)

  10. tudza says:

    I had a procedure described to me that sounded very like cupping. It was performed in a hospital by regular doctors as an attempt to improve lung function by clearing congestion in the lower part of one lung.

    What could this have been?

    1. That was lung percussion which is an age old technique to help clear thick secretions from in the airways.

  11. RetroPastiche says:

    I was accidentally cupped a few years ago by an over-enthusiastic masseuse. Here in Australia, we have recently had a proliferation of ‘hole-in-the-wall’ massage therapists, usually in large shopping centres. As I have a fairly sedentary job (interspersed with intensive tertiary teaching) I tend to suffer from lower back pain. Wishing to avoid chiropractors (thank you Dr Gorski and others!) I generally go to one of the local massage places for a 45 minute bout of pain relief. Unfortunately, one time the masseuse got to my back with the glass cups before I could scream placebo. I have photos of my back, taken by my patient daughter. And yes, amorous octopus would be my diagnosis.

    1. Alia says:

      Or an amorous Old One or another Elder Race (sorry, I’ve been reading too much Karl E. Wagner recently and everything looks like tentacles to me right now).

  12. Chris Hickie says:

    When I saw the title of your blog, I thought I’d finally made the big time (with the usual misspelling of my last name). Dang.

  13. Cupping is a form of myofascial release therapy and when used properly is a great adjuvant to the overall care protocol mostly for pain, but can be beneficial in RSD/CRPS, SSS, FM and neuropathies.

    As usually some nuts will dramatized the therapy and people who want to be naysayers will use this to disavow all of the data.

    It is valid just as Acupuncture and all of the other alternatives that have been vetted.

    1. Lytrigian says:

      I think most here would agree that cupping is every bit as valid as acupuncture.

      1. So you also have surcome to the groupthink mentality. Please do some research and you will see the links.

        1. WilliamLawrenceUtridge says:

          Why don’t you provide us with the links Steve? Why don’t you give us the evidence that supports your assertions?

          1. Windriven says:

            Oh he has, William. But the links are all to silliness like Gunn. IR really does not seem to understand the difference between scientific evidence and a collection of anecdotes. We talk back and forth with him but it is in different languages.

            This is like trying to explain to Jamie Coots that god ain’t gonna save him from rattlesnake venom. He believed just as strongly as our friend here believes – right up to the point his heart stopped. I wonder if his last thought was WTF?

            You can lead a horse to water but you can’t keep him from drowning in it.

            1. WilliamLawrenceUtridge says:

              You can lead a horse to water but you can’t keep him from drowning in it and it’s illegal to hold their head underwater

              FIFY

        2. Lytrigian says:

          That’s “succumb”. And I actually tried acupuncture a few times. I went to the most reputable practitioner in a heavily Chinese area; he was an acupuncturist others brag about having been trained by.

          Not only did it do nothing for me, but I didn’t even get the warm fuzzy treatment you’re supposed to receive from CAM practitioners. The actual problem was stress and associated symptoms, but not even the enforced relaxation of being made to lay there with needles all over you did anything.

          1. WilliamLawrenceUtridge says:

            Ah, but Lytrigian, you weren’t getting real acupuncture. If you were getting real acupuncture, the kind that Steve provides, based on ancient wisdom and some books published in the early 80s, then you would have gotten better. See, real acupuncture works, and if it didn’t work for you it’s because you didn’t get it.

            Reasoning provided by a Scottish friend of mine.

            1. Lytrigian says:

              I’m pretty sure that if it wasn’t coming from me, Steve would approve of this guy. His office reeked of moxibustion fumes, but apart from the TCM he had all the trappings of a medical office, including folders with patient records, an array of examination rooms, and a receptionist.

              The Chinese herbal pills he sold me didn’t do anything either.

  14. “Wishing to avoid chiropractors (thank you Dr Gorski and others!) ”

    Wow, what a short sighted way to view medical therapies!!! The UK/Australia are attempting to reconstruct the wheel by foolish means that will slow effective and vetted therapy for a lot of people in pain.

    It is happening in the US to some degree too

    Unethical !!!! (in my personal opinion)

    1. Windriven says:

      Wow, what a short sighted way to view medical therapies!!!

      What does chiropractic have to do with medical therapies?

      1. Exactly who should bless a medical therapy?? Hopefully a lawsuits will help expedite a more broader view to healthcare. With the advent of social media, I hope a few motivated neglected souls will connect and make this happen.

        The problem with scientist is that if they are completely sure they will do harm.
        I am not but I want to know. Juggling old stale data around is futile.

        All I want are legitimate RCTs that includes the up to date concepts, the best clinical practitioners and researchers.

        1. weing says:

          “All I want are legitimate RCTs that includes the up to date concepts, the best clinical practitioners and researchers.”

          Then do it. Apply to NCCAM for a grant. Don’t waste your time with us making claims.

        2. WilliamLawrenceUtridge says:

          Anyone else starting to wonder if Steve’s a Turing test in training? As time goes on, his comments seem to make less and less sense.

          1. Windriven says:

            If he is, they’re running it on a TRS-80

          2. That is because you guys are not doing any extra reading or research,

            On any account, cupping is a valid adjunct therapy in the list of MF release therapy hands-on.

            1. WindriveA says:

              We’re all doing lots of reading and some of us are doing considerable research … Just not in areas that you want.

              We’ve told you repeatedly: acupuncture has been studied. It is bullcrap. It is placebo with potential harms. We aren’t going to spend time on this.

            2. weing says:

              “That is because you guys are not doing any extra reading or research,”
              I’ve told you before. The onus is on you to prove it. You do the research, publish it, and we will review it. Your NCCAM has had years to fund this type of research.

  15. “There is no reason to waste time and money on interventions with no reason to work.”

    That is a personal opinion that has been formed on the weakest possible research filled with biases comments and as such is not at all scientific. This is a good example of confirmation bias.

    Read my list of authors to expand the research field and I am certain that your conclusions will be different.

    1. WilliamLawrenceUtridge says:

      That is a personal opinion that has been formed on the weakest possible research filled with biases comments and as such is not at all scientific. This is a good example of confirmation bias.

      This is an indication that you do not understand Dr. Crislip’s objections. See, there is no physiological reason why cupping should have any systemic effects. At best it might impact muscle, joint or other mechanical pain. It is certainly an opinion, but one informed by a deep understanding of how the body actually works, how disease starts, how to stop it, and the theoretical background that informs cupping (i.e. essentially the presence of unidentified “toxins” and “energy” for which there is no evidence). The research underpinning a conventional medical understanding of the body is quite massive, quite excellent, and quite strong, with a compelling convergence of data indicating that even if our understanding is perfect, it is far more accurate than the prescientific ideas of traditional Chinese medicine (which is informed, in part, by astrology). Confirmation bias is not an issue since the evidence base supporting cupping and TCM is quite weak and no strong studies have been identified on the topic, despite numerous efforts.

      Steve, can you even define confirmation bias? Have you ever took to challenge your own confirmation bias? How would you do that?

  16. Brad says:

    “April 12/13 I will be in Manchester at QED ostensibly to give a talk and participate in panel discussion. I am really there to see if there are any English beers better than those here in Beervana. I doubt it.”

    I love your posts, but this took it over the line. As a native Mancunian I urge you to want to leave after sampling the finest ales in the world. :P

  17. All the comments above have failed to address the TRUE issue with this article.

    Namely:

    Why didn’t Mark get his warp engines upgraded, like the USS Voyager, did, so that they wouldn’t damage subspace above warp 5?

  18. Rokujolady says:

    As far as I know, the Egyptians didn’t do cupping. We have a few medical papyri, and I don’t recall reading about it.
    Crocodile dung pessaries, though….I don’t see that becoming popular anytime soon.

    1. WilliamLawrenceUtridge says:

      Not to split a hair or anything…

      Go here and type in “A608649″ in the search box. It’s dated 300BCE to 300 CE, and is from Egypt. Not one of the ancient medical papyri, but still Egyptian :)

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