Doctors Without Behavioral Borders

NY Times ^ | September 5, 2004 | HAROLD VARMUS

[neverdem]

The pilot episode of "Medical Investigation," NBC's new medical science series, retells a famous old New York story about a rare type of food poisoning that produces blue patients. (The pilot will be broadcast on Thursday night at 10 Eastern; the following night at the same time, the show will assume its regular slot). Though its source isn't credited, the episode (written by Jason Horwitch) is an homage to "Eleven Blue Men," the great medical journalist Berton Roueché's classic account of a mysterious food poisoning that literally turned 11 New York City alcoholics blue.

Well, perhaps "homage" isn't the right term. Roueché's account, first published in The New Yorker in 1947, is careful and understated. As the narrator, he solicits the facts retrospectively from two seasoned, courteous investigators from the New York City public health department who seem to be competing for a modesty award. They have obviously done a clever, systematic and ultimately revealing investigation, working in collegial fashion with the doctors and nurses caring for the patients. And they succeeded: all but one patient survived, and the two sleuths traced the source of the toxic substance to bowls of oatmeal and a single salt shaker that contained sodium nitrite (rather than regular sodium chloride) from a mislabeled package. But the detectives also admit, with humility, to a few loose ends to their story; the survivors were discharged from the hospital before they could verify that they had eaten at the same table and used the salt shaker vigorously. In Roueché's account, as in real-life medicine, good investigators are left with a few nagging doubts.

The pilot's first departure from its source material is its setting. "Medical Investigation" features doctors from an elite (and fictional) unit of the National Institutes of Health. The producers say that the show is meant to celebrate the agency, and indeed, the opening credits mention that N.I.H. has spent more than 100 years improving the world's health.

However, contrary to the premise of "Medical Investigation," that work does not include flying off in helicopters to investigate outbreaks of bizarre maladies. As the millions who saw the film "Outbreak" could probably tell you, such work traditionally belongs in the domain of the Centers for Disease Control in Atlanta, the agency that local hospitals and city health departments turn to when they are stymied by medical mysteries. (I know this, because aside from having seen "Outbreak," I spent six years as the director of the National Institutes of Health). The N.I.H., through its government labs and grant recipients, does medical research on diseases and basic biological problems in laboratories and hospitals; it does not organize the immediate response to medical emergencies: outbreaks of unexplained illnesses, seasonal epidemics, or evidence of bioterrorism. (Later in the season, the show's producers say, "Medical Investigation" will depict clinical tests of new therapies, which is closer to the institutes' actual work.)

Unlike the quietly competent municipal employees who solved the case on which the pilot is based, the staff in "Medical Investigation" looks and sounds like a terrorism response team from a military unit. The doctors have no charm, no uncertainty, and less modesty. The lead investigator, Stephen Connor (played by Neal McDonough), has admittedly useful qualities: extensive medical knowledge and a determination to cure the sick. With angry energy and unremitting focus, he gets the job done. But the trait that overwhelms the viewer, as Connor barks intimidating orders to associates and insults to local hospital personnel, is the man's insupportable arrogance. He marches into the hospital, commandeers the staff and upbraids the seemingly reasonable physician in charge by suggesting that contesting his authority would place eight million lives at risk. One of the producers, Laurence Andries, says the Connor character satisfies the American public's "aching for heroes." But has our fear of terrorism and outbreaks become so great that viewers will accept such uncooperative behavior as anything other than obnoxious?

The other members of Connor's team are not much more likable than he is — which says something about Hollywood's idea of a competent federal agent. Connor's female co-investigator is also his apologist (Connor "suffers from a bad case of high expectations," she says). An African-American technician portentously places Connor in historical context ("the unreasonable man makes the world adapt.") A public relations staffer teases, harasses and temporarily imprisons a reporter who is on to the mystery, successfully suppressing the story until it is solved. (According to Mr. Horwitch, this is supposed to be "comic relief," but it comes off as mean-spirited, lacking in purpose and even unethical.)

As in the original "Eleven Blue Men," the symptoms lead the investigators to a poisonous salt mistakenly placed in a single shaker at a busy diner. But the victims have changed along with the investigators. Instead of an outcast population of old alcoholic men — from whom viewers might feel disengaged — the patients are varied by age and gender. The only one we get to know is a middle-aged man who develops his symptoms as he walks through Midtown Manhattan talking smugly on his cellphone about Amgen shares and Martha Stewart. He's a good personality match for Connor.

Amid all the hectic helicoptering and hectoring behavior, there are a couple of moments of solid medical detective work. Connor tests the contents of the salt shakers by mixing them with drops of his blood in spoons; in one case the blood dramatically darkens. This is more fun to watch and, according to Dr. Robert Hoffman of the New York City Poison Control Center, more credible than the fancy analytic machine that earlier flashed "nitrate, nitrate" when processing the patients' blood. The show also briefly illuminates how a good epidemiologist might think when it portrays Connor reconstructing events: in a waking dream, he imagines the restaurant full of patrons, only a few of whom become the unlucky patients who sat at the wrong table and shook the contaminated salt onto their food.

Unfortunately, such moments are few, and the dominant impression is that epidemiology is about screaming, not about useful, difficult scientific work. It's hardly surprising: unlike the movies, in which scientists have made decent showings (think of the climatologist in "Day After Tomorrow" or the rocket engineers in "Apollo 13"), scientists have rarely if ever made it to prime time network television intact. In its better days, "E.R." used to create dramatic situations that displayed the scientific issues underlying treatment of H.I.V., drug abuse or organ transplantation. But television's efforts to portray medical scientists at work usually involve geeky sidekicks or connivers trying to boost their reputations or salaries with dishonest scientific practices. With its aggravating characters, distorted picture of the role of federal agencies and limited portrayal of medical investigation, this new show seems destined to be just another failure to present scientific work in a smart and appealing way.

If the producers wanted to convey a more realistic atmosphere of threatened terrorism, while sticking with chemically induced cyanosis, they might have scuttled the ambiguous tribute to Roueché and taken their cue from a case recently reported in the Centers for Disease Control's weekly online journal by Dr. Hoffman and his many co-workers. In 2002, five adults of Middle Eastern descent were poisoned in Yonkers by ingestion of sodium nitrite taken from a bag plainly labeled Table Salt. Was this a mix-up or a criminal act? Were other contaminated bags distributed around the country? You will have to read the article (online at www.cdc.gov/mmwr/PDF/wk/mm5129.pdf) to find out. When you do, you'll notice that the public health experts treated all five patients successfully before knowing the cause of cyanosis; Connor's team waited for his spoon test before treating his blue patients, therefore losing a patient. Which is just one more reason you might not want to entrust your Friday night — let alone your medical care — to a doctor like him.

Harold Varmus, president of the Memorial Sloan-Kettering Cancer Center, shared a Nobel Prize for studies of cancer viruses.

[neverdem]

ping

[Criminal Number 18F]

Television. People still watch that?

Funnny thing. I used to just think it was my professions that TV always got wrong, but it had all the others right. But the more people I meet, every one of them says the same thing: TV totally screws up its depiction of my profession. And the list of professions that it might be getting right is getting smaller and smaller every day....

Poor Dr. Varmus probably thinks that they only screw up medicine and science. Well, I can tell him they screw up the military and aviation. My friends say the same for police work, firefighting, and law.

d.o.l.

Criminal Number 18F

[RonHolzwarth]

"a mysterious food poisoning that literally turned 11 New York City alcoholics blue."

I thought that alcoholics often die, and then turn blue.

[neverdem]

Television. People still watch that?

I still keep cable channels on for breaking news frequently. I'm a news junkie. I gave up TV shows about the military and medicine long ago. I may watch movies or the history channel if there's nothing on Fox News, Dennis Miller or Joe Scarborough but a seasonal hurricane. There was a funny movie on Cablevision's channel 75 in NYC tonight called "Shanghai Fever" if you could tolerate subtitles.

I wonder what the big brains are thinking now that Fox News had higher ratings than the broadcast networks for the RNC convention.

[neverdem]

I thought that alcoholics often die, and then turn blue.

That has nothing to do with being an alcoholic. The other ten victims turned blue before surviving. The mislabeled sodium nitrite interfered with the normal carrying capacity of hemoglobin, the special protein in red blood cells, for oxygen. So the one person who died was chemically suffocated. Here's a link

[clee1]

Television. People still watch that?

For the past six years, if it isn't the Fox News, History, Discovery, and whoever-has-the-Braves-game channels, it doesn't get watched at my house.

[clee1]

I wonder what the big brains are thinking now that Fox News had higher ratings than the broadcast networks for the RNC convention.

One word: RETIREMENT!

[KeyWest]

Ron was making a funny, and a good one too.

However, I remember back in my drinking days that I would turn blue, but usually the day after.

[TASMANIANRED]

ping

[RonHolzwarth]

ME: I thought that alcoholics often die, and then turn blue.

Neverdem: That has nothing to do with being an alcoholic.

Keywest: Ron was making a funny, and a good one too.

Well, actually there is more to that story. Within the last several months I had a horrifying series of experiences with an alcoholic roommate that also has a serious drug abuse problem.

He drank himself into a stupor (like he did about every night), and then took a number of sedative pills. Later, I learned that the sedative pills, I do not know exactly what, but some sort of relation to Valium, when combined with alcohol, suppress the breathing mechanism.

He didn't get up for work the next day, and later his dog suddenly made a HUGE fuss from his bedroom. Thinking that he was simply to lazy to let the dog out to relive himself, I opened the door, and saw my roommate lying on the bed with a distinctive bluish tint, especially on his lips.

I did chest pounds to get him breathing again, frantically called 911, and the medics were able to revive him, and so he lived to drink again.

Later, he did it again, but not to the point of cessation of breathing. Later, I had to drag him to bed, and later to the bathroom, since he was no longer able to walk, not wanting to call 911 AGAIN! (The hospital bill from LAST time was not yet paid off, I doubt it ever will be.)

A couple days later, when he came to, he said, "Someone must have slipped something in my drink!"

Rather soon after that, I found another place to live, and moved out, I simply could not deal with that situation.

That is why I was under the impression that:

Alcoholics often die, and then turn blue.

[Erasmus]

Back in the 50's there was a TV series called "Medic" starring Richard Boone.

This was the theme of one episode; except, as I recall, they had the owner of the diner intentionally substituting the Sodium Nitrite because it was cheaper than Sodum Chloride.

Years later, I began to think about this episode. How can anything be cheaper than table salt?! If Sodium Nitrite really was cheaper, I don't see how the diner owner could possibly be saving more than about a nickel a month.

[neverdem]

How can anything be cheaper than table salt?!

It could have been stolen, then sold at a bargain price.

[lainde]

BTTT