Wednesday, November 26, 2008

The Wisdom of Crowds


The following is an MDOD original experiment.


Above is an image from the medial ankle of a 70ish year old male. He has had similar ulcers on his anterior and posterior legs over the past year. He travels broadly and regularly. He is generally healthy and has no known vascular disease, diabetes or history of an insect bite.


Here is the experiment: What The Heck Is This Lesion?


"The Wisdom of Crowds" is a term popularized in a book of the same name that makes the argument that the aggregation of information in groups results in decisions that are often better than could have been made by any single member of the group. A famous example is of a crowd at a county fair that accurately guessed the weight of an ox when their individual guesses were averaged. This average was the single best estimate of the weight (better than any single person's guess, including 'regular folks' and 'experts').


I want to see if the most common guess for the diagnosis of this lesion is the actual diagnosis.


I personally think the masses are a bunch of morons. Prove me wrong.

98 comments:

  1. I could be all Internist-y and list 30 possible diagnoses, all of them wrong, but I'll take a shot in the dark...I've seen enough CSI to recognize a bite wound when I see one! What I want to know is who's been biting those ankles? and more importantly why? Is there a Night of the Living Dead Flesh Eating Zombie Uprising goin on that the medias ignoring in the post-coital Obama victory bliss?? Or it could just be a venous stasis ulcer.

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  2. Ew, I don't like it when frank get's all medical.


    Ruins that badass image.

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  3. I like the venous stasis idea, but will guess diabetic neuropathy ulcer.

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  4. My vote is for venous stasis ulcer.

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  5. Venous stasis, I think you guys are thinking way too hard on this one.

    Cutaneous leishmaniasis ? ReallY? Just seems like a far stretch for me, considering these are isolated to the LE's.

    http://dermatlas.med.jhmi.edu/derm/result.cfm?OutputSet=2&BO=AND&Diagnosis=1020654547

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  6. Looks just like the cutaneous leishmaniasis rampant in this part of the world, but I'm just a no account Army doc waiting for some real training...

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  7. yeah, but with leishmaniasis, you always have to think about it in a nondiabetic with an ulcer who has traveled to somewhere with a beach that has endemic leshmaniasis...so since this guy travels extensively, the likelihood that he crossed a beach is high, and the chance that he got bit by the sandfly is high as well....

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  8. Spider bite? (I'm not a doctor, nor have I stayed at a Holiday Inn Express.)

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  9. I think it looks like a rotted carrot.

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  10. Cutaneous anthrax

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  11. OK, I can't resist the opportunity to play Internist...."You can classify skin lesions by etiology, for example, Infectious,(Bacterial, Fungal, or Viral), Neoplastic(primary or metastatic),Rheumatic, Asthmatic, Socratic, Democratic, Enthusiastic, Auto-Immune, Picayune, Camp Lejeune, blah, blah, blah, 45 minutes later they'll get to venous stasis ulcers...Which it probably isn't now that I think about it...

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  12. I vote for cutaneous leish. No hx of diabetes or vascular disease, extensive travel, and recurrent ulcers.

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  13. ER Diagnosis: non-emergent lower extremity ulcer

    Plan: change dressings daily and follow up with primary physician next week, return if worse

    Common things being common and location being important, it's a venous stasis ulcer.

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  14. That looks frighteningly like the MRSA I tangled with last year...so that would be my best guess.

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  15. The whole leg looks like venous insufficiency, so I'll go with the herd and say venous stasis ulcer. Perhaps this patient has a DVT (or has had one) given the travel. The reddish tissue surrounding the ulcer looks like stasis dermatitis to some degree.

    Or, if I'm sticking with nursing, I'll say "Wound check", give it a triage score of 4 or 5 depending on if I'm feeling generous or not, and direct the patient to the magazines and television for a long wait.

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  16. i'm digging the cutaneous leishmaniasis and cutaneous anthrax possibilities. the other lesions make a brown recluse bite unlikely but it was my first thought.

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  17. Looks like staph. Maybe cooking under a hiking boot for a few weeks.

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  18. I'm in the non-expert category. I have no formal training. That said, I'm still going to throw in a few thoughts to represent the Great Unwashed Mass.

    1. He's old. Old people just don't notice shit wrong with their bodies until it's gross and stinky. They don't go to the doctor because they have this fear that everytime they go to the ER, "Those doctors are just going to put me in the hospital and take away my car!" So I'm suspicious of that. Something like this just didn't happen overnight. What did it look like early on?

    2. Old people are fragile. For every old person who runs four marathons a year, another 100,000 are languishing on the downward slope of life. Nothing works right in their bodies anymore. Their skin falls of in sheets. They bruise with an angry stare at previously healthy skin.

    3. It's directly over a bony prominence. Active, much travel? Poor fitting shoes that caused a subtle break in the skin leading to population of bacteria and shit? Maybe it began as cellulitis but went untreated.

    So my final take -- the patient neglected his injury until it became this disgusting mass of stinking flesh flaking off in the shower, leaving a pus-stained mess on his bed sheets.

    And: Rheumatoid arthritis-associated ulcers compounded by his venous insufficency.

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  19. Hey, I just realized... THIS PATIENTS DEAD!!!! Ewwwwww..... Better shoot him in the head quick before he comes back to life and joins his Zombie buddies. Still looks like a Venous Stasis Ulcer.

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  20. Oh, yeah. That changes things a bit.

    ER diagnosis: dead patient with nonemergent leg ulcer

    Plan: send his body to the morgue and open up that room so I can see someone who isn't dead yet.

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  21. I hope y'all have a great Thanksgiving. Turkey's in the oven, football game's about to start....time to crack the first beer!

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  22. the turkey gobbled his ankle

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  23. After slogging around the Peruvian Amazon, I was guessing leish as well. I saw some cases that looked exactly like that. Yerk.

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  24. MSRP, no!
    NRA, no!
    CREEP, no!
    NAACP, no!

    MRSA, yeah that's the one!

    I think it is MRSA. But then, I'm a comedy writer and not a doctor, so what do I know? I've had a few MRSA infections; you pick them up where the dregs of life are milling about, like in prisons and comedy clubs.

    Jerry

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  25. He's dead? How do you know he's dead?

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  26. Disgruntled internist11:54 PM, November 27, 2008

    Heck, I'm going with Corynebacterium pyogenes, acquired in Thailand.

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  27. Anonymous,
    You can tell he's Dead by the faint ring of "Liver Mortis" visible at the circumferential wound margins, more astute observers will notice the dissecting/autopsy table at the top of the photo, and most obviously, if this was a LIVING patient the HIPPA Police would have ETOTHEIPI locked up faster than Barney Frank goin down on a new Puerto Rican Pool Boy.

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  28. Lol. A good ol game of guess the disease. What you docs do for fun makes me laugh. Sometimes my friends and I play this game instead of quarters. Your pics of dead people ankles are amazing!

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  29. Looks like venous stasis to me, or one hell of a spider bite.

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  30. I've got it!! This is a man who was cheating on his wife of 30 yrs, the wife who put him through law school and bore his five children.
    She discovered that he has been cheating on her with that skanky blond secretary with fake tits that she never liked anyway. She promises hubby mind-blowing sex, but she has to tie him up first. He was found weeks later by a neighbor complaining about the smell from apt. 13. Wife was cleared of all charges by female judge.

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  31. Probably not the cause of death, right?

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  32. Open subcutaneous MRSA abscess caused by skin-popping heroin while traveling?

    Ok, moooo...go with the herd: venous stasis ulcer.

    But I'm just a nurse.

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  33. You can tell he's Dead by the faint ring of "Liver Mortis" visible at the circumferential wound margins, more astute observers will notice the dissecting/autopsy table at the top of the photo,
    Dammit, Frank, no fair! I thought that table was the checkout counter at McDonald's.

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  34. I think it looks like something from a parasite or a small animal chewing at it. I wonder if this guy has some neuropathy which makes him fail to notice the rats chewing him up at night. Or if he has leishmaniasis. Or something like that.

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  35. Ahh got it now! Post-mortem bite wound from a hungry Kitty!!

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  36. I have a carbon copy of that ulcer on the top of my right foot, so I know what it is. But I'm not telling.

    Monday mornings at the Wound Care Center are such fun -- coffee, danish, and debriding!

    Some of what I have learned? "We like red!" "The technical term for that stuff is s-l-o-u-g-h." "30 grams of Collagenase Santyl costs 65 bucks." "Enzymatic debridement beats the shit out of having Brandi brandish her scalpel and shiny scraping do-dad." "Elevate, elevate, elevate!"

    The winner? Ten little words: "Paper tape and skin barrier wipes make great Stocking Stuffers!"

    Oh, and that man is clearly alive.

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  37. Wegners Granulomatosis or vasculitis? Not a doctor, just playing along.

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  38. Heres a free ID consult:

    Depends on where he's travelled to: Mycobacterium ulcerans (Buruli ulcer) and CL both look like this. CL will often heal spontaneously , a Buruli ulcer won't.

    I'd biopsy the edge of that baby.


    Probably just a venous stasis ulcer or pyoderma gangenosum though.

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  39. Its been long enough Etotheipi, whats the answer?

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  40. Eto'a a Pathologist, they don't work weekends.

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  41. So after arriving late to work, 3 cups of coffee, and boinking the new 19 year old phlebotomist we should have our answer around 3pm on Monday.

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  42. Being a non-medical person but the owner of a fine computer and using my internet skills, I am going to go with a Ischemic ulcer rather than Venus only because the patient is ACTIVE and over 65 with no history of Diabetes or circulation problems and the wound is kinda white in the middle. (and I thought the table in the background was the lunch tray provided by the very caring food server/volunteer at the hospital)

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  43. Is not the patient a moron for allowing this lesion to get in this condition? For that matter is not his doctor a moron? My 95 year old father is a Doctor still practicing medicine after most men have long been retired. Why does he still practice? Because, as he says, he hasn't gotten it right yet...apparently there are other doctors out there who should continue to practice.

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  44. Sandi, hate to bust your bubble, but the only reason 95 year olds still practice is the chance to do "Sports Physicals" on 16 yr old cheerleaders. Patient might be a Mo-ron but what would YOU do when your blood don't flow so well anymore? Besides, most diabetics can't fell anything south of their bellybutton anyways.

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  45. That's a really bad case of dry skin. Has the patient considered a good moisturizer? That's if he is still alive. Otherwise, never mind.

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  46. It really looks like a venous stasis ulcer, but they usually are not over bony prominences are they? And you said no known vascular disease...so no arterial problems or venous return problems, and that black area at the top....hmmm. MRSA? But I just don't see MRSA like this in elderly people come to think of it. Makes me think more of a pressure type lesion...where are the wound care nurses when you need them?

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  47. etotheipi posted this, i think, because he doesn't know the answer and the case is a puzzler. if not, it is time for the great reveal sir. now get that net zero dial-up thing cranked up and tell us the answer.

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  48. Oh you waited too long etotheipi! Your answer better be amazing now! It's like a long joke that has no punch line, or the punch line is really lame. I hope you don't wait this long before diagnosing all your patients!

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  49. All of his patients are dead, so no biggie.

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  50. He's a Pathologist, thats what they take 6 years to learn how to do, To take 3 weeks to tell you its either
    A:Cancer,
    2:Inflamation,
    C: Cancer WITH Inflamation, or
    4: Normal..
    They're like Radiologists with cold hands and creepier personalities...Y'all think he's jokin about bu-fuing the dear departed...

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  51. I dont care wtf it is that caused it but I will say you deserve an award for the originality of this whole blog! Well done, well written and personally I have enjoyed it thoroughly. That said, Im guessing a meteor hit him right in the ankle.

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  53. cutaneous ulcer due to rheumatoid arthritis

    no idea- just a pharmacy student, not a diagnostician

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  54. Are ‘the crowds’ wise?

    Well, here’s the tally:
    Venous stasis: 11
    Cutaneous Leishmaniasis: 5
    MRSA: 3
    Pressure ulcer: 3
    Spider bite: 3
    Buruli ulcer: 2
    Pyoderma gangrenosum: 2
    And one each for: diabetic ulcer, anthrax, c. pyogenes, vasculitis, meteor strike, and Ellen Kimball rambling incoherently.

    Actually, a pretty good differential overall.

    BTW Frankie, the patient IS alive, and, yes, I avoid the hospital on weekends so I can spend them on my yacht, eating ortolan* with Beyonce / Sasha Fierce.

    Diagnosis to follow shortly. Patience is a virtue so chill the fuck out.


    *For centuries, a rite of passage for French gourmets has been the eating of the Ortolan. These tiny birds—captured alive, force-fed, then drowned in Armagnac—were roasted whole and eaten that way, bones and all, while the diner draped his head with a linen napkin to preserve the precious aromas and, some believe, to hide from God.

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  56. Amy, let you in on a little known medical secret, all those "Cultures" get thrown in the red "Biohazard" bag thats only a ruse, cause you gotta pay extra to dump "Biohazard" bags at the landfill. I mean, has anyone ever actually gone and looked at a culture? Even if you did, is there a properly filled out Chain-of-Custody form?? Nope. Reminds me of this GP's office from Med School, had an X-ray machine right outta Frankenstein, red flashing lights and everything, only problem was, every film came out as dark as Ted Kennedy's Soul, didn't keep him from reading the same old films "Wizard of Oz" style, to get that Placebo affect...

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  57. Now that I'm back in the "world," with time to think...given the hx, no vascular disease, etc., and given his extensive travels, I'd ask if the pt was in any desert, not necessarily beach, areas. This lesion looks exactly like the cutaneous leishmaniasis I see frequently in Iraqis. Venous stasis is possible, but...the hx indicates otherwise. Looking forward to the Grand Pronouncement.

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  58. Looks like venous stasis with surrounding varicose eczema. Don't have much experience of CL as it's too cold and damp for any interesting organisms/fauna to survive in the UK- apart from Foot & Mouth of course.

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  59. Oh and Gordon Brown, who is a very curious specimen.

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  60. Haven't read all the posts yet, or if you already gave the answer, but my guess is: diphtheria, cutaneous manifestation

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  62. primary cutaneous blastomycosis

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  63. This is, btw, a "live" case.

    I'll give my dx tomorrow if all info and other shiznit is in.

    E, out.

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  64. also, an unrelated comment:

    the poll on the right side of the screen about a survival medicine course is poorly designed. Of course people are going to vote for a lower price as to what they will pay. Without looking at the polling results I can tell you that '250$' or 'not interested' is going to get the most votes.

    get your head out of your ass 911.

    Oh, and I hope your thanksgiving was great.

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  65. A theoretical question off subject here.

    You have a father-in-law (who you like and has a mean game of golf)who has sudden onset of abdominal swelling. Was always a bit heavy, but now we're talking about Santa Clause belly here. Dizzy when he stands. Goes to GP. Gets some x-ray/EKG that requires swallowing fluid. All normal except lots of abd. fluid and liver is a bit on the small side (he's a small man theoretically anyway). Blood work comes back slightly diabetic and thyroid off-kilter slightly. Rx drugs to offset. Send to Gastoent for eval. Drain fluid. Fluid comes back w/in days and causes lots of pain/nausea. Face very sunken and skin pale/pasty. Still lots of dizziness. The GP has ruled out cong. heart frailure. Now have discovered nodules on pancreas and something up with liver. Theoretically, would you recommend your father-in-law to see a cardiologist or who? Thanks for any theoretical ideas.

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  66. dear anonymous,
    this is not good news re our theoretical patient. you might look up the term 'ascites' online and i suspect that the theoretical patient may have been drinking a bit. the nodules require biopsy, probably by needle-guided CT scan, also, studies on the fluid that was drawn off might yield a diagnosis. the best advice in this case is to press hard to get the workup complete and get the diagnosis. there are rarely two diagnoses at once and there almost certainly will be a unifying diagnosis here. i do not think the cardiologist is next, i think the gastroenterologist and interventional radiologist are next. best .

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  67. Don't know how to tell ya this annonymous, but your Father in Law is Pregnant, maybe the radiation and teratogenic drugs will work, maybe not. I'd call in a scrip for some pre-natal vitamins, but that OB liability is just insane....

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  68. 911 Doc - theoretically I think we're on the same page, he's seeing a gastroent. However, the theoretical patient does not drink - has only had about 10 beers in his lifetime (72 YO), which is throwing everyone for a loop. Drinks a LOT of coffee though. Theoretically we're heading for the biopsies of the nodules on pancreas and a liver biopsy. Rx's by GP in July are metformin and levothyroxin, lisinopirl-lt.

    Frank - you are too funny! The theoretical Father-in-Law loves kids and I'm sure he WISHES he could be the "pregnant man"!

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  69. anonymous,
    i was really hoping for drinking in the history. please do keep us updated and as long as we don't form a doctor-patient relationship we are happy to help. in fact, thinking about starting another blog where we do just this sort of thing. ask the GP if 'cytology' was done on the fluid and if so, what the results were. best.

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  70. 911DOC - I think the idea form a blog for this sort of thing would be of great value or at least comfort. I know a lot of people, like me and my friends, who aren't med-saavy enough to understand all the verbage on WebMD. To have someone who can point you in the right direction, or at least to maybe think of something which you haven't, could be of real value. And, of course, with you guys' sense of humor it can be very entertaining! I very much and deeply appreciate your help! While we may not change the outcome, we might at least be able to take away his high level of pain. Cytology wasn't done on first fluid draw - but will be on this one this week. Will keep you updated. Thanks again! Let us know if you start the other blog!

    BTW - would one of you post SOMETHING so that disgusting ulcerous-whatever won't be the first thing you see on the blog! BLECH!!

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  71. "Diagnosis to follow shortly. Patience is a virtue so chill the fuck out."

    In true pathologist form, 5 days to get a simple answer. Come on you bastard spill the beans, I have 10 dollars riding on this.

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  74. Ortolan attack to the lower extremities. Payback's a bitch.

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  75. I think you blog idea is a great one too, 911doc. Opens up so many closed doors in communcation on not only doctor to patient relationships, but also doctor to doctor relationships. (I purposefully omitted a sweet gay joke here to show my support.)

    I hope your hilarious posts don't get scarce because of it tho. Because I am very needy of entertainment and I like your politics and disgusting photo shoots, and the Greatest Comments Section Ever. I leave for a day and there's 80 of 'em, and Doctor E. is telling me to chill out cuz patience is a virtue and shit! It's so great!

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  76. "And one each for: diabetic ulcer, anthrax, c. pyogenes, vasculitis, meteor strike, and Ellen Kimball rambling incoherently."

    Lmfao.

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  78. Amy, Amy, Amy, I told ya, Bacteria are fake! How could people live with billions of microbes in their guts??? Jeez, you probably thought the "Wizard of Oz" was a real Wizard..And Greta, was the joke the one about the poor guy getting a rectal exam and feeling the doctors hand on his shoulder? Then he felt the hand on his other shoulder? Thats Rodney Dangerfield, circa 1974

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  79. Ellen your so cute when your angry.

    I have this vision in my head of you pounding the keyboard screaming, I'm not a rambler ! I'm not a rambler!

    Now Ellen dearest, in Etotheipi's defense (not that he needs it) I have to ask you what on earth did your response have to due with the question that was asked ?

    From what I understand from your "post" it had something to do with lotion, flatulence, and old people.

    See you lost me with your opening sentence of; "On behalf of elderly people everywhere" That was just not enticing to me, maybe it will become more flavorful when those AARP mags start piling up in the bathroom.

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  80. Ellens in her "I'm really gonna figure out who these guys are" phase again, it's cute.

    Hey, Docs, if I ever unknowingly pitch a job to you, don't yell at me*, kay?

    =)


    (I've only been yelled at twice this year, EM Docs are nice, those hardcore sub-specialists though...have reduced some people to tears.)

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  82. dear ellen,
    please do not attribute comments made anonymously to the authors of this blog. we say enough controversial stuff that you need not go to the anonymi to find stuff to complain about. also, please cease and desist flogging your blog here. i will, as stated above, delete gratuitous link posts. if someone is interested in your blog they may simply click your name in the post.

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  83. Both of my parents are in their 70's. While they do have friends who are "old and decrepit" and are just looking to sit in their rockers on the front porch, there are some older people who are just of "advanced age" - as they like to put it. But even so with their active lifestyles and healthy attitudes and well-cared for bodies - they still can't tell you where a bruise on their arm the size of a baseball came from or when they got it. And honestly, they both have memories that are sharp as tacks, so they must really not be able to feel this stuff when it's happening.

    Of course, they can't drive for squat and should be taking driver's test every couple of years, but that's another topic entirely.

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  84. Caption from an entry in Ellen Kimball's blog:

    Old Fat Naked Women for Peace -- CAUTION! Contains NUDITY!

    I'm just sayin'?

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  85. Ellen:
    Trying to uncover the real identities of anonymous bloggers is as acceptable as spitting in someone's Coke. It's not done. Please stop.

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  87. its the same shit i have. When you get a diagnosis , let me know

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  88. I am an an orthotist in NYC , not a Dr. That's a diabetic foot with neoropathic (Charcot?) thats been treated poorly with an ill fitting orthosis. Dr's are not looking at the mechanical cause of injury.

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  89. blacksilicon: And why does Ellen need her husband, presumably, to report this information?

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  90. Hi Ellen. I wrote those anonymous comments. And just for the record, they're correct. Old people are a ticking time bomb of a shart, fart, or big greasy shitsplosion of the most awful stench in the world.

    I asked old people what they thought of your comments and they replied:
    1. Who is this uppity bitch who downplays our fear about going to the hospital?
    2. Is this uppity bitch old? Doesn't she realize that when it takes a duragesic patch and 8 advil to make it to noon that it's no fun being old?
    3. Why get these gross leg ulcers fixed when I can use them to guilt my family into giving me whatever I want by playing the cripple card? I'm using a new Wii Fit because of those dopes.

    So Ellen, quit hating on the elderly. It's fucking rude.

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  91. Little Late, but can't resist piling on the Old Farts..If AGE is so great why aren't we all driving 57' Chevies?? Cause they'd fall apart at the first speed bump, if you even made it that far with the no seat belt, White Shark Teeth tipped Dash Board. Sure, a few collectors drive them, just like we do with old people, once or twice a year, on special occasions, rest of the time they're locked up in a dark garage with a cover over them....

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