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The Woman Who Needed to Be Upside-Down (discovermagazine.com)
301 points by danso on Aug 31, 2012 | hide | past | favorite | 60 comments

This sounds a lot like the occasional support request that comes in to me....

At first it's dis-believable and impossible, and you think the person is crazy, but after "troubleshooting" something rational pops up.

I can't tell you how many times this has happened. But it really doesn't help having a product/service that manages (on Windows) an underlining system of Virtual Hosts, dozens of configuration files, Apache, PHP, and MySQL, and a bunch of other software and tools (http://www.devside.net/server/webdeveloper).

It very much reminds me of one time when I had a spare screw that had fallen behind the motherboard, in the case.

Every once in awhile, I'd bump my desk and the computer would shut down, and wouldn't boot until I thumped it. ("Russian components, American components, ALL MADE IN TAIWAN!")

Completely baffled me until I was upgrading something with a friend, and he found the little guy rattling around.

My favorite example of this was a user who wrote to me about audio streaming software that he could use with classical music, but that disconnected when used to stream rock and roll.

After a great deal of highly baffling troubleshooting, I finally figured it out. The streaming software sent the music over UDP, where each packet contained a pre-set amount of audio encoded with a lossless codec. Classical compresses better than rock, so it generated smaller UDP packets. The guy had somehow managed to set the MTU of his LAN interface to 1200 bytes, and the software was using IPv6, which doesn't do IP-level fragmentation when the MTU is below 1280 bytes.

When playing classical music, every audio packet was less than 1200 bytes. When playing rock, an occasional packet would not compress well and end up too large, then fail to send. The software would then abort the connection in response to the error.

Wow, that is absolutely insane. You get major kudos for going to all that trouble to find out the answer to that one.

Agreed - you are my hero for today.

This was a great story, and really demonstrates the value of being calm and accessing a situation. This could have easily turned into a worse situation had the doctors forced the man to drop his wife and then examine the situation.

It's like the medical version of the 500-mile email.

In similar vein here is a case of the programmer who couldn't login to his system when he entered password standing up. http://netlib.bell-labs.com/cm/cs/pearls/sec0510.html

Now that is an interesting story, and one I've never seen before. I'll have to keep that in my back pocket.

I posted my own similarly mysterious story a while ago on here: http://news.ycombinator.com/item?id=1293849

Good to remember the next time you get a bug report from a user. Perhaps your system really isn't as perfect as you think it is.

Truly. The story reminds me of all the times I've coded and stumble upon a bug that simply shouldn't happen because it defies logic. It usually takes a nap or re-write to realize the impossible bug was a minor typo.

The worst are when you spot a bug that means the functionality should never have worked in the first place, yet somehow has been working fine in production for years. I really rather hate those ones.

"Hate" isn't even a strong enough word for how I feel when that happens. The cognitive dissonance is so strong and discomforting that I don't even have a word for it. I mean, there you are, looking at a bit of code that absolutely, totally, could not possibly work, and yet you know that it has been working. When I encounter that, I suspect I feel something like what the characters in H.P. Lovecraft stories[1] feel when they come face to face with some terrible, grotesque, eldritch being that could not possibly exist.

Iä! Iä! Cthulhu Fhtagn! Ph'nglui mglw'nafh Cthulhu R'lyeh wgah'nagl fhtagn!

[1]: http://en.wikipedia.org/wiki/Cthulhu_Mythos

Whenever this happens I am tempted to "debug" the non-problem but I know it would be a waste of time to find out why something worked. Drives me crazy.

IDEABOLT: Create a central repository of interesting cases and diagnoses, with a super intuitive UI, make it freely available to all MDs in the world to fill up and consult, sort of like the github for doctors.

You can make money by being the intermediary to find subjects for experiments, e.g. "For a study we are looking for identical twins who cannot see from birth but now one has restored vision where the other does not".

Does something that looks remotely similar exist?

I've been thinking about this for a while, in more general terms. Last year I had an issue with my eye. I bumped around from doctor to doctor (including one eye specialist) for nine months, for at least half of that period on two different antibiotics and a ten minute a day eye cleaning ritual. Finally when nothing seemed to be working I was bumped up to an eye doctor at a bigger hospital two hours away. Within a minute of seeing me, he had a diagnosis. It involved no medicine at all, cleared up the problem within 48 hours, and still seems to be working fine nearly ten months later.

My thinking is that a properly programed medical diagnosis expert system probably could have figured out the issue by the second or third trip to the doctor. Further, my guess is that a nurse who has been properly trained to use such a system would be at least as accurate as your average doctor.

Unfortunately, my next guess is that any such system would be opposed by the medical establishment and quickly sued into non-existence by patients it made mistakes on (even if the rate of such mistakes was significantly below that of normal doctors).

You're right physicians as a rule generally dislike software like that (partly because of their egos and distrust of software and partly because of job security). There are so many edge cases and so many examples physicians could give you of the AI/computer being wrong. A simple example is that any software will need input regarding the patient's history, his/her vitals. Right now heart rate data in ICUs is fed every second to storage systems. Let's say the this is a NICU and the baby's heart rate is suddenly elevated to extreme levels. The software would assume that something is wrong with the baby, when in reality a nurse is simply taking a blood sample and the baby started crying, being agitated by the nurse/needle. There are a lot of examples like this, it's a non-trivial problem to build use machine learning to take all of these factors into account to produce a diagnosis/treatment/intervention plan.

I was recently at a medical/technology conference and the physicians in attendance were all actually in support of moving to using machine learning/AI (selection bias though, that was what the conference was about). They would rather have a machine with a 5% error rate than a human with 20% error rate. They believe that the role of physicians is going to change and become more of a management role as technology catches up.

Sounds like the mother of all selection bias, but still this makes me hopeful!

Back in the 90s, I was a research assistant to a couple of doctors who were working on that kind expert system. The main difficulty is the lack of electronic patient records. Most things in medicine are still done on paper. The other problem is that an expert system that does patient diagnoses is regulated by the FDA as a medical device, and it's incredibly involved to prove that it works well enough to be safe. That's why you see these systems pop up in research settings all the time, but very rarely deployed in the real world.

Such a system was developed in the 70s, MYCIN (http://en.wikipedia.org/wiki/Mycin). It wasn't used because of the state of technology at the time. Today it would probably perform much better.

Something similar does already exists, telemedicine. A lot of hospitals are starting to experiment with consulting via telemedicine (with robots for instance for video communication and bedside visits) for interesting/hard cases. It's not the same as what you're describing, but HIPAA regulations and how hospitals work would most likely rule out an "open" service like that.

I looked into a related, more advanced version of this a couple years ago. It's basically impossible. You can't do it on patient records directly (HIPAA) and if you do it through case studies in PubMed, for example, the copyright holders (e.g., NEJM) will destroy you on licensing fees.

Can't you have doctors enter data into the system (without giving any patient identifying information), for example like the article here? Then, if you want more specific information, you can control the doctor perhaps.

No. Doctors can't give out patient information under HIPAA, even anonymized information.

Then how does PubMed get it?

Sorry, I mean without specific releases. The patient has to agree to have their information published.

That's one of IBM's plans for Watson: http://www.wired.com/wiredenterprise/2012/03/ibm-watson/

There was something floating around on HN a few months ago. I've seen the topic come up a few times. I actually think doctors do have services like this, its just they are a walled garden supported by lots of expensive contracts and sales reps, as all things healthcare seem to be

Yes. Dr. House, MD.

As a big fan of House MD and a software engineer I have always been wondering how often doctors turn to the web to look up strange cases, or is there a benefit in creating a better structured and curated site specifically for that? I guess WebMD is this kind of site, but could someone knowledgeable in medical practice share the thoughts on that?

Granted, once I knew she was on pacemaker, I figured that this has something to do with electrical connectivity. But then again, may be this is consequence of my poor soldering skills and watching too much of House MD.

A few months after IBM's Watson won Jeopardy, the IBM Research team came to the Texas Medical Center in Houston for a dog and pony show about its possibilities for health care. They presented for two hours to an auditorium of a hundred doctors and administrators from TMC, one of the premiere medical communities in the world. From a technical point of view, it was pretty impressive what Watson can do, reading everything, never forgetting, assigning weights to knowledge over time, able to explain where it got an answer. But when the time came for the doctors to respond ... ouch! One male doctor said "I already have access to a $500,000 decision support system and I don't use that. Why would I start using your stuff?" Another woman cardiologist said she could see using Watson on about ten percent of her office appointments, but she had a hard time seeing how to integrate it and not be slowed down for the other 90% where it was unnecessary. Doctors are a tough crowd.

The Ruby Rogues podcast had Conrad Barski, author of Land of Lisp, a while ago:


Barski is a medical doctor who gave up medicine to code. He explained how it just didn't fit the medical culture to be interested in thinking deeply about an interesting problem, House MD not withstanding. Medical training is designed to give real time answers to presented problems, and it is, er..., 'highly discouraged' to tell a patient "That's an interesting case you have there. I'm going to go google that tonight and I'll have more information in the morning."

When I was young enough to be in pediatrics, my doctor once pulled out a pocket-sized electronic device and keyed in my symptoms. The result it suggested matched his guess, but it was unusual enough he was reassured to have a second opinion :)

Doctors do publish novel cases in journals. I think this case is not novel in the sense that journals look for - that is, conditions truly never seen before. This case is novel in the sense that it's an unusual story.

There are a variety of technical online references. One example would be uptodate.com. they are generally behind pay walls though, so hard to access as a patient.

It is frequently referenced.

Reminds me of a children's joke - which i didn't even think was funny at the time - but enjoyed anyway:

"Dr, Dr! Every time I drink a cup of coffee, I get a stabbing pain in my right eye..."

(google it if you don't remember)

Exhibits, the same kind of ability to see the whole situation and make a diagnosis

Disclaimer: I worked as software engineer for a CRM device company.

From what I learned during my medical training, this king of issue is not so uncommon, but it is usually diagnosed very easily. Her peacemaker can be disabled using a simple magnet. This is a common test in nearly all protocol to check how the heart is working without the help of the device. Doing this simple test while upside-down would have shown that the paecemaker was effectively working in that position. That should have be enough to ring a bell to most of the cardiologists.

I just keep wondering why he was picking her up by the ankles in the first place..

It someone is feeling faint it is standard practice to lower their head to increase blood flow to the brain. Presumably her husband knew this. I felt faint after donating blood recently (I have low blood pressure) and they have a standard piece of foam to lift your legs up while lying on a bed.

I kept wondering how he got her to the hospital... did they walk?

If the bed is up against a wall, it could easily be the easiest way to shift her back onto the bed.

I had a feeling she just had a screw loose.

She's pretty talented if her craziness can cause a heart monitor to indicate that her pacemaker has stopped working.

The joke was that the problem was a screw loose in the pacemaker...

Can't believe how far that went over my head.

It was a crappy reddit style joke , and I hope it gets down voted.

It was funny, and I don't regret reading it, but I regret reading it here.

I thought it was just a regular joke. I'll try to make it less reddity next time.

Happens to the best of us!

How did they get her to the hospital if she needed to be upside-down the entire time?

She probably 'sat' with her back resting against the bottom of the seat and her legs around the headrest.

I had no idea "Mork & Mindy" was a documentary.

No comment on the overall story, but as soon as I heard the description of the man carrying her, and he said "I'm her husband", my thought was Izumi Curtis and her husband Sig. =D

Sorry, but I couldn't resist mentioning House. One of the episodes had similar situations. http://en.wikipedia.org/wiki/Dont_Ever_Change_(House)

Since in there they say patient has "Nephroptosis, also known as 'Floating Kidney'", which is a listed medical condition, conditions like OP should not be uncommon.

Great story. But I wonder what would have happened if she was not five feet and him seven feet tall !

I was wondering about her husband. She's 60 years old, so he's presumably in the same age range. How many 60 year old guys, even big guys, have the strength to carry a full grown woman around by her ankles for a half hour?

This is the sweetest story I have ever heard in my life!

People who enjoyed this story will love a book by neurologist Oliver Sachs called "The Man who Mistook his Wife for a Cat."

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