Category Archives: Travel

What Can Be Learned From The Italian Healthcare Experience?

Since traveling to Italy, the skeptical cardiologist has been in contact with Nicola Triglione, a native of Southern Italy who completed his cardiology fellowship in Milan.

As he has spent some time training in Seattle, WA and recently set up his practice in Milan, I asked him to compare and contrast the Italian health care system to our American system.

The Italian Perspective

by Nicola Triglione,

Medico Specialista in Cardiologia


Italy ranks among the World Health Organization’s top 10 countries for quality health services. The Italian healthcare system is far from perfect though, as this rating is mainly based on equality of access and health outcomes such as life expectancy and healthy life years.

Let’s take a closer look at the national healthcare system (NHS).

Universal Access To Care

Italy’s NHS is tax-funded, regionally-based and it provides universal coverage, largely free of charge at the point of service. Italian territory is made up of 20 administrative Regions, which are extremely varied in size, population, and levels of socioeconomic development. The well-known divide between Northern and Southern areas is still relevant nowadays.

Regions are responsible for ensuring the delivery of services through a network of population-based local health authorities and both public and private accredited hospitals.

The Origins Of Healthcare In Italy

During the Italian Renaissance, hospitals were the embodiment of physical and spiritual healing. The poor received free treatments, senior doctors were employed and food and wine were served to patients. Monks and nuns did the nursing with almost one nurse per patient. There are similarities with the contemporary era, in fact, the medical models developed by Tuscan hospitals formed the foundations for today’s healthcare practices.

The NHS was established by the government in 1978 in order to fight public dissatisfaction with the existing system. Those who want to have a ruthless and ironic portrait of the Italian healthcare before this date should watch one of the greatest Alberto Sordi’s movies “Be’s free” (1968).









Contained Healthcare Expenditure

In 2015 total health expenditure in Italy was about 9% of GDP, 75% of which was financed by the public sector. Out-of-pocket expenditure accounted for 23% of healthcare expenditure and the remaining 2% related to voluntary schemes like private insurances and mutual funds. There are two main types of out-of-pocket expenses: 1) co-payments for diagnostic procedures, pharmaceuticals and specialist consultations; 2) direct payments by users for the purchase of private health care services and over-the-counter drugs.

One of the most reassuring aspects of Italy’s NHS is that emergency care is considered a right, and it’s available to anyone in Italy whether or not they are registered in the national system. Residents have free or limited cost emergency care, and even visitors can access emergency care at a very low co-payment.

Yes, if you plan to break your leg while on vacation then Italy is the destination of choice.

What About Non-Urgent Visits?

If you are sick, you go to your General Practitioner and thanks to your national health card you do not pay anything at the time of the visit. If you need a specialist, things might become complicated because waits can be long. The average wait time for a cardiological visit is 67 days. At best, it’s 51 days in the north-east and 79 days in central Italy. So what do wealthy Italians do? They go to a private pay doctor who charges more than the government rate and the patient pays the difference. The fees are usually very reasonable, compared to other countries with similar costs of living.

On the other hand, the US is the only country spending 17 percent of its GDP on healthcare and according to many, it doesn’t get the expected value. It wasn’t uncommon during my stay in the US hearing colleagues defining the American healthcare system as “broken”.

Drug companies and emergency rooms charge whatever they want. As a result, they get lower patient compliance and therapy adherence.

What else? Hospital services and diagnostic tests cost more. Doctors get paid more, however education does have a cost, in fact, medical-school graduates carry a median $200,000 in student debt. A lot more money goes to planning and managing medical services at the administrative level.

Choice And Access

To me, one particular misconception about the US system is the notion of choice. People are led to believe that buying into a private insurance plan means they will have more choices. In reality, I think that sometimes the choice of care is neither on patients nor on doctors. More often it is insurance companies that decide when, where and for how long people can receive treatments.

I have no doubt that the best healthcare is available in the US, but how many Americans have access to it?

In my opinion, the US could work on providing universal access to treatments and medications, with minimal point-of-service payments as well as prices softened by government negotiation.

In the last 10 years, American citizens have witnessed nearly a doubling in prescriptions and health-related costs have become the leading cause of personal bankruptcy. We have the same issue in Italy, though hubris instead of money drives the phenomenon. In fact, it’s a common belief that a longer prescription means a smarter and considerate prescriber. That’s why in the last few years some virtuous Italian Regions have established a medication reconciliation clinic where general practitioners, internists, and pharmacists work together in order the refine the art of deprescribing.

The Exodus Of Doctors

As I have already pointed out, the Italian NHS is far from perfect. In fact, although medical facilities are considered to be adequate for any emergencies, some public hospitals are overcrowded and under-funded. Public finances are constrained by high levels of government debt. Consequently, resources available for welfare expenditure are considerably lower than in other countries. More than ten thousand Italian doctors left Italy to go working abroad between 2005 and 2015 in search of meritocracy, better career prospects, and higher salaries.

Of course, they miss the five weeks’ vacation, the maternity leave, and the sick leave but once they experience healthcare elsewhere they wouldn’t return to Italy unless the circumstances changed. Italy is not an attractive place to work for doctors because of poor working conditions, little career progression, low salaries and so on.

Life Expectancy

However, people who live here are some of the healthiest in the world. Long story short, Italy boasts excellent life expectancy and healthy life expectancy rates, 82.7 and 72.5 years, respectively. Life expectancy is the third highest in Europe, after Switzerland and Spain.



What’s the secret ingredient?


Italian Ministry of Health, Open Database 

Italian National Institute of Statistics, Health statistics

Dott. Nicola Triglione 
Medico Chirurgo
Specialista in Cardiologia s
Dr. Triglione can be contacted on LinkedIn or by his email address

N.B. As Nicola pointed out, the cost of healthcare in the US (including both government and private expenses) equals 17.1% of the national GDP, compared to 9.1% in Italy. whereas life expectancy in Italy is 4 years higher than in the US.

48 Hours In Asheville: Chill Tonics, Moogs, Mountains, and Music

In order to escape Hurricane Dorian’s imminent arrival at Wrightsville Beach, NC the skeptical cardiologist and the wife formerly known as the eternal fiancee’ (WFKATEF) fled to Asheville, North Carolina.

There we spent a delightful 48 hours before heading to Mt. Airy, NC to participate in my daughter’s wedding.

We had never been to Asheville but found it to be a cozy town full of great food, music, booze, art, architecture, and books-surrounded by beautiful mountains with intriguing hiking trails.

We were lucky enough to snag a room at the Cambria hotel which is perfectly centered in downtown Asheville.

While the WFKATEF napped I strolled across the street and
investigated a gorgeous old building. This former and current shopping arcade was built by EW Grove.

A Tasteless Quinine Chill Tonic

Grove created a tasteless quinine (which for 300 years was the only effective malaria treatment ) tonic and by 1890 according to the Grove arcade website:

The chill tonic was so popular the British army made it standard issue for every soldier going off to mosquito infested lands and, by 1890, more bottles of Grove’s Tasteless Chill Tonic were sold than bottles of Coca-Cola.

Grove moved his tonic operations from Paris, Tennessee to St. Louis in 1890 but “the heavy pollution of the factory district caused Grove to develop lifelong breathing issues”.  As a result, Grove visited Asheville for its climate, which he found was good for his health and relieved his bronchitis.

Lots of wealthy individuals with tuberculosis visited Asheville between the 1880s and the 1930s due to a widespread perception in that era that its climate was optimal for curing the disease.

When Grove Arcade held its Grand Opening in 1929, it quickly became home to a fine collection of local shops and services. Following a period as the home of the National Weather Records Center it reopened in 2002 in its current incarnation.

A Delightful Book Exchange And Champagne Bar

My first discovery at the Grove was  the Battery Park Book Exchange  and Champagne Bar. I was intrigued by the combination of fine wine and champaign and old books.

Wandering through the various nooks and crannies of the Book Exchange one encounters delightful tables and chairs where one can consume a beverage and peruse classic literature. In one nook (or perhaps it was a cranny) I came across two of my all-time favorite books in a wonderful leather-bound format.58932518484__BADA9D50-717E-41B0-82C0-B3C87542082A No, I’m not a Eugene O’Neill fan but I strongly considered buying this gorgeous Franklin Library First edition of Barbara Tuchman’s description of the calamitous 14th century to replace my dog-eared and coffee-stained paperback edition.

Cool Random Art

Wandering around downtown Asheville we encountered sseemingly  random cool art such as this ironwork arbor of medicinal herbs featuring a bust of Elizabeth Blackwell the first woman to be awarded a medical degree in the United States..

The medicinal plants represent wild yam, Virginia creeper, sycamore, sweet gum maple, oak sassafras, witch hazel, and tulip poplar. Each of the plants incorporated are native to North Carolina and were used for medicinal purposes. The seats on the bench are made to look like gingko leaves. The monument is part of Asheville’s Urban Trail, a walking tour of the city’s downtown, highlighting historic people and events relevant to Asheville.

Elsewhere we encountered a giant iron.

Apparently this giant replica of an antique iron refers to the Asheville Flat Iron Building (1926)  designed by Albert Wirth and reminiscent of the ground-breaking 1902 skyscraper that graces Fifth Avenue in Manhattan.

In putting this post together I realized that these features are part of the Asheville Urban Trail which features various artistic references to” George Vanderbilt, E.W. Grove, Thomas Wolfe, F. Scott Fitzgerald, Douglas Ellington, and a short story writer calling himself O. Henry ~ just to name a few.”

Musical Jams At Jack of the Wood

As I rambled past an interesting looking Irish pub, Jack of the Wood, I noticed a flyer indicating that  old time music jam sessions occurred there every Wednesday night. We ended up there that night mesmerized by  a rotating group of locals playing banjos, guitars, fiddles, and a string bass.

We liked Jack of the Wood so much we came back the next night for the bluegrass jam.

Excellent Beer, Booze, Farm To Table Food

That night we Ubered to west Asheville and had a wonderful meal at Jargon. The WFKATEF ordered a cocktail named the Icebreaker 2.0 predominantly because it involved smashing a “hollow smoked ice ball” in our presence.

(Ice Breaker 2.0 – Knob Creek Bourbon, Carpano Antica vermouth, Ramazzotti Amaro, Angostura bitters, hollow smoked ice ball )
Asheville has a thriving craft beer scene but as I was in a keto frame of mind I didn’t partake extensively. It is also known for its excellent farm to table and foodie restaurants.
I won’t bore you with the details of a food and booze tour that we took or random rum tasting but if you are interested in such things Food and Wine has their own “48 hours in Asheville” which focuses on (shocker) food and booze in Asheville here.

Gorgeous Blue Ridge Mountains and Trails

Asheville is surrounded by the Blue Ridge Mountains which offer lots of great hiking opportunities. Our time was limited but we managed a short drive on the Blue Ridge Parkway to take a brief hike at Craggy Pinnacle 

The Blue Ridge Parkway  is a 500 mile road stretching from Virginia to North Carolina and managed by the National Park Service. It is a “series of parks providing the visitor access to high mountain passes, a continuous series of panoramic views, the boundaries of its limited right-of-way rarely apparent and miles of the adjacent countryside seemingly a part of the protected scene.”

Moog Factory Tour

A highlight of Asheville for me was the Moog factory tour

Moog Music synthesizers are deisgned and handcrafted in the Moog factory in downtown Asheville, NC and they offer a free tour daily.

While waiting for the formal tour to begin you find yourself in a room containing a painstakingly recreated version of the Moog modular that Keith Emerson played on tours and on fantastic albums with Emerson, Lake and Palmer..

You are also surrounded by every Moog synthesizer and processor that Moog sells. Even more fun, if you get there early like I did you can play every single one.

I own several Moogs and I could talk forever about the history of Bob Moog and Keith Emerson but I will leave that for another post.

Keith Emerson discovered the Moog synthesizer with his band The Nice in 1969. Shortly thereafter, he reached out to Bob Moog and acquired one of the first Moog modular synthesizers, which was built for the Museum Of Modern Art’s “Jazz In The Garden” public performance.  From then on, the names Emerson and Moog were entwined forever. Keith became the most-visible proponent of the synthesizer revolution, using the Moog loyally onstage for almost every show of his career. Emerson became the brightest name in the world of progressive rock music, his influence and creativity rivaled only by Jimi Hendrix. He was a masterful musician in many styles, but also a renowned showman who understood that elaborate theatrics would elevate the experience of the audience to a fever pitch. Part of his “show” was to faithfully include the monstrous wall of modules and cables that his Moog had become over the years, as it had developed an instantly recognizable sound that no other instrument could duplicate.

The Unseen Biltmore Estate

The leading tourist attraction in Asheville is the Biltmore estate. It is apparently the largest house in America but as I am a little burned out on fancy large palaces in Europe we decided not to go there.

I did want to wander through the gardens at Biltmore but you can’t purchase a ticket to do just that. You must purchase the $69 ticket and

Escape from everyday life to George Vanderbilt’s 8,000-acre estate in Asheville, NC. Your admission includes a self-guided visit of the breathtaking Biltmore House & Gardens, Antler Hill Village, and a complimentary wine tasting at our Winery.

All in all I would rate our visit to Asheville as one of the best 48 hours I’ve had in any American city.

Serendipitously Yours,


L’Italia È Molto Bella

Dr. and Mrs. Skeptical Cardiologist have returned from two weeks in Italy and I have to say, this is one of the most beautiful places I’ve ever seen.

Here are my top 3 experiences:

  1. The Cinque Terre. Five villages tucked into the cliffs above the Mediterranean and connected by trains and trails, featuring gorgeous vistas available to those willing to climb and hike.
Vernazza, one of the five villages of the Cinque Terre, viewed from the trail that connects it to Monterosso.
Vernazza, from the beginning of the trail to Corniglia. The hike took us about 2 hours and was strenuous but wonderful. 
From high up on the Vernazza-Corniglia trail. Corniglia in foreground, Manarola in distance.

2. The heart of Tuscany, in the Val d’Orcia,

View from our B&B at La Foce, near Montepulciano, looking into the Val d’Orcia.

Garden at the La Foce Estate
From the base of the ruined castle known as the Rocca di Tentennano, which sits on a pinnacle high above the Val d’Orcia, with the small village of the Rocca d’Orcia just below.
Sunset, Rocca d’Orcia with Monte Amiata in the distance.

3. Florence, chock full of Renaissance architecture, art, tourists and incredible panoramic views from Giotto’s Campanille and the top of the Duomo:

Perusing the artwork in front of the Duomo, part of the complex of buildings that make up Florence Cathedral on the Piazza del Duomo in Florence, Italy.
“the gloaming” on the river Arno


We did lots of stair climbing in Florence. We climbed 463 steps to get to the top of the Duomo, from which Giotto’s Campanille (bell tower) can be seen. An hour earlier we climbed the 414 steps of the bell tower. Per Wikipedia “the tower is one of the showpieces of Florentine Gothic architecture with its design by Giotto, its rich sculptural decorations and its polychrome marble encrustations.”
The skeptical cardiologist descending the narrow and often windy stairs from the Duomo roof. 

To any patients who were inconvenienced by my delayed return, my sincere apologies. The good news is that your cardiologist is now fully recharged and ready to resume practice with renewed vigor and enthusiasm.



Italy And The Valsalva Manouevre

Antonio Maria Valsalva (1666-1723) was an Italian anatomist, physician and surgeon whose name is familiar to cardiologists for two reasons. First, he described what are now termed the sinuses of Valsalva, the three areas of dilatation in the proximal portion of the aorta just outside the opening of the aortic valve.

Second, in his textbook on the ear, De aure humana tractatus, published in 1704 in Bologna, he showed an original method of inflating the middle ear (now called Valsalva’s manoeuvre) in order to expel pus. A variation of this classic Valsalva maneuver is used frequently in cardiology for diagnostic and therapeutic purposes.

The skeptical cardiologist and his newly-minted bride, will be jetting off to Italy in a few weeks but, alas, we are not visiting Bologna. Hopefully we won’t need to utilize the original Valsalva manouevre to equalize the pressure between our middle ears and the cabin atmosphere in order to prevent otic barotrauma as we descend.

I don’t feel so bad about the rock because the wikipedia caption reads as follows:Sections of Hadrian’s Wall remain along the route, though much has been dismantled over the years to use the stones for various nearby construction projects.

I’ve been fascinated by the Roman Empire since I took Latin in high school. I was so obsessed with all things Roman that when my family traveled back to England to visit relatives and such, I insisted on us visiting Hadrian’s Wall. Don’t tell the authorities, but I still possess a rock I took from said wall.

The only time I’ve been to Italy was 30 years ago after presenting at the European Society of Cardiology meeting in Nice, France. I foolishly rented a car and drove north to Lago Maggiore. It was one of the most harrowing experiences of my life.

The Italian Itinerary

This time we are flying into Rome and then taking a train to Florence.

From Florence I’m planning to rent a car (having failed to learn my lesson) to drive to La Foce, an historic estate, which lies on the hills overlooking the Val d’Orcia.

La Foce

We’ll spend two nights in the B&B portion of this place, which sounds amazing:

Midway between Florence and Rome, it is also within easy reach of Siena, Arezzo, Perugia, Assisi, Orvieto. Renaissance and medieval gems such as Pienza, Montepulciano, Monticchiello and Montalcino are only a few miles away. The countryside abounds in lovely walks among woods and the characteristic crete senesi (clay hills); the food is among the best in Tuscany and famous wines such as the Vino Nobile and Brunello can be tasted in the local cellars. The Val d’Orcia has recently been included among the World Heritage sites of UNESCO.

From the heart of Tuscany, we then drive to the coast of northern Tuscany to meet up with the in-laws in Viareggio.



After a few nights in Viareggio with Geo (the man on the statin fence) and Wendy, we will all take a ferry to the Cinque Terra, staying in Manarola.

Lastly, we will travel to Milan, and then fly home.

I’ve got a good idea of what the top tourist destinations are in these cities from reading Rick Steves’ book on Italy and from discussions with friends who have been there.

However, we typically prefer wandering semi-aimlessly in great cities, rather than dealing with large tourist herds at the must-see attractions.

I’m actually more interested in La Specola in Florence than I am in seeing Michaelangelo’s David. La Specola:

spans 34 rooms and contains not only zoological subjects, such as a stuffed hippopotamus(a 17th-century Medici pet, which once lived in the Boboli Gardens), but also a collection of anatomical waxes (including those by Gaetano Giulio Zumbo and Clemente Susini), an art developed in Florence in the 17th century for the purpose of teaching medicine. This collection is very famous worldwide for the incredible accuracy and realism of the details, copied from real corpses. Also in La Specola on display are scientific and medical instruments. Parts of the museum are decorated with frescoes and pietra dura representing some of the principal Italian scientific achievements from the Renaissance to the late 18th century.

I tend to rely on Rick Steves’ books for European travel, but if any readers have experience in these Italian areas please feel free to add them to the comments section or send me an email at I would be especially interested in “off-the-beaten path” things of interest (especially if they have a literary, medical or scientific connection) and restaurant recommendations.


To all my patients, please accept my apologies for any rescheduling this may have caused.

In my absence you will be in good hands as my partners, primarily Brian Kaebnick, will be covering for me.



In Flight Medical Emergencies: This Doctor Is Now Ready To Heed The Call

In a previous post the skeptical cardiologist wrote about the reluctance  of doctors to “heed the call” , i.e., to respond to an in-flight medical emergency (IME) when the flight crew requests assistance from qualified medical professionals.

Only 20% of physicians in my (very unscientific) poll would respond to such requests.

I pointed out that:

“In 1998 Congress passed the Aviation Medical Assistance Act, which tries to protect medical Good Samaritans who heed an airplane call. The act protects physicians, nurses, physician assistants, state-qualified EMTs and paramedics:

“An individual shall not be liable for damages in any action brought in a Federal or State court arising out of the acts or omissions of the individual in providing or attempting to provide assistance in the case of an in-flight medical emergency unless the individual, while rendering such assistance, is guilty of gross negligence or willful misconduct.”

but I and other physicians  had concerns beyond medical liability, as I detailed in my post.

Physicians Who Prefer Not To Head The Call

At the time I wrote that piece, to be honest, I was in the camp of physicians who would prefer not to heed the call.

I tended to agree with Dr. Winocour on Larry David’s  Curb Your Enthusiasm who justifies his failure to respond in flight with two comments:

“Give it a minute. He’s gonna be fine.” and

“Have you ever been part of an emergency landing? Is that what you want, Larry? To spend the night in Lubbock, Texas, at a Days Inn with a $15 voucher from Cinnabon? Think about it.”

Although Winocour was correct that the vast majority of in-flight medical “emergencies” resolve without any specific intervention it is still helpful for a physician to attend on such patients and assess the situation.

And it is true that if he had attended on a patient with a serious non-transient medical problem he would suddenly find himself having to make an incredibly difficult and life-deciding decision on whether or not to  divert the plane or make an emergency landing with insufficient diagnostic tools and inadequate information.

But somebody has to make that call and the physician heeding the call will have the assistance of experts in the field on the ground.

Qualified Physicians Should Be Prepared To Heed The Call!

After pondering the issue for a few years and reading an excellent review on the topic in a recent JAMA I have changed my stance and am now completely ready (almost eager)  to heed the call.

Leslie Nielsen as Dr. Rumack in Airplane! He heeded the call.

In fact, I am currently writing this while en route from frigid and
snowy St. Louis to sunny and warm San Diego on a Southwest Airlines flight and I’m considering pre-identifying myself as a physician in case an IME develops. (The only thing stopping me is that it seems a little pretentious and likely unnecessary, perhaps if I just put wear my stethoscope constantly that will be enough.)

I have in my backpack several items that will assist me in handling cardiovascular emergencies should they arise:

  1. AliveCor Mobile ECG-With this and my iPhone I will be able to rapidly ascertain the stricken passengers heart rate and rhythm-crucial information to help diagnosis and proper treatment. (I also have my Apple Watch 4 for the same purpose.)
  2. Qardioarm BP cuff-Rapid, efficient assessment of BP without tubes, or wires.
  3. Stethoscope-a good one with which I can hear heart murmurs and lung sounds. Although the FAA-mandated emergency medical kit on board should have both a BP cuff and a stethoscope , I have no confidence they will be either accurate or functional.
  4. Sublingual nitroglycerin. The kit on the plane should have these  along with 325 mg aspirin tablets, IV atropine, and injectable glucose, epinephrine and lidocaine.
  5. An epinephrine auto-injector. For the stricken passenger who is suffering anaphylaxis from the mixed nuts being served across the aisle.

Should there actually be a cardiac arrest I’m completely up to date on Advanced Cardiac Life Support (ACLS) and CPR training and there should be an AED on board to defibrillate if appropriate.

I’ve also decided that despite my reluctance to bring attention to myself, it is highly likely that I will be the most qualified person to rapidly diagnose and treat any serious cardiovascular condition that arises on my flight.  As a doctor, I believe, I should be striving to provide assistance to those suffering whenever and wherever I can, be that in the air, on the sea, in the hospital or in the office.

Call-heedingly Yours,


N.B. One (of many) of the newly-minted wife’s favorite Airplane! lines  comes from the doctor who heeded the call.

  • Rumack : You’d better tell the Captain we’ve got to land as soon as we can. This woman has to be gotten to a hospital.

    Elaine Dickinson : A hospital? What is it?

    Rumack : It’s a big building with patients, but that’s not important right now.

Were They Visions of Quilotoa Or The Birthplace Of Little Rocket Man?

The skeptical cardiologist periodically updates the “header image” for this blog, typically uploading an iPhone “pani” of somethinng he considers beautiful, cool or quirky from one of his travels.

I can’t recall any comments on the header images so I had presumed that nobody really cares what is up there.

However, for my last header image (which at the time of this writing should still be above) I used a picture from my recent trip to Ecuador.

Stunning views of the lake in the caldera of Quilotoa and the surrounding mountains. The hike down to the water is steep and dusty. Due to the altitude of 13,000 feet climbing up was really difficult and 3/4 of our party elected to pay 10$ for a donkey ride. Only the galloping gastroenterologist, David Lotsoff could make it up on his own two feet.

After returning from the Galapagos we drove north from Quito for 4 hours to Quilotoa and took the picture that is the current header image.

Per Wikipedia

Quilotoa (Spanish pronunciation: [kiloˈto.a]) is a water-filled caldera and the most western volcano in the EcuadorianAndes. The 3-kilometre (2 mi)-wide caldera was formed by the collapse of this dacite volcano following a catastrophic VEI-6 eruption about 600  years ago.

A reader, commenting on my aspirin post, added the following cryptic words:

Also, I would be (very) interested to know about your ‘attachment’ / interest in Chang Bai Shan (‘Great White Mountain’ on the border of China / N Korea; one of the world’s largest stratovolcanoes)??? FWIW, we have(nick-)named one of our grandchildren (boy) with this name. My wife is Chinese/Taiwanese; my daughter has lived for 15? years in Beijing… All speak Mandarin (& English)…
I had no idea what he was talking about until I googled chang bai shan and looked at this image of “Heavenly Lake” which looks remarkably similar to the view we had over the Lagoon inside Quilotoa.



“Changbaishan Nature Reserve is the largest reserve in China, covering over 850 square miles. The rocks of Changbaishan supposedly have a white shimmer, giving the area its name (changbai means “ever white” in Chinese). The vast reserve comprises a collection of craggy peaks encircling Heavenly Lake, which occupies the crater of a long dormant volcano.”

This Chinese tourism site notes that a third of the Heavenly Lake lies in North Korea ” and its environs are considered sacred by both the Chinese and North Koreans; in Korean the area is known as Paektusan, and the North Korean leader Kim Jong Il claimed it as his “birthplace”. The imperial Qing dynasty, a Manchu family, revered Changbaishan as a holy land and the cradle of the Manchurian race.”

Despite the attraction of seeing the birthplace of Little Rocket Man, I have decided not to put Changbaishan on my bucket list because

Heavenly Lake’s cross-border status demands careful hiking – as recently as 1998 a British tourist was incarcerated for a month in North Korea for accidentally stepping across the poorly demarcated international line.

Stratovolcanically Yours,


N.B. One of our party (who shall remain eternally nameless) experienced symptoms likely related to the rapid ascent to 13000 feet.

Acute mountain sickness is the most common type of high-altitude illness and occurs in more than one-fourth of people traveling to above 3500 m (11 667 ft) and more than one-half of people traveling to above 6000 m (20 000 ft). Symptoms include headache, fatigue, poor appetite, nausea or vomiting, light-headedness, and sleep disturbances. Symptoms usually occur 6 to 12 hours after ascent and can range from mild to severe.

Here’s  a cool graphic from JAMA related to it

Boobies and Such Encountered In The Galapagos

I have returned from The Galapagos and a most amazing Voyage on the Samba.

Early AM kayak departure from the Samba

The experience was exhilarating, enlightening and enchanting (therefore exhausting) and at some point I shall edit a brief movie/slideshow and post it somewhere for those interested.

Until then, here’s a red-footed booby I encountered on the island of Genovesa where a veritable cornucopia of exotic birds feed, nest and fly about,  seemingly unconcerned  about human visitors.

Red-footed Boobies are spectacular divers, plunging into the ocean at high speeds to catch prey. They are beautifully adapted for diving, with sleek, torpedo-shaped bodies, closeable nostrils, and long wings that wrap around their bodies as they slice into the water. This one, nesting in a red mangrove, seemed unperturbed by me standing a foot away but was intrigued by my red (Olympus TG-5 underwater) camera.

Charles Darwin did not visit Genovesa and none of the boobies (blue or red-footed or otherwise) played a role in his Theory of Evolution to my knowledge. They are not endemic or unique to the Galapagos.

The Song Of the Flightless Cormorant

There are many endemic animal species in the Galapagos which likely influenced Darwin’s thinking. On the youngest island,

It is found on just two islands; Fernandina, and the northern and western coasts of Isabela. Distribution associates with the seasonal upwelling of the eastward flowing Equatorial Undercurrent (or Cromwell Current) which provides cold nutrient rich water to these western islands of the archipelago. The population has undergone severe fluctuations; the 1983 an El Niño-Southern Oscillation (ENSO) event resulted in a 50% reduction of the population to just 400 individuals. The population recovered quickly, however, and was estimated to number 900 individuals by 1999.

Fernandina,  I encountered the flightless cormorant. The Galapagos cormorant is the only flightless cormorant in existence.

Evolutionary biologist Patricia Parker (who is the senior scientist at the St. Louis Zoo) appears to be the leading researcher on endemic Galapagos bird species. She collected blood from the Galapagos cormorants, searching for mutations that might explain their useless wings.

She and her fellow researchers  discovered about a dozen mutated genes in the Galapagos cormorants known to trigger rare skeletal disorders in humans called ciliopathies, often characterized by misshapen skulls, short limbs, and small ribcages. Since Galapagos cormorants have short wings and an unusually small sternum, the researchers suspected this link was significant.

The Sexual Attractiveness of The Male Blue-footed Booby 

The blue-footed booby (BFB) is more famous on the Galapagos, primarily because of its mating dance but also because of its fascinating bright blue feet. During the mating dance the male booby prominently displays his sexy feet.

Blue-footed boobies on Isabela Island. Note the varying shades of blue in their feet

A fascinating study published in 2006 suggests that the brighter the blueness of the male booby feet, the healthier he is and the more likely he is to hook up with a female booby.

When male boobies were food deprived their feet became duller and when re-fed fresh fish the blueness brightened within 48 hours.

Variation of dietary carotenoids induced comparable changes in cell-mediated immune function and foot colour, suggesting that carotenoid-pigmentation reveals the immunological state of individuals.

In a second experiment the researchers captured male BFBs after their female mate had laid a first egg and painted a dull blue make-up on the male BFB feet. The females “decreased the size of their second eggs, relative to the second egg of control females, when the feet of their mates were experimentally duller. Since brood reduction in this species is related to size differences between brood mates at hatching, by laying lighter second eggs females are facilitating brood reduction.”

Another  study in 2011  found that  damage to the DNA  of sperm increases with the age of male blue‐footed boobies. Furthermore, like humans sexual attractiveness (foot colour) declines with age in the BFB and is correlated with sperm DNA damage. The authors speculated that. “By choosing attractive males, females might reduce the probability of their progeny bearing damaged DNA.”

I will leave discussions on the technique for acquiring BFB sperm and for applying make-up to their feet to less squeamish authors. In the meantime we can all rest easy with the knowledge that female BFBs like their human counterparts prefer youngish males with brightish  blue suede shoes.

Galapageinosly Yours,


(Featured image credit: Cassiano “Zapa” Zaparoli)

What’s The Best Treatment For Seasickness? Part I, What Won’t Work Well

While stocking up on key items for our Galapagos cruise, the eternal fiancée of the skeptical cardiologist (EFOSC) bought an item that set off the skeptical cardiologist’s (extremely sensitive) BS detector.

Once I began looking into the seasickness treatment options and science I soon realized that the vast majority of OTC medications, patches and devices offered are snake oil.

There is one highly effective treatment which requires a prescription, one possibly effective OTC treatment which will likely put you to sleep, and one very slightly effective treatment which will also likely put you to sleep.

First let’s look at the totally bogus patch Jen purchased.

It calls itself a “motion sickness patch.” It is manufactured in China. (Somebody should put a tariff on this junk!)

It also carries the allure of being natural which people (mistakenly) assume means free of side effects.

Since most people have heard of an effective motion sickness patch, they naturally assume that this is legitimate. 

It appears to be highly rated on Amazon with 80% of over a thousand reviewers giving it 4 or 5 stars. However, 10% of reviewers give it 1 star, usually commenting that the MQ patches were useless  and were purchased as they were cheaper than the prescription patch that worked for them before.

And it is no surprise that it doesn’t work for many because the ingredients would not be expected to have any effect on motion sickness.

The main Ingredient are listed as

safflowertall,gastrodia,tuber,sanchi,hairy datura flower,borneol,pinellia tuber,obtuseleaf cinnamon bark,frankincense,dahurian angelica root,etc.

Yes, in these patches you get the added bonus of “etc.” in the formulation!

In case you needed more explanation of how this works, check out the bizarre “working theory” of the mysterious ingredient’s efficacy:

Working theory
1. Adjust the control of the vagal nerve to gastrointestinal tract, inhibit the motility of the gastrointestinal, thus preventing nausea and vomiting.
2. By expanding the capillaries of the skin, to improve the microcirculation of body and increase the amount of oxygen to brain, thus comes to the effect of refreshing your brain.

All I can say about those who have experienced relief with this MQ nostrum is “the placebo force is strong with you!”

After reading the reviews for the MQ patch and  listening to an NPR story on paid Amazon product reviews  my faith in Amazon product reviews is at an all time low.

Similarly, most of the sites on the internet which promise to give you the top 10 products in a certain area I have found to be bogus. For example, the amazingly useless MQ motion sickness patch is ranked #5 on the “Best Reviews” Guide to Motion Sickness.


The second product the EFOSC purchased online was the oddly-named Bonine.  Bonine is the brand name for meclizine, a first-generation antihistamine with anti-cholinergic properties which is often prescribed for benign positional vertigo.

There is not much evidence supporting meclizine for sea sickness but it is widely used owing to its accessibility and marketing. Like all first-generation antihistamines, it will make you drowsy. Before the second generation, non-sedating antihistamines were introduced, I would walk around in a zombie-like state when my allergies required an antihistamine.

Keep in mind you can get a prescription for 30 tablets of meclizine 25 mg for about 12$.


More evidence that the placebo force is particularly strong in the motion sickness world is the widespread marketing, sales and testimonials to “acupressure”  devices.

The EFOSC with her Sea Band. She likes to wear it because it is blue and white, her favorite colours.

The EFOSC suffers from car sickness and several years ago purchased something called the  Sea Band.

Wrist bands like the Sea Band claim to reduce nausea and other symptoms of seasickness through stimulation of the “P6/Neiguan” acupuncture point by applying acupressure or electrical acustimulation.

These work primarily through placebo effect and studies have shown a “sham” acupressure band works as well as a real one.

One fascinating study examined  a self-fulfilling prophecy (SFP) approach to combating seasickness:

the authors experimentally augmented the self-efficacy of naval cadets by telling them that they were unlikely to experience seasickness and that, if they did, it was unlikely to affect their performance at sea. Naval cadets (N = 25) in the Israel Defense Forces were randomly assigned to experimental and control conditions. At the end of a 5-day training cruise, experimental cadets reported less seasickness and were rated as better performers by naive training officers than were the control cadets

The EFOSC is gravely concerned about debilitating seasickness during our 8 days on the Samba. To maximize the placebo force in her I should have emphasized how well the Sea Band and the MQ patch work. Hopefully she won’t read this post.

In Part 2 of the Best Seasickness Treatment I’ll discuss transdermal scopolamine and dramamine, the treatments with the best evidence for efficacy, safety and tolerability.

I’ll also examine the evidence for ginger.

What’s been your experience with sea sickness and treatments for sea sickness?

Vertiginously Yours,


Drinking From The Giant Tortoise Pericardium

In preparation  for our Voyage of the Samba in the Galapagos Islands I’ve been reading the chapter of Darwin’s Voyage of the Beagle that describes his 31 days in the archipelago.

Darwin felt the reptiles of the Galapagos  gave the “most striking character to the zoology ” of the islands. He spends considerable time in his diary describing the creatures for whom the Spaniards named the islands. the giant tortoises.

Giant Tortoises

A Galapagos giant tortoise  can weight up to 600 pounds and live up to 150 years. A distinct species of tortoise developed on each separate island, adapting to differing environments.

On Charles Island (now Floreana) Darwin encountered the slowly

Lonesome George was the last survivor of the abingdonii subspecies, which became extinct with his death on 24th June, 2012.

lumbering (4 miles per day) tortoises when they traveled to the central highlands to fill themselves with water.  Prior to encountering humans the tortoises had  had no natural predators and both the natives and the crews of whaling ships feasted on their easily obtained meat.

“the staple article of animal food is supplied by the tortoises. Their numbers have of course been greatly reduced in this island, but the people yet count on two days’ hunting giving them food for the rest of the week. It is said that formerly single vessels have taken away as many as seven hundred, and that the ship’s company of a frigate some years since brought down in one day two hundred tortoises to the beach.”

Natives savored both tortoise flesh and tortoise oil:

The flesh of this animal is largely employed, both fresh and salted; and a beautifully clear oil is prepared from the fat. When a tortoise is caught, the man makes a slit in the skin near its tail, so as to see inside its body, whether the fat under the dorsal plate is thick. If it is not, the animal is liberated and it is said to recover soon from this strange operation. In order to secure the tortoise, it is not sufficient to turn them”

Darwin also partook of tortoise:

“While staying in this upper region, we lived entirely upon tortoise-meat: the breast-plate roasted (as the Gauchos do carne con cuero), with the flesh on it, is very good; and the young tortoises make excellent soup; but otherwise the meat to my taste is indifferent.”

I’m pretty certain the passengers on the Samba will not be consuming any Giant tortoise meat this August but we will definitely encounter some of the surviving species on special farms and I will be listening for bellowing males:

During the breeding season, when the male and female are together, the male utters a hoarse roar or bellowing, which, it is said, can be heard at the distance of more than a hundred yards. The female never uses her voice, and the male only at these times; so that when the people hear this noise, they know that the two are together”

Perhaps I will be allowed to startle or ride a tortoise in the manner of Darwin:

“The inhabitants believe that these animals are absolutely deaf; certainly they do not overhear a person walking close behind them. I was always amused when overtaking one of these great monsters, as it was quietly pacing along, to see how suddenly, the instant I passed, it would draw in its head and legs, and uttering a deep hiss fall to the ground with a heavy sound, as if struck dead. I frequently got on their backs, and then giving a few raps on the hinder part of their shells, they would rise up and walk away; — but I found it very difficult to keep my balance.

Drinking FromThe Pericardium Of The Giant Tortoise

Finally, as this is a cardiology-oriented site I must take note of the following peculiar Darwinian observation:

“I believe it is well ascertained, that the bladder of the frog acts as a reservoir for the moisture necessary to its existence: such seems to be the case with the tortoise. For some time after a visit to the springs, their urinary bladders are distended with fluid, which is said gradually to decrease in volume, and to become less pure. The inhabitants, when walking in the lower district, and overcome with thirst, often take advantage of this circumstance, and drink the contents of the bladder if full: in one I saw killed, the fluid was quite limpid, and had only a very slightly bitter taste. The inhabitants, however, always first drink the water in the pericardium, which is described as being best.”

When I came across this description I was flabbergasted. Not at the inhabitants drinking tortoise urine (for indeed the tortoise does use his giant bladder as a water reservoir during times of drought) but at the Galapagoans drinking pericardial effusions.

The Pericardium

The pericardium is the sac around the heart. I am very familiar with the pericardium in humans as I look at it on every one of the  many echocardiograms I read.  Normally, it has only a very tiny bit of fluid in it, enough to lubricate the heart as it contracts and relaxes.

Thus, in a normal giant tortoise one would not expect more than an ounce of liquid in the pericardium-hardly worth butchering an ancient kind beast.

In the video below one can see a small to moderate sized pericardial effusion (the black crescent on the left of the heart) which corresponds to about 90 ml or 3 ounces.

I asked Jim Scharff, a cardiothoracic surgeon,who slices open the pericardium of humans on a daily basis what he typically encounters when the sac is opened. The question I texted him was:

“When you open the pericardium of someone without pericardial disease or effusion how much fluid do you typically encounter and what does it taste and look like?”

He responded  “Usually 15-20 mL of serous looking fluid. I have no idea what it tastes like but it does not have any odor.”

Serous means ” typically pale yellow and transparent” and limpid, Darwin’s term, means transparent and clear.

Some diseases cause inflammation of the pericardium (pericarditis) and with this fluid (pericardial effusion) can build up in the pericardial sac. Large pericardial effusions compress the heart, impeding blood from entering it, and can cause shock and death (tamponade).

Pericardial effusions due to inflammation typically are not limpid as they contain blood cells and protein from the inflammation of the pericardium.

Ultrasonic Explorations

If the inhabitants were sometimes encountering significant amounts of tasty, yet limpid fluid in the pericardial sac of the giant tortoises was this normal or did it indicate the turtles had pericardial disease?

I was unable to find any indication that giant tortoises suffer unduly from pericardial disease but I did encounter one study which utilized ultrasound to document a pericardial effusion in an 80 year old spur-thighed tortoise which was suffering from pneumonia.

Consequently, I’m looking into taking a portable ultrasound device to take with me to the Galapagos to examine the hearts of the giant tortoises and answer once and for all the mystery of the giant tortoise pericardial fluid.

Testudinally Yours,





We Are Soon Bound For The Galapagos Islands In Search Of Darwin, The Giant Tortoise, and Dangerous Ideas

This is not the Samba. It is Her (or His) Majesty’s Ship, The Beagle

In August, the skeptical cardiologist and his eternal fiancée (and our friends Dave and Barb) will be visiting the Galapagos Islands on the 78 foot yacht, the Samba.

I’ve long wanted to visit this archipelago with its fascinating geographic and biologic features and its connection with Charles Darwin.

Darwin, born in 1809, was the son of a successful Shropshire physician and financier. By the age of 8, he writes in his Autobiography, “my taste for natural history, and more especially for collecting, was well developed. I tried to make out the names of plants and collected all sorts of things, shells, seals, franks, coins, and minerals. The passion for collecting, which leads a man to be a systematic naturalist, a virtuoso or a miser, was very strong in me, and was clearly innate, as none of my sisters or brother ever had this taste.”

After 2 years of studying medicine at Edinburgh University, Darwin writes, “my father perceived or he heard from my sisters, that I did not like the thought of being a physician, so he proposed that I should become a clergyman.”

In the course of obtaining the undergraduate degree needed to join the ministry, Darwin  developed a passionate interest in natural history, and two books in particular, instilled in him the desire to be a scientist:

During my last year at Cambridge I read with care and profound interest Humboldt’s Personal Narrative. This work and Sir J. Herschel’s Introduction to the Study of Natural Philosophy stirred up in me a burning zeal to add even the most humble contribution to the noble structure of Natural Science.

After graduating Cambridge, Darwin, being recognized as “a young man of promising ability, extremely fond of geology, and indeed all branches of natural history,” was offered a position on a ship destined for a 5 year voyage around the world. This would profoundly influence his life and mankind’s vision of its origin.

The Voyage of the Beagle

In preparation for my visit to the Galapagos and our voyage on the Samba, I have been reading (from a free digital download) Darwin’s account of that historic voyage:  “The Voyage of the Beagle” (originally entitled “Journal of researches into the natural history and geology of the countries visited during the voyage of HMS Beagle round the world,” published in 1839), which Darwin introduces thusly:

Captain Robert Fitzroy..As Darwin gathered the threads of what would later become his ‘dangerous idea’, FitzRoy guided them safely through treacherous waters, measured tides, studied weather systems, surveyed new territory, corrected existing charts and, for the first time, established a series of reference points around the globe that others would calibrate their instruments by. courtesy RNLIWhen Darwin published On the Origin of Species, FitzRoy admitted that it caused him the ‘acutist pain’. As a passionate creationist, he was wracked with guilt at unwittingly playing a part in its construction. This, along with mounting debts and failing health, soon locked him into a losing battle with depression. Just weeks before his 60th birthday, Vice Admiral FitzRoy  took his life.

HIS MAJESTY’S ship, Beagle, under the command of Captain FitzRoy, was commissioned in July, 1831, for the purpose of surveying the southern parts of America, and afterwards of circumnavigating the world. In consequence of Captain FitzRoy having expressed a desire that some scientific person should be on board, and having offered to give up part of his own accommodations, I volunteered my services; and through the kindness of the hydrographer, Captain Beaufort, my appointment received the sanction of the Admiralty.

The Beagle was only 12 feet longer than the Samba motored sailing boat that we, along with 12 other adventurous passengers, 5 crew men and a guide, have selected for our Galapagos tour. However, Darwin’s vessel carried, in addition to Fitzroy and Darwin, 71 other passengers (whose names you can ponder here).

The Beagle Sets Sail

On the 27th of December, 1831, the Beagle sailed from Devonport with the object of completing:

“the survey of Patagonia and Tierra del Fuego, commenced under Captain King in 1826 to 1830, — to survey the shores of Chile, Peru, and of some islands in the Pacific — and to carry a chain of chronometrical measurements round the World. ”

The Beagle spent four years surveying the east coast of South American and didn’t reach the Galapagos until the fall of 1835, nearly 4 years after its launch.  Darwin describes the islands as follows:

“SEPTEMBER 15th. — This archipelago consists of ten principal islands, of which five exceed the others in size. They are situated under the Equator, and between five and six hundred miles westward of the coast of America. They are all formed of volcanic rocks; a few fragments of granite curiously glazed and altered by the heat, can hardly be considered as an exception.

Darwin disembarked on San Cristóbal (September 17-22), Floreana (Charles)(September 24-27), Isabela (Albemarle)(September 29-October 2) and Santiago (James)(October 8-17).

FitzRoy and his officers developed updated charts of the archipelago, while Darwin collected geological and biological specimens on the islands.

(Our voyage below, visits the northwestern Galapagos, islands crossing paths with Darwin when we land in Isabella and Floreana









The Giant Tortoises of the Galapagos Islands

Darwin learned much on his voyage, not just about the geology and biology of the islands, but also about himself and the importance of reason and observation:

I discovered, though unconsciously and insensibly, that the pleasure of observing and reasoning was a much higher one than that of skill and sport. The primeval instincts of the barbarian slowly yielded to the acquired tastes of the civilized man.

Apparently his acutely observant father identified these changes in thinking just by looking at Charles:

That my mind became developed through my pursuits during the voyage, is rendered probable by a remark made by my father, who was the most acute observer whom I ever saw, of a sceptical disposition, and far from being a believer in phrenology; for on first seeing me after the voyage, he turned round to my sisters and exclaimed, “Why, the shape of his head is quite altered.”

So, dear friends and patients, pay close attention to the shape of my head upon my return from the Voyage of the Samba. You might assume the large occipital protuberance is a result of a nasty fall from the top of a giant tortoise when, in fact, it is the outward representation of all the brilliant observations and dangerous ideas I have acquired on my trip.

Galapaghostly Yours,


N.B. Of the many observations that Darwin made while he was on the Galapagos Islands, I found his comments on the pericardium of the giant tortoises the most intriguing. My next post on Darwin and the Galapagos will explore in detail this fascinating cardiologic observation.