Category Archives: Travel

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.

Why Are The Dutch So Heart Healthy and Happy (And Tall)? Part I: Is It Their Diet?

The Skeptical Cardiologist and his  eternal fiancee’ recently spent 5 days in the Netherlands trying to understand why the Dutch are so happy and heart healthy.

We were driven by Geo (former statin fence-sitter) from Bruges to Haarlem, a city of 150,000, which lies about 15 km west of Amsterdam and about 5 km east of the North Sea.


Haarlem is one of the most delightful towns I’ve ever stayed in.



I was struck by  the beauty of its architecture, its canals and the happiness, height and friendliness of its inhabitants.

I was lucky enough to have a bike at my disposal. One day I set off randomly, and after 20 minutes of riding on delightfully demarcated bike lanes, I scrambled up a sand dune and looked out at the North Sea.

Just down the road was the  beach resort of Zandvoort, where one can enjoy sunbathing, surfing or a fine meal while gazing at a glorious sunset.





Like Amsterdam, which is a 15 minute train ride away, bikes and biking abound in Haarlem, but unlike Amsterdamers, the Haarlemers were universally engaging, polite and friendly. Everything and everyone seemed clean, well-organized, relaxed and pretty…and, well, …happy.

The Dutch High Happiness Rating

The World Happiness Report 2017, which ranks 155 countries by their happiness levels, was released in March of this year at the United Nations at an event celebrating The International Day of Happiness.

The report notes that:

Increasingly, happiness is considered to be the proper measure of social progress and the goal of public policy

Norway was at the top of the happiness list but

All of the other countries in the top ten also have high values in all six of the key variables used to explain happiness differences among countries and through time – income, healthy life expectancy, having someone to count on in times of trouble, generosity, freedom and trust, with the latter measured by the absence of corruption in business and government.

The top 4 were closely bunched with Finland in 5th place, followed by the Netherlands, Canada, New Zealand, and Australia and Sweden all tied for the 9th position.

Despite the immense wealth of Americans, the report notes:

The USA is a story of reduced happiness. In 2007 the USA ranked 3rd among the OECD countries; in 2016 it came 19th. The reasons are declining social support and increased corruption  and it is these same factors that explain why the Nordic countries do so much better.

Dutch children seem to be especially happy.

A UNICEF report from 2013 found that Dutch children were the happiest of the world’s 29 richest industrialized countries.  America ranked 26th, barely beating out Lithuania and Latvia.

Cardiovascular Disease in The Netherlands

Ischemic heart disease (IHD) deaths are due to blockages in the coronary arteries. Typically, this comes from the build up of atherosclerotic plaques in the arterial system and in most countries heart attacks from this process are the major cause of death.

The Netherlands has the third lowest rate of IHD deaths in developed countries, only slightly higher than France and less than half the rate of the USA.Screen Shot 2017-07-26 at 10.53.26 AM

In all developed countries over the last thirty years we have seen a marked drop in deaths due to IHD. In The Netherlands it has dropped 70% and the rate in 2013 was nearly as low as France’s rate.

In addition, the Netherlands has a very low rate of deaths from  hypertensive heart disease. This table from 2008 shows that they are second only to Japan and their mortality rate is a third of that in the US.

A recent update noted

The current Dutch age-standardised mortality from circulatory disease is 147 per 100,000, and only Spain and France have lower cardiovascular mortality rates (143 and 126 per 100,000, respectively). In all other European countries, including for instance Switzerland and Greece, cardiovascular mortality is higher [26].

What factors could be causing all this happiness and heart healthiness?

The Seemingly Horrid Dutch Diet

We have been programmed to believe that heart attack rates are related to saturated fat in our diets.

The fact that the French consume lots of saturated fat and rank so low in IHD deaths has been called the French Paradox as it seems to contradict the expected association.

One thing is clear-the Dutch are not following a whole foods, plant-based diet. They are among the world leaders in consumption of both fat and sugar as the graph below indicates.

While in The Netherlands I sought out raw herring,  a dish which Rick Steves and others indicate is a Dutch obsession.

Since there is evidence that fish consumption, especially fatty ones like herring and mackerel, is associated with a lower risk of coronary heart disease, perhaps this was protecting the Dutch.

I didn’t see much herring consumption in Haarlem (a native Haarlemer informs me that the Dutch raw herring consumption might be confined to older generations or tourists).

It turns out that the Dutch aren’t meeting their own nutritional guidelines for healthy food .

The recommendation to eat fish at least twice a week, of which at least once fatty fish such as salmon, herring or mackerel, is followed by a mere 14 percent of the population. Less than 25% of them meet the recommended daily amount of fish, fruit, and vegetable consumption.

Screen Shot 2017-07-26 at 11.58.57 AM
purple bar=women yellow bar=men orange bar= total

They do catch and export a lot of fish and shellfish and are in the top 10 of seafood exporting countries (99% of all those mussels consumed in Belgium come from The Netherlands).

And, to my great surprise, they eat lots of French, or as I have started calling them, Flanders fries.


I personally witnessed  massive amounts of cheese and butter consumption.

In fact, the Dutch average 15% of calories from saturated fat, which is far above the 10% recommended by the Dietary Guidelines for Americans.

A recent analysis of Dutch fat consumption found:

The mean baseline intake of total saturated fatty acids (SFAs)  in the population was 15.0% of energy. More than 97% of the population exceeded the upper intake limit of 10% of energy/d as recommended by the Health Council of the Netherlands.

The Dutch weren’t eating so-called healthy fats as “The main food sources of SFAs were cheese (17.4%), milk and milk products (16.6%), meat (17.5%), hard and solid fats (8.6%), and butter (7.3%).”

Surprisingly, the more saturated fat the Dutch consumed, the LOWER their risk of death from IHD:

After multivariable adjustment for lifestyle and dietary factors (model 4), a higher intake of energy from SFAs was significantly associated with a 17% lower IHD risk (HR per 5% of energy: 0.83; 95% CI: 0.74, 0.93)

The Dutch Paradox

Data shows that  the Dutch are eating lots of saturated fat from dairy and meat, but it appears to be lowering their risk for heart attacks

Yes, despite 40 years of high saturated fat consumption, the Dutch have seen a 70% drop in mortality from heart attacks. Their rate of dying from ischemic heart disease is lower than the US and only slightly higher than the French.

Thus, rather than talk about a French paradox, we should be talking about the Dutch paradox.

For the French paradox many theories, both fanciful and serious,  have been proposed

The one most laypeople remember (due to a 60 Minutes episode in 1991) is that the French are protected by their high red wine consumption. Although this theory proved a great boon to the red wine industry (sales rose 40% the year after Morley Safer made his presentation on 60 Minutes), it has never had any serious scientific credibility.  Current thinking is that all forms of alcohol in moderation are equally protective.

Others have proposed garlic or onion or faux gras consumption. My own theory for the French is that it is fine cheese and chocolate consumption that protects them.

In subsequent posts I’ll lay out the evidence for my startling new theory to explain the Dutch paradox.



The Skeptical Cardiologist Abroad

The skeptical cardiologist is about to embark on a two week vacation in Europe.

I and my Eternal Fiancee’ will fly into Paris and spend a few days  there lapping up the Parisian food, booze and ambiance. Then we will take a train from Paris to Bruges, Belgium for another few days of sight-seeing.

The tour will end in Haarlem, The Netherlands (aka Holland) where the Eternal Fiancee’s parents (Wendy and Geo of “Are you on the fence about statin drugs ” fame) have swapped their house (and car) in Annapolis, Maryland (temporarily) for a  house in Haarlem  (and car and bikes!).

For a cardiologist, a  two week vacation in Europe used to mean severing almost all communication with one’s practice. I can recall my first visit to France in 1987; there was no internet, no cell phone and no text messaging. A several minute phone call to talk to my children seemed prohibitively expensive.

For this trip, however, I am loaded up with a laptop, a cell phone and an ipad, anticipating the ability to stay in communication with everyone, everywhere.

This super-communicative status means I could do a whole lot of patient care on this European Vacation.

If I wanted to, I could log in to my hospital’s EHR and check on my patients. I could see what their latest blood pressure and weight was, or how low their potassium had dropped after diuretics. I could write orders to lower their diuretic dosage or for additional potassium.

For my outpatients, I could check labs results and send them messages. I could stop blood thinners prior to surgery or advise those having questions or problems.

If my patients have had diagnostic imaging studies, I could remotely read and report echocardiograms, nuclear stress tests, long term monitors, coronary calcium and CT angiograms.

In short, I could continue to keep an eye on my practice even while trying to vacation thousands of miles away.

Fortunately, I have an outstanding partner in my practice, Dr. Scott Brodarick and a wonderful medical assistant, Jenny Clancy, who will be covering me and handling the low potassiums and the surgical clearances and all the myriad unforeseen patient developments, making it possible for me to focus on being a skeptical tourist rather than a clinical cardiologist for two weeks.

Perhaps I shall encounter a grisette in Paris.

Mark Twain visited Paris 150 years ago. In “Innocents Abroad” he wrote about searching for grisettes in Paris whom he expected would be beautiful, graceful, happy and “charmingly, delightfully immoral.” When he finally saw them he was disappointed: “They were like nearly all the Frenchwomen I ever saw–homely. They had large hands, large feet, large mouths; they had pug noses as a general thing, and moustaches that not even good breeding could overlook; they combed their hair straight back without parting; they were ill-shaped, they were not winning, they were not graceful; I knew by their looks that they ate garlic and onions; and lastly and finally, to my thinking it would be base flattery to call them immoral.”

Innocently Yours,