Feet First

“It is much more important to know what sort of a patient has a disease than what sort of a disease a patient has.” - Sir William Osler

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    Monday, February 24, 2003
    Three Patients

    I have a few clinical vignettes for you about some of my patients.

    The first one is a patient who I've been seeing for several years. She's Orthodox but very modern in her way, outgoing, loves her kids (she has six and would love to have a seventh, believe it or not). Once, I offered one of her children a sticker; the only ones I had were bright orange and labeled Allergic To: (they usually go on the front of the chart), but the child was charmed with the bright color and gladly took the sticker. "We don't let them watch TV," said my patient. "At the pediatrician's they don't know who all those cartoon characters are, so they usually ask for flower or dog stickers." My response: "Good for you." And I think it's great, as long as she can keep them entertained sans TV without their driving her nuts.

    Anyway. I saw her last week and I made some remark during the exam about buying duct tape (that seems to be an obsession of mine lately). Then we started talking about smallpox vaccination.

    "I'd take it, for sure," said my patient. I thought for a moment and said, "I would, too. It hasn't been offered to us yet, but if it is I will definitely take it." She nodded approvingly. A few minutes later she told me that she'd been trying to talk her husband into moving back to Israel: "I feel so much safer there."


    "Every Israeli is issued a gas mask and told how to use them," she explained. "Every house has a sealed room. People are just so much better prepared there."

    I haven't been able to get that conversation out of my head.

    Patient Two I saw a few days later. She came in for a routine physical and casually mentioned that she'd recently been vaccinated for smallpox. She works in a biologic laboratory - and they're manufacturing smallpox vaccine.

    I had never seen a smallpox vaccination site before and, after asking her permission, eagerly took off the Band-Aids covering the vaccination site. It was eight days old, and was a round white raised spot, slightly larger than a dime, surrounded by a mildly reddened area of skin. I went and got one of my colleagues, who was eager to take a look as well. After admiring it, I re-covered the site with Band-Aids and then asked (slightly nervously) if any precautions should be taken.

    "Well, you should wash your hands," she advised. I did. Thoroughly.

    Patient Three, you'll be relieved to hear, has nothing to do with bioterrorism. I hadn't seen her for over a year; when she came in I saw she'd gained a lot of weight (nearly fifty pounds) and that her blood pressure was way up. She'd been in better condition the last time I saw her and had been able to discontinue her BP meds.

    She explained that the stresses of her job had a lot to do with the state of her health: She works in the child abduction department for the county of Los Angeles. She is the only provider for the entire county.

    "What do you think of the Amber Alert system?" I asked her. (California recently started statewide alerts for missing children, named after one child named Amber who was kidnapped and murdered several years ago.)

    "Usually the lawyers won't let us use it," she replied.

    "The lawyers?" I queried. "Why not?"

    "Practically all our abduction cases are parental. Either the parent takes the kid or a friend or relative of the parent takes the kid and then turns them over to the parent. That recent case you may have heard about, where the mother took the kid?" [I nodded, though I couldn't remember which one it was.] "Well, the only reason that one got broadcast is because the cops got the info out before the mother's attorney turned up and tried to stop it."

    Unbelievable. But at least it's good to know that there aren't as many maniacs out there abducting kids as I had thought. She then went on to tell me about a recent tangled case she'd had to deal with on Valentine's Day - apparently I'm not the only one with weird associations with Valentine's Day and work. Briefly, the case involved a family of gypsies; the mother had had the child taken from her at the age of one by the father. Father wound up in jail and the child had been passed from relative to relative within the tribe. Mother finally got the kid back - after five years - on Valentine's Day. The kicker: she wasn't even sure who the father was. The child was kidnapped by a "father" who may not even have been a relation.

    Do you wonder that her blood pressure's up?



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