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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    Tuesday, April 29, 2003
    Day Two

    In medicine, to "diurese" means to give a medication - a diuretic - that forces the kidneys to absorb less fluid during the process of filtering urine than they ordinarily would. The result is that the patient urinates more and loses fluid - a useful thing if one is in congestive heart failure or is otherwise fluid overloaded.

    In the rough-and-tumble world of inpatient medicine, diuresis has another meaning; it is used to describe the process of lightening one's inpatient service by discharging patients from the hospital, which is exactly what I am trying to do. I am aided in this process by a case manager who is as sharp as a tack. She was on me as soon as I walked in the door of the hospital yesterday with suggestions about which patients needed physical therapy consults (a prerequisite for nursing home placement) and which families I needed to open negotiations with regarding placement for their loved ones (to go home or to the nursing home?) As I was frantically trying to find my feet with sixteen patients at two different hospitals, I was initially annoyed, but today I see the benefits. One went home today, two and possibly three are going home tomorrow, and the IV antibiotics and home care are all lined up.

    I guess what I'm trying to say is, this isn't as bad as it was in January.

    I had an interesting encounter today down in the radiology department - ran into a guy who used to be a member of our group and left earlier this year to open his own practice. (Among other things, he got tired of the bimonthly staff meetings or "Monday Night Meetings" which we've had ever since the group was founded.) He was full of questions:

    "Still going to those Monday night meetings?"
    "Are you still getting bombarded with patients?"
    "How's the hospitalist program going?"

    I asked him how he was doing. He actually appeared upbeat, almost bubbly, which for this guy is a rarity. I've always gotten along with him fine, but he had a reputation as a grumbler.

    "I've been happy every single day since I started," he said. These are words I would not have expected to hear. "I mean, there's the stress of getting an enterprise like this off the ground, but I work half days and I'm making money after three months. There is money to be made in this business!"

    I asked him some questions about billing and insurance. He doesn't take Medicare or Medicaid, but he does take certain insurance plans and he even has some cash patients (where the hell did he find those?) I believe some of his medical group patients followed him to his new practice, but he must be getting referrals from someone.

    I wished him well. This seems to suit him and I'm sure he'll be successful. During the rest of the afternoon I wondered, as I sometimes do, what it would be like to have my own practice. Would it be possible to do it and make money? Maybe, but I'd have to work a lot harder than I do right now and I'd rather not. I'm talking about things like paying office rent, conforming to OSHA regulations, hiring and firing employees and setting up a 401(k). Plus, I like being able to duck down the hall for a curbside consult with one of my partners (especially the specialists) or just for a chat. Solo practice, I think, would be awfully lonely.

    No, I'm a groupie, and I'll stay one.

    Monday, April 28, 2003
    My Life Is an Open Book

    V. just called. Less than an hour after I posted and she's on the line:

    "WHAT are you doing being the hospitalist again??"

    I can't get away with anything!

    Happy Monday

    Argh. I'm hospitalist again this week. Yes, I know I said I'd never do it again, but here I am... doing it for the money. As a result, blogging may be light this week - but here's another delightful email from Chuen-Yen, reporting on conditions in Malawi:

    Salutations! Here are some thoughts for this week:

    I occasionally fantasize that I�m well adjusted to Malawian culture. Anon, I am inevitably reminded that this is a delusion. The farrago of warm welcomes I received upon returning from vacation is case in point. BAH staff declared it a pleasure to have me back. Friends embraced me. Some patients delivered fresh produce. I was offered another goat.

    After initial greetings, �Did you gain weight?� was a common follow-up question. As I hadn�t checked, I awkwardly responded, �It�s quite possible,� to the first few enquirers.

    Another recurrent statement was, �You must have enjoyed your holiday. You�re a bit pale.�

    With such pleasantries, I became a tad self-conscious and rushed to a mirror at first opportunity. The reflection suggested my pallor had actually decreased due to recent elemental exposures. Expat friends confirmed this observation. Later, I stepped onto the hospital�s only scale. The reading was identical to that of three months prior. Several nurses tried to console me by remarking, �You look heavier than that.�

    My sunburn was another point of interest amongst the locals. Having walked across a glacier sans protection, my peeling face required intermittent application of various salves. However, the dark Malawans aren�t familiar with sequelae of sun exposure. Burdened by an average life expectancy of thirty-six years, most don�t survive long enough to appreciate skin cancer. On the other hand, they are well acquainted with chemical injuries and fire accidents. Hence, I gave a lengthy explanation using the analogy of industrial mishaps.

    Such interactions are contextually logical. In a country ravished by disease and famine, obesity is a status symbol. Where poverty equals interminable days of laboring under glaring sun, only the privileged are pale. Most people don�t have the luxury of worrying about consequences of UV radiation. Hence, when complimented on how fat and pasty I have become, I now graciously accept the flattery.

    Take care,

    Friday, April 25, 2003
    On the Same Subject:

    A British woman has invented a device which is supposed to improve women's orgasms. It is a disposable, soft plastic device which fits over the finger and is used as a clitoral stimulator. If this works, it could be extremely useful, as many women have either anorgasmia or difficulty achieving orgasms.

    The funniest part of the article, however, is at the end:

    The actual winner of the British Female Inventor of the Year Awards was Trish Fearn with a lightweight ergonomic fork for mucking out stables.

    Mrs Fearn, from Wetherby, West Yorkshire, spent 12 years developing the Lite-Lift Shaving Fork after she was told she could no longer look after her 200 rescued horses due to chronic tendonitis caused by heavy stable work.

    Where were the judges' priorities?!

    Q Fever!

    This is sick but funny:

    Contraceptive Sponge Available Again; Likely to Replace Intra-Vaginal Swiffer

    It's probably funnier if you're female.
    (via GruntDoc)

    Thursday, April 24, 2003
    Lies, Damned Lies, and Statistics

    Yesterday I read this abstract from the New England Journal of Medicine about adverse drug events in outpatients. I got it through the ACP Online email service. Although I don't have the link to the entire article (subscription required), the ACP condensation and the abstract raised some questions in my mind, so I'd like to talk about it anyway. The data for the study was collected from chart reviews and by having patients fill out surveys asking them if they had had any symptoms related to medications (I'm assuming the patients just filled out the surveys without asking health care providers whether the symptoms were likely to be due to the medications or not).

    Here is what the ACP had to say about it, and I emphasize this because any reports in the lay press about the study are likely to be similar:

    A recent study found that one-quarter of primary care outpatients suffered an adverse drug event. That figure is four times the number of events reported in hospital settings.

    A patient survey of four primary care practices in Boston found that the drugs most commonly cited in adverse events were selective serotonin-reuptake inhibitors, antihypertensives and nonsteroidal anti-inflammatory drugs. While none of the events were life threatening or fatal, 13% were serious and 11% were preventable.

    Authors of the study, which was published in the April 17 New England Journal of Medicine, said that physicians could have avoided many of the preventable events by using computerized prescribing tools. Researchers also said that physicians could have prevented or ameliorated many errors through better communication strategies, such as using e-mail and translators.

    The authors also recommended better monitoring of side effects by physicians, nurses or pharmacists.

    To restate: this study says that 25 percent of all patients in outpatient primary care practices are having side effects or "adverse drug events." This means, most likely, that anything - diarrhea following antibiotic use, headache, mildly upset stomach, anything - was viewed as a side effect.

    Now, I don't want to give patients medications that make them worse off than they already are. And it's true that some adverse drug effects can be serious. But one of the facts of life is that medications have side effects, pure and simple. There is no such thing as a "smart drug" that only affects one symptom or organ system. Nonsteroidals can cause stomach pain or ulcers; serotonin reuptake inhibitors can interfere with sleep patterns or make people jittery. The question to me is, don't these medications have more benefits than side effects? The other question is, was any attempt made to separate really significant side effects or avoidable problems from run-of-the-mill complaints? It seems to me that the only thing this study is likely to do is to make people more reluctant to take medication that they actually need.

    Before I close this sounding like a hard-nosed "take your medicine and shut up" doc, I should say that I always tell my patients to call me if they're having problems with their medications. I also try to tell patients what the most likely side effects are with their meds and what they can do to ameliorate them (if that's possible). Communication is important and it can be lifesaving. When I see statistics like this, though, my first reaction is to doubt the study, not to believe it.

    Fun Site

    I wonder if this is what it's actually like on the floor of the New York Stock Exchange. Drop the indicator to the negative zone and watch the agitation level rise!

    (thanks to Tim Blair)

    Wednesday, April 23, 2003
    Happy Anniversary

    2003 is the 50th anniversary of Marshmallow Peeps! Break out the confetti, it's going to be a big year!

    Ah, where would we be without the lowly Peep. Victim of sadistic scientific experiments, source of massive sugar rushes, trigger of sentimental childhood memories... you don't think it was really a madeleine that instigated Proust to produce those six volumes, do you? Mais non! It was a Peep.

    I'm having password withdrawal.

    You may not be as fixated on computer passwords as I am, but I have a reason. (Honest.) At work I have several programs that I have to sign into whenever I use them - my Microsoft Outlook, our computer appointment scheduling program, the online access to hospital labs. Because I wind up having to sign in a dozen times a day, I use the same password for everything to keep things simple. Unfortunately, about every four months I have to change passwords because they expire. I realize this is a security precaution, but I still find it annoying; it's a strain to think of new passwords. To minimize password-picking anxiety, I tend to run in patterns. For awhile I used various religious words or names of saints ("stluke", "stmark" and my favorite, "heresy").

    Now I'm on a different tack: names of detectives. No, I won't tell you which one I'm using at the moment, but I just switched and I'm upset. My new password is awkward to type but it's the right length (passwords can't contain more than a certain number of letters, which tends to restrict one's creativity). My old password was clever, unusual, stylish and easy to type. It felt like having the perfect outfit hanging in your closet, or finding an extra twenty in your wallet.

    Alas, all good things come to an end, and my password, as it were, passed on. Expired. The system won't allow re-use of a password so I had to move on and console myself with a new one. I'm still in mourning, though. I'll never forget you, password.

    Tuesday, April 22, 2003
    Spinach or Cheetos? You Decide!

    Found an interesting website today. I'm not quite sure whether I approve of it or not but I certainly think it's worth a look. The site is called Center for Consumer Freedom and basically campaigns for people to use their common sense regarding health choices as opposed to "nanny" policies by the government. It vents a lot of wrath on the Center for Science in the Public Interest, the Robert Wood Johnson foundation, and PETA. Check out their Tarnished Halo Awards, in which the CCF...

    awards prizes annually to America's most notorious animal-rights zealots, environmental scaremongers, celebrity busybodies, self-anointed "public interest" advocates, trial lawyers, and other food & beverage activists who claim to "know what's best for you."

    The Tarnished Halo Awards highlight the winners' use of misinformation, duplicity and even violence to further a political agenda or fatten their own wallets.

    Now I don't think the answer for obesity is to eradicate McDonald's from the earth, and if the Center for Science in the Public Interest is relying on flawed studies to make its claims (as the CCF claims it does) then I certainly don't approve of such tactics. On the other hand, it's true that diabetes, hypertension, and other lifestyle-related diseases are skyrocketing and that a large part of the population is making bad food choices. While I agree -- in theory -- with the CCF's position that people can make intelligent choices and that it's not the place of government to be your mother, the fact is that in many cases those intelligent choices are not being made. Some prodding from Big Brother might be a good idea. Then again, I think patients are more likely to pay attention to one-on-one counseling from a health care provider than to a billboard telling them to eat their peas.

    Your thoughts?

    Monday, April 21, 2003
    More From Malawi

    Here is the next installment of my friend Chuen-Yen's adventures, in which we learn that one wife is worth five to ten head of cattle and that you should always book through a reputable Western Hemisphere travel agency if you want to try to climb Mt. Kilimanjaro:

    Jambo (Hi in Swahili). I'm back in Blantyre for a day. Here's a brief update:

    "Brushing your hair is a poor substitute for washing it."
    -- Most profound thought at 5,895 meters

    Summiting Mt. Kilimanjaro is an amazing experience. However, reaching the trailhead can be the most challenging part of the adventure. At Dar es Salaam airport, Jason, John and I were agreeably swindled into purchasing a package deal. However, our $250 per person deposit covered only local transport to Moshi, a good place to begin a Kilimanjaro trek. This hypothetically five-hour bus journey lasted twelve hours and left me crusted with dead insects, bird feces, shards of glass and a fellow passenger's blood.

    Our first delay was Kili Express' brake failure. During the compulsory rest stop, I met Denas, a twenty-three year old Masai boy who had shirked traditional tribal life in pursuit of classroom education. He lamented that he was, at this mature age, unmarried and childless due to paucity of cattle. Denas limned that every Masai boy receives one cow at birth. With proper animal husbandry, he should own five to ten cattle by his eighteenth birthday. With these, he may procure one wife. As the herd enlarges, he will acquire more mates. However, Denas' family had consumed some of his stock while he attended school. With only three remaining animals, he was unmarriageable.

    A few hours into the saga of Denas' tragedy, we splurged $12 more for seats on a passing bus with functional brakes. Unfortunately, this one grazed a lorry, explosively injuring the driver and shattering several windows on my side. Luckily, I was leaning forward to assess what items had been filched from my pack during the previous breakdown. While surrounding travelers were severely lacerated and had debris embedded in their skin, I was only stung by a mist of glass needles and showered with my neighbor's blood. The wounded, including our driver, were rushed to a local clinic as officials collected multiple reports, thus causing further delays.

    Fortunately, the now repaired Kili Express caught up as we loitered outside "Barcelona Rhythms Nightclub," a roadside stand with a boom box. We scurried back onto the original bus. At 11 pm, we reached Moshi Central only to discover that Flugo Tours had paid for no further arrangements. I suppose $762 is a bargain for such priceless entertainment.


    OK, I'm Back

    Nice trip, but I got sick. My sister's youngest, William, is 11 months old and has a cold. He also has a charming habit of sucking on his fingers and then sticking them up the nose or in the mouth of whoever is carrying him at the time. Very sweet kid, though, and even-tempered even when sick. He has learned to crawl and just figured out how to go up stairs, which meant we had to keep an eagle eye on him and break out the safety gate.

    Unfortunately, I came back to an avalanche of work. More later.

    Thursday, April 17, 2003
    How To Email? Type and Hit Send!

    Are you a klutz when it comes to flirting by email? Have you sent embarrassing personal emails to the entire company by mistake? Then you need to take the Yahoo Email Master Class. Yes, apparently people actually do have this problem, as noted in this article. Pity the poor souls who describe email as a "huge burden."

    Wednesday, April 16, 2003
    Okay, One More

    I saw something in GruntDoc's blog today that reminded me of my experiences as an independent contractor, ten years ago when I first got out of residency.

    This is how moonlighting works (and how residents get into financial trouble): after one year of internship, an MD is qualified to apply to the state for a license to practice medicine. Armed with said license, residents can moonlight in other jobs (usually after-hours clinics), where they can learn and get paid at the same time. Almost all moonlighters are paid as independent contractors, which means you have to estimate and pay taxes quarterly, as opposed to regular full-time employee paychecks which have taxes taken out as you go along. The good news is the paychecks look huge when you get them. The bad news is the tax bill can come as a nasty surprise if the moonlighter is a novice. This usually happens in the first tax season after the resident has started moonlighting and has not bothered to estimate quarterly taxes for the first few months.

    One of my friends from residency was sitting in the doctors' lounge one April morning lamenting her financial situation as follows:

    "I started moonlighting to pay off my credit card bill, and everything was great until I saw how much I owe in taxes! What am I going to do?"

    "Put your taxes on your credit card and start all over again," I suggested.

    I thought this was funny. She didn't.


    Today, I hit the "I'm Feeling Lucky" button without entering anything - because, well, I felt lucky.

    I got this.

    So, it's not like playing a one-armed bandit. Damn!

    Name That Aneurysm

    One thing I like about medicine is that you're always learning, no matter how long you've been in practice. It's no shame to admit you're unfamiliar with a disease or topic; instead, you're encouraged to read, investigate and ask questions.

    Last week a patient of mine presented to the emergency room with abdominal pain. She was worked up and sent home, but I was called by the ER doc because the radiologist had found a splenic artery aneurysm on her abdominal X ray (it was an incidental finding and not the source of her pain). As an internist, I am totally unfamiliar with splenic aneurysms; in fact, I'm not sure I had ever heard of one before. So what do we do about this?

    We check Google. Now that we have personal computers and Internet access at the office, I use Google a lot more than textbooks when I want to look something up; it's much faster. So here are the results of my search for "splenic artery aneurysm".

    Hmmm. So they do rupture. Apparently one of the higher risk scenarios is during pregnancy - at least, there are several listings regarding pregnancy and splenic artery aneurysms. My patient is postmenopausal, so that is not an issue, but one of the articles suggests that aneurysms larger in diameter than 2.0 cm are at higher risk of rupture. According to the radiologist the diameter of this one is 2.0 x 2.5 cm, so now I email our surgeon for input.

    "Get a CT scan" is the answer. The closer the aneurysm is to the branching point or origin of the splenic artery, the more likely it is that the entire spleen will need to be removed. In some cases, when it's further away, the surgeon can merely take out the dilated section of artery and anastomose (sew together) the open ends of the artery, preserving the spleen.

    So now we're waiting for the CT, which should be done sometime this week. We will then have time to have the patient meet with the surgeon and get her vaccinations before proceeding to surgery. (Since the spleen is an important part of the immune system and helps fight off bacterial infections, we like to vaccinate people against things like Strep. pneumonia and H. influenza prior to surgery if possible.)

    I also found a great article written by a man who suffered a ruptured splenic artery aneurysm - and survived. He ran thirty miles a week and was in great shape, which is probably why he lived despite several hours' delay in treatment.

    Parenthetical note: blogging will be light or none till next week as I am going to be away for Easter. Enjoy your Easter/Passover, or just enjoy spring.

    Monday, April 14, 2003
    Evil Grand Rounds: The Redux

    Let's try a little humor here. In an attempt to get my mind off federal bureacracy, I present more Grand Rounds (and other activities) To Be Avoided:

    All announcements are verbatim from my emails.

    Department of Surgery sponsors
    Surgery Grand Rounds
    "Surgical Experience with 25 Conjoined Twins"
    Chang and Eng, Orthopedists!

    Department of Medicine
    Division of Nephrology sponsors
    �The regulation of parathyroid growth in uremia�
    A guaranteed cure for insomnia...

    Cedars-Sinai Alumni Association sponsors
    Attending Staff Gomers
    The Housestaff Blues

    For those of you who don't know, "gomer" stands for "Get out of my Emergency Room" and is applied to elderly demented patients who turn up in the ER for no really good reason. I do not find it flattering to be referred to as a gomer.

    Department of Psychiatry sponsors
    "The New Role for Psychiatry In
    An Age of Terrorism and Weapons of Mass Destruction"
    New role? Try "tranquilizer dispenser"

    �Lessons Learned from Litigation Against Oncologists�
    Cancer is a very bad disease. Try not to get it.

    HIPAA Update II

    This is rich... our risk manager has informed us of the following curve ball regarding faxes: we can fax patient information, but only if we fax from a "white-paper fax machine" to another white-paper fax machine. In other words, it has to be a freestanding fax, not a computer program that can send and receive faxes... because with the latter, the information could possibly be left hanging out there in the Internet ether, and therefore is not privacy protected!

    So now we have to ascertain whether the receiving fax is a white-paper fax. This means we have to ask everyone this question before we fax anything anywhere.

    I have to go kill myself now. Bye.

    HIPAA Update

    We're already having problems. One of my colleagues is trying to do a preop exam on a patient who needs a breast biospy, and she can't get the results of the patient's mammogram or ultrasound. The surgeon's office is refusing to fax the information to her because of HIPAA. Now, this legislation is not supposed to affect the transfer of information from doctor to doctor, but in practice it is hindering it because now our staff is too damn scared to release any information at all.

    More updates as they happen, if anything really outrageously stupid turns up.

    Well, HIPAA ("making your life better by making it worse") goes into effect today. It started out as health insurance reform - the acronym stands for Health Insurance Portability and Accountability Act - and, as originally postulated, was a good idea. (The key words here are "as originally postulated.") The purpose of this piece of legislation was to make it possible for someone to keep health insurance when they changed jobs; in the past, someone with a bad health record, or a family member with a bad health problem, could be denied insurance through their new employer when they changed jobs, since the new insurance company might not want to accept someone with high health costs.

    So far, so good. Then someone decided to tack on "administrative simplification" to the bill, as follows:

    The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA, Title II) require the Department of Health and Human Services to establish national standards for electronic health care transactions and national identifiers for providers, health plans, and employers. It also addresses the security and privacy of health data. Adopting these standards will improve the efficiency and effectiveness of the nation's health care system by encouraging the widespread use of electronic data interchange in health care.

    Again, nothing really wrong here, either; it makes sense that simplifying the transfer of medical information and encouraging electronic record storage would be a good idea. Medical records, in large part, have not changed since the nineteenth century; notes are still hand written and stored in paper files. Record storage and retrieval is a constant bugaboo for hospitals and physicians. Patient privacy also needs to be considered, and this has taken over most of HIPAA; the most stringent and detailed regulations of the Act deal with this issue.

    The problem here is that the regulations, as drawn up, are not a simplification, they are a complication. Medical centers and physicians' offices have had to invest a lot of money and time in training everyone on these procedures. This means residents, attending physicians, ward clerks/secretaries, medical assistants, maybe even janitorial staff. Everyone. The list of things the regulations affect are huge: I can't email my patients, for instance, because we do not have encrypted email. When I finish charts at night, I can't leave them on the counter at my nurses' station any more because the cleaning staff might walk by and see patient information. When I pointed out that the office cleaners would have the same access to charts in my room, I was told that the nurses' station was "public space" as opposed to my "private space"; equally vulnerable physically, but protected legally. You figure it out.

    In addition, every patient coming in now has to be given a copy of our medical group's statement of compliance with HIPAA regulations and patient rights, and they have to sign a form stating that they've been given this copy, and if they refuse to sign we have to document that. We're trying to figure out how we can indicate that a patient has already signed off on this so they don't wind up signing multiple times and getting multiple copies (for instance, if we refer the patient to our gastroenterologist in some other office, he/she will be given another form to sign unless we can figure out how to let the office staff know that the patient has already been counseled).

    Our administrative risk manager is buzzing around the office now making sure everything is shipshape, so I'd better sign off. If she catches me blogging she might have a heart attack, and I'd like to spare her that.

    Saturday, April 12, 2003
    It's A Zoo Out There is a website written by a doctor named Jen Jen, who works at Changi General Hospital in Singapore and is coping with the SARS epidemic. It's gripping reading. One of her posts begins, "How shall I put this delicately: I AM TERRIFIED." Thanks to Medpundit for the pointer, as well as for a link to this article on a new drug to prevent stroke damage. The drug is called caffeinol and combines coffee and alcohol.

    I am not making this up. Go see the link. Wouldn't it be great if we could just hand every stroke patient an Irish coffee?

    May I Have This *zap* Dance?

    To those of you who surf for medical content, I apologize for the number of non-medical posts... but as I have said before, this is a somewhat eclectic blog. Here's something just barely medically related that I had to post about: it falls more into the "I can't believe all this stuff is on the Web" category. It's a website that sells antique European dance cards. My favorite item for sale is the seventh card down which is rather elaborate and consists mostly of a model of a machine (three-dimensional). Description, and I quote:

    No date or Ball name. Manufactured by Marton Alajos, Budapest. Again the "card" would have been located under the metal design. The "machine" was used for shock therapy treatment, so, we assume that this was a favor for a psychiatrist ball. Purchased on Cape Cod. Price:SOLD

    Of course it's sold, I bet it was the first one to go. Oh, those crazy, romantic Hungarians! I wonder what they put on dance cards for psychiatrists' balls nowadays... probably models of Prozac or Zyprexa tablets.

    Friday, April 11, 2003
    Odor Eaters Might Have Helped

    Here's a silly Friday post for you:

    Dutchman fined for smelly feet

    [A] 39-year-old Rotterdam man was fined �70 for repeatedly going into the university library in Delft and taking off his shoes.

    He was convicted of trespass because he kept going into the library despite the fact he had been banned for upsetting other users.

    All SARS, All the Time

    SARS Watch focuses on the spread and investigation of SARS around the globe. Check it out if you're interested.

    (via Tim Blair)

    Wednesday, April 09, 2003
    Truth In Advertising

    Candidate for worst slogan of the year:

    "Hong Kong will take your breath away."

    Could I just settle for being mildly impressed?

    If you want to see the current report (for April 9) on SARS statistics from WHO, go here. Currently 2722 probable cases have been reported worldwide with 106 deaths. Two weeks ago the statistics were 1323 cases worldwide with 49 deaths. SARS continues to spread, but it is not growing exponentially at this point. Hopefully the quarantines and respiratory precautions will limit its reach. Unfortunately, it's too late for Hong Kong to benefit much from this.

    Tuesday, April 08, 2003
    Sit! Heel! Pee!

    If you ever want a dog to go where it's not supposed to go (unlikely, I admit, but you never know), read this.

    "One-Take Nico" sounds like a pretty smart dog - and he's got his own suite at the Sofia Hilton!

    "I Sat on Saddam's Throne"

    ... is an interesting study of the function of the digestive tract during wartime. (Well, no, not really.)

    Apparently the stories are true: the loo and fixtures have gold leaf all over them. Check out the picture.

    Monday, April 07, 2003
    Robert Benchley Said It Best

    Our medical center is now deluging the staff with information about preventing SARS outbreaks. By fax and email come documents: "SARS Screening", "Preventing the Spread of Severe Acute Respiratory Syndrome (SARS)".

    V. responded to the latter announcement with this emailed suggestion: "Run away! Run away!"

    But what I think of most is what Robert Benchley said when he was asked how to avoid catching colds:

    "Don't breathe through your nose or mouth."

    Sunday, April 06, 2003
    Film Rant

    One of my favorite movies is a French crime film from 1955 called Bob le Flambeur. It's about an aging gangster and compulsive gambler who comes up with a plan to rob a casino with some of his buddies when his gambling losses get too much for him, despite having sworn off committing crimes years before. This film is full of moody black and white photography, with great scenes of Paris at night. Bob is played by an actor named Roger Duchesne, who looks better in a trenchcoat than any man I have ever seen; he has a wonderful world-weary air about him. (I saw Bob le Flambeur in an art-house theater in LA about a year ago, and as my friends and I were exiting the theater I said, "If Duchesne had just stood in his trenchcoat and looked at the audience for two hours it would have been almost as good.")

    So this weekend I picked up a copy of Entertainment Weekly and read that an American remake of Bob is being released this week.

    Starring Nick Nolte.

    Titled The Good Thief. (Why don't they just call it "Generic Title" and have done with it?)

    Now let's be fair here. The film has gotten some favorable reviews. Nor am I trying to imply that Nick Nolte can't act. But...

    It's just not right. For instance, why did the filmmakers make the Bob character a heroin addict? (Which they did.) The original film makes it clear that Bob has an addiction to gambling, and this addiction both precipitates his involvement in the crime and influences the outcome of the robbery attempt. It drives the plot, in other words. Now unless changing Bob's addiction sends the film in a whole new direction, I don't see the point.

    And Nick Nolte, with all due respect, is no Roger Duchesne. I can't see the guy in a trenchcoat.

    Oh, I'll probably see it for curiosity's sake. But the French are pissed off enough at us as it is without making films like The Good Thief out of classics like Bob le Flambeur. Chirac will probably never speak to us again.

    Saturday, April 05, 2003
    Photic Sneeze Reflex

    Let us speak of an odd little phenomenon that you have probably either observed in others or suffer from yourselves: the photic sneeze reflex. What happens when someone with this reflex steps into bright sunlight from a darkened or indoor environment? They sneeze, usually two or three times, then acclimate to the brighter light and stop sneezing.

    I find this interesting because I have the photic sneeze reflex, and I know exactly where I got it from: my dad. This is an autosomal dominant trait, which means that if a sneezer has children, each child has a fifty percent chance of inheriting the reflex. The photic sneeze reflex is most often seen in Caucasians, but it can be seen in other racial groups too.

    The cause is felt to be some sort of crossover in nerve feedback between the optic nerves and the trigeminal nerve nucleus in the midbrain, sort of like a short circuit. Many people refer to the reflex as being "allergic to sunlight," and while this is medically incorrect, having experienced it myself I can see why they say this: the intense light makes your nose tickle as if you'd just inhaled a bushel of cat dander.

    Have you experienced the photic sneeze reflex? And wouldn't "Photic Sneeze Reflex" be a great name for a rock band? Send me your comments!

    Friday, April 04, 2003

    President Bush Issues Order Authorizing SARS Quarantine

    Lock 'em up.

    Call Me Paladin*

    Busy, busy, busy today. We had lots of doctors out at various medical conferences... either the ACP national meeting in San Diego or the Pri-Med in Long Beach. That means I'm covering for lots of people and trying to solve all sorts of problems. I got the office manager to distribute some of the phone calls to other docs, but I still had to review dozens of referral requests and...

    Why am I burdening you with this??

    Anyway. This weekend promises to be a busy one. I am taking hospitalist call tonight, which means I can expect to get pulled from my bed at some point this evening to admit one or more patients, and I'm also doing telephone call for the group Saturday and Sunday. I am doing this, of course, for money. Renovating one's home comes expensive.

    When my medical director asked me earlier this week if I'd take telephone call, she quoted me a price and I said, "Done," and then realized that this was just like the bargaining scene in "Pretty Woman." I'm for sale... a medical slut. Or should I rather say, a hired gun?

    *Which leads me back to the title of this post... Paladin was the lead character in "Have Gun, Will Travel." At this point I feel my slogan should be "Have stethoscope, will travel."

    Thursday, April 03, 2003
    Give Today to Stop This Illness!

    There are many disease syndromes related to workplace exposures or work-related injuries. As I have mentioned in the past, the ICD-9 codebook is a great source for names of these illnesses. A few would be:

    Farmers' skin (692.74)
    Brickmakers' anemia (126.9)
    Wool-sorters' disease (022.1)
    Clam diggers' itch (120.3)

    But what could surpass the heartbreak of guitar nipple?
    (I'm guessing this code would be 611.7. Via Medpundit.)

    Wednesday, April 02, 2003
    More From Chuen-Yen

    Another delightful email from my internist friend Chuen-Yen, who is working as a volunteer in Malawi for a year: She has apparently become an expert on everything under the sun by virtue of her medical degree...

    Hi again!

    Every inhabitant of Malawi is a jack-of-all-trades by necessity. So, it�s only logical that, despite my background, I treat psych, ob-gyn, pediatric and minor surgical problems. It�s also plausible that I have become an endocrinologist, cardiologist, nephrologist, etc by default. However, since the advent of �Ask Dr. Lau,� my weekly column in The Daily Times, I have been increasingly obliged to address issues beyond the realm of medicine.

    The newspaper advertises, �Dr. Lau, an Internal Medicine Specialist, will answer your questions about health and fitness every Tuesday.� One might, based on this information, speciously anticipate inquiries about common medical concerns. But given that an expert in one field must be a universal authority, I�ve received some amusing queries.

    For instance, a hospital visitor recently accosted me with an urgent plumbing matter. After confirming that I was actually "the doctor", she began to unpack a large bag. Several feet of flexible metallic tubing materialized. Then emerged a showerhead at one end of the conduit and a portable electric heating device at the other. A relative had kindly sent this contraption. How she might utilize it? The lady was further confused about the accompanying item � a valve handle. I clarified that these were likely bathroom fixtures. The little thermal box should be connected to a water source, which the spigot would regulate. Delighted with this explanation, she thanked me for being a good physician.

    This evening, another character approached me for advice about potato cultivation. Fortunately, I had recently discussed the topic and was able to describe the tubers� water, fertilization and six-week incubation requirements.

    Readers are sending a multitude of interesting inquiries: How do you can foods? Where does salt come from? Why do frogs make that dripping noise? What makes a person feel happy? I didn�t learn all this stuff in school. But life is full of lessons that aren�t found in books. Hope you�re enjoying your education.

    Any questions?

    Tuesday, April 01, 2003
    When the Interpreter Is a Child

    The state of California is pondering a bill that would prevent children from interpreting for their parents to doctors or lawyers. You can read more about the bill here.

    Children are often inappropriately used as interpreters for their non-English speaking parents in medical, legal or social service settings, said a San Francisco lawmaker who introduced a bill Tuesday to ban that practice.

    "I think that all of us who come from an immigrant background have had an experience of having to translate for our parents," said Assemblyman Leland Yee, who immigrated to the United States from China when he was 3.

    Asking a child to translate information about medical or legal problems can hurt the parent-child relationship, traumatize the child and can result in a less-than-accurate interpretation of health advice, said Yee, a Democrat.

    His bill would ban state agencies and organizations that use state money from using children as translators. Those groups could instead turn to professional or volunteer interpreting services, community groups or ask older family members to translate, Yee said.

    Now in theory I think this is a really good idea. Have you ever tried to take a sexual history from a patient using a child (or, indeed, any family member) as an interpreter? It destroys patient privacy. There's also no way to know that the child will be able to understand the terms the doctor is using, even if the problem is couched in layman's language. Unfortunately in a state like California, where there are literally dozens of languages spoken, there is no way to ensure that a non-family member will be available to interpret. We're not just talking about Spanish here - I have patients who speak Russian, Armenian, Hindi, Chinese, Korean, Tagalog... there's no way we can cover all those bases.

    But people bring their family as translators because it's convenient and it's free. Often children are the only people available to the patient who are even partially bilingual. And doctors don't have the time or funds to find translators for patients in multiple languages:

    Medical providers warned the bill could cause access problems for Medi-Cal patients in rural areas because doctors won't be reimbursed for the expense of hiring an interpreter.

    Interpreting services cost about $1 per minute, said Heather Campbell a lobbyist for the California Medical Association. If a doctor has a 15-minute visit with a patient, Medi-Cal pays $22 for reimbursement, she said.

    After paying for the interpreter, the doctor would be paid $7 for that patient's visit, Campbell said.

    "It will probably stop physicians from taking patients who bring in a child as an interpreter," she said.

    We shall see. I definitely think more interpreters should be available as a resource for doctors and patients - it could only improve communication between them - but if the bill passes and does, in fact, restrict access to health care for Medicaid and other patients by discouraging doctors from accepting them, it won't have done any good.

    Don't Forget Your Tetanus Shot!

    Here's a little moral tale for you. Today I saw a new patient who was complaining of hair loss. When a patient (especially female) presents with thinning hair, something that should always be checked is the thyroid. Her thyroid exam was normal, but as I was evaluating it I noticed a scar at the base of her throat which could only have come from a tracheostomy.

    "What happened here?" I queried, touching the scar. "Were you ever put on a breathing machine?"

    She'd grinned when I noticed the scar. "Yes," she said with the air of someone who knows they have something to say that will get your full attention. "I had tetanus."

    "Did you?" I echoed, stunned. I've never seen a case of tetanus or anyone who'd had it in the past.

    "I was eight. It was when we were living in Jamaica."

    "Didn't they vaccinate?"

    "Well, they did, but when they came to my school I had a fever, so they said they'd give me the shot next year. But I got hurt over the summer, before I could get the shot, and that's when I got it. I was out of school for three years."

    "I believe you. That's a really serious illness."

    Quick Internet fact: Eleven percent of tetanus cases are fatal. I try to vaccinate all my patients who haven't had a booster in the last ten years. If you don't know when your last tetanus booster was, go get one.