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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    Friday, February 25, 2005
    Why Photoshop Was Invented

    Those ridiculous romance novel covers finally get what they deserve. I particularly liked Lord of the Hissy-Fit, but they're all good. Enjoy, and have a good weekend.

    Wednesday, February 23, 2005
    "Bertha Upstairs"

    Via Bookslut comes the news that Great Britain has released a series of stamps honoring Jane Eyre. Apparently they are reproduced from illustrations from a recent edition of the book. I honor the thought (Jane Eyre has always been one of my favorite books), but these are some freaky pictures: forgive me, but on the second stamp from the top Jane looks as if she's straining to pass a bowel movement.

    I read Jane Eyre for the first time in eighth grade and loved it. I still have fond memories of the quizzes we were given, because the day after the test the teacher would present us with a list of our writing mistakes to critique. This was an opportunity for great hilarity as we dissected run-ons, dangling participles, and the like. No, this was not an exercise in humiliation: names were not included. My favorite one, which I still remember after nearly thirty years, was in answer to the question, "Why do people still read Jane Eyre?":

    "People love mysteries. Bertha upstairs."

    Tuesday, February 22, 2005

    There are days I really wish I had a cutlass and an eye patch so that I could run down the hall spearing patients at will.

    Today has been one such day. I had a new patient, very sweet woman with a multitude of medical problems, come in to the office. Among her other requests was a list of medication refills. She takes fifteen medications. Fifteen.

    I sent her down the hall for an X-ray and lab tests while I wrote all fifteen prescriptions. When she got back, before she left, she looked at the prescriptions and looked puzzled.

    "Are these all for three months?" (Mail-order prescriptions are written in ninety-day quantities.)

    "No, these are regular prescriptions that you take to the pharmacy."

    "No, no, I use mail order." (Needless to say, she said nothing about mail order when she handed me her list.)

    I really really really wished I had a cutlass at that point. I settled for telling her that I was sorry, but I had no time to rewrite her prescriptions just then. Arrr.

    Monday, February 21, 2005
    Various Things

    I've been posting out of boredom, or more specifically a desire to escape my online traffic school lessons. (Be strong, only two to go...) Should you ever find yourself slapped with a moving violation and forced to attend traffic school, I can recommend the one I've been using: EasyFastCheap.com. What can I say, the name attracted me.

    So how did I wind up in this sad, sad situation? Thereby hangs a tale. One morning back in December I was trying to see a nursing home patient in the far reaches of Hollywood before work. This was at a nursing home I hadn't been to in years, and didn't much like. The patient got transferred there because the daughter of the patient was being fussy and turned down two or three perfectly adequate, much closer places. I was headed back west on Santa Monica Boulevard and ran into a wall of cars coming off the 101. In an attempt to evade traffic, I made a quick left turn down a side residential street...

    ...and got nailed by a cop. Apparently the good folk of the neighborhood had enacted a "no left turn" policy during rush hour. The cop said there was a sign posted, which I honestly did not see - partly because I was stuck behind a large truck rig, partly because I was looking at ONCOMING TRAFFIC like you're SUPPOSED TO. I was not looking for a bloody sign. Long story short, I was not able to talk my way out of it and got a ticket. To look on the bright side, I've been living in LA for eleven years and this is my first one, so I guess I'm doing okay. I'm still nursing a grudge against the patient's daughter though.

    I don't know if other cities have the huge number of traffic schools that exist here. Traffic schools are a big part of Angeleno culture; after I got my ticket and started complaining about it, I was surprised to find how many people I know had been to one. I have a friend who once attended one in West Hollywood taught by a transvestite (he commented that the teacher dressed up to the nines for every class - false eyelashes, manicure, heels, the whole nine yards). And, of course, there are any number of "comedy" traffic schools, which I refused to even consider: I have better things to do than listen to a third-tier comic lecture me on the rules of the road while wearing a fright wig or acting like Groucho Marx. Come to think of it, with the advent of online traffic schools I wonder what all those lousy wannabe comedians are going to do for a living?

    To other things. I have quite a few links I've been saving up for you if you're lucky enough to be enjoying a three day weekend, unlike myself. The Firm does not take Presidents' Day off. Here we go:

    Here is a funny post from a woman who runs a great blog, all about her adventures teaching calculus to a bunch of math-impaired students in Vancouver: Tall, Dark and Mysterious. She also linked to this story, which I found interesting, about two mathematicians who crocheted a model of chaos theory. (My favorite line from the story: "Why don't you crochet something useful?" She showed him.)

    On a similar, somewhat math-related theme we have this extremely cool chart about baby names and their popularity in the last century. Check it out. (Requires Java.)

    Comics Curmudgeon: If you haven't clicked on this guy yet (he's linked on my sidebar), do yourself a favor and read him. He dissects the likes of Cathy and Garfield with vitriol and grace, but you have to read him on Mary Worth and Apartment 3-G to fully understand his genius. As a bonus, the comments are every bit as fun to read as the actual posts. If you just can't get enough Mary Worth, check this guy out. He's just as funny. (His blog doesn't focus on comics, so keep scrolling down to look for MW entries, but it's worth it.)

    I realize I'm really late to the party here, but if by any chance you haven't been following Lileks' Joe Ohio serial then do yourself a favor and start reading it. He based all these stories on random matchbooks he's been collecting. I can't wait to see how the Salt Lake City mystery pans out.

    And lastly (yes, I really am going to go to bed now), I give you Chez Miscarriage whom I found by way of Ilyka. (Read Ilyka!) This woman has converted her struggles to achieve motherhood into a wickedly funny series of posts. This one in particular is hilarious: I'll have to try that fake-IM-conversation trick sometime.

    And a happy Prezdets' Day to you all.

    Saturday, February 19, 2005
    More Rain?

    My phone rang at 3:00 this morning. My neighbor Debbie was on the other end.

    "I'm assuming you're awake," she said.

    "Actually, no, I wasn't," I mumbled.

    "You're kidding! How can you sleep through this?"

    Suddenly, I realized that I was hearing pounding rain and sharp tapping on the window, even as Debbie said, "It's hailing! The pounding on my skylight woke me up!" At the same time lightning flashes were strobing through the bedroom. (I have a hearing problem in one ear and was sleeping on my 'good ear', which is why I hadn't wakened earlier.) I peeked out the window and, sure enough, there was hail on the lawn. I've never seen that before.

    This is the wildest winter storm season I can remember, and I've spent most of my life in Southern California. We've gotten three times our normal quota of rainfall already, and February isn't over yet. The rain cut out for several hours this afternoon, but it's back again now and will probably continue for another couple of days. Meantime, we're coping with flooded freeways and mudslides.

    Bring on summer, I've had enough. I'm just hoping that the weather will discourage visits to the ER and minimize my call trauma tonight.

    Dr. Alice Cooks

    ... when she feels like it. (My motto around the office is "I can cook, I just choose not to" - as I once told my secretary.)

    I really ought to cook more often, but with my insane work hours and not getting home till 8 or 9 pm it's difficult to do. Also I'm usually too hungry simply to skip dinner. I often wind up eating junk food (Bad doctor!) or frozen dinners. I try to eat salad, which you can pour right out of the bag, but who wants to eat salad for dinner on a cold rainy night? Considering the number of food blogs I link to and read on a regular basis, you'd think I could put on a better show in the kitchen.

    Sometimes on the weekend I'll dust off the chopping board and try something new. Super Bowl weekend, for instance, I tried Stewed Chicken with Lentils from Diana Shaw's book Almost Vegetarian which was quite good and relatively easy. You chop two cups each of celery, carrots, leeks and onion and saute in olive oil, then add a spoon or so of tomato sauce and a can of diced tomatoes, then throw in a cup of lentils and 2 or 3 cans of chicken broth. Put in the chicken and cover, throw in the oven and cook for at least two hours. The chicken was falling off the bone and absolutely delicious. The only thing I didn't like about the recipe was the spices: Shaw appears to be very fond of cinnamon. The recipe called for two teaspoons. Scenting trouble, as it were, I cut this to one but I think it was still too much. The cinnamon does blend nicely with the lentils, but still almost overwhelmed the dish. Next time I'll ditch the cinnamon and try a bay leaf and lots of garlic. Did I mention the leftovers freeze well?

    One standby for me is aioli (garlic mayonnaise). It goes with pretty much any vegetable you can think of - potatoes, green beans, asparagus (yum!), broccoli, cauliflower, even beets. I adapted the "aioli platter" recipe from one of the Silver Palate cookbooks for Easter one year - it was a smash hit. I've been making it ever since. You can make it in a blender or food processor: Put in several cloves of garlic, two egg yolks, and blend. Scrape down the sides of the processor and add the juice of a lemon, one teaspoon Dijon mustard, a dash of white pepper, salt if needed, and blend again. Then, with the processor running, slowly add 1 1/2 cups of oil, half olive, half peanut. You'll have a nice emulsion: aioli.

    Now you have the aioli sitting in the fridge. What you can do (again, all this ahead of time) is blanch/cook whatever vegetables you want to go with it, chill in ice water and arrange on a platter. As a condiment for protein, it's extremely versatile: fish, chicken and beef go with this. You can roast a chicken, let it cool, put the meat on a platter and chill (or for a really impressive meal, cook a beef tenderloin and carve and serve at room temp). You can also do grilled swordfish or tuna, which are strong enough to stand up to aioli. This is a great meal for a warm spring weekend, with fruit for dessert (I like sliced oranges and strawberries with it).

    I like cooking - in small doses. What I do enjoy is canning. Quite a bit of work, but very scientific. I'm hoping to make some loquat chutney this year (My parents have loquat trees in their backyard). Should I pull this off I will certainly blog about it!

    Friday, February 18, 2005
    Icky Nematodes

    (Warning: you won't want to read this while you're eating.)

    I haven't told you about the Worm Girl. She's been making my life interesting for the last three weeks. Worm Girl called me up in a panic one morning (Stat voice mail) and said she'd passed a worm and wanted to know what to do. My first reaction: "yeah, right." I have seen quite a few people who thought they had worms in their stool; what they bring in usually turns out to be plant fiber or some such. I thought it would be the same this time. I was wrong: my secretary came in two hours later bearing a jar. I looked in and GAAHHHH!! It was a huge worm, about fourteen inches long, coiled up in said jar.

    Well, we sent the specimen off for identification and I spent the next few days placating the patient and her mother, who called me on the following Sunday night wanting to know what the hell was going on and why we hadn't started treating her daughter yet. Just so you know, treating parasitic infections is not like treating bacterial infections: You can't just let loose with a broad-spectrum antibiotic and hope for the best. It really helps to know exactly what you're dealing with, as this determines both what medication you use and the dosage. Antiparasitic drugs, as a class, tend to carry the potential for significant side effects, so you want to minimize the dose when possible.

    Finally the ID came back. It was Ascaris lumbricoides, a roundworm. This particular fellow is known for multiplying in the digestive system and causing "worm balls" which can block the intestines. For examples, see here (lots of info and a disgusting picture at the bottom). The day we got the results, I caught my secretary with the medical dictionary in her hand looking up "ascaris" and wincing in disbelief. Next came the ghastly pictures pulled off the Internet and emailed around the office (I'll spare you the sight of a kid passing a worm ball, but trust me, it's out there somewhere). That same day, the sight of gummy worms in the lunchroom was greeted with shrieks, not enthusiasm.

    I still don't know how Worm Girl acquired her infection. She hadn't traveled anywhere likely, but she may have gotten it from her dog. (Public Health Warning: kissing the dog on the lips is not a good idea!) She's been treated twice with an appropriate antihelminthic - mebendazole (we couldn't get albendazole) - but continues to complain of symptoms and "something poking me in my stomach." I'm not sure if this is a symptom of ongoing infection or caused by anxiety. I'll let you know if anything more transpires...

    Wednesday, February 09, 2005
    "What's a Smudge Cell?"

    ...asked V. on the phone.

    "I used to know that. Who's got smudge cells?" I answered.

    V. had drawn routine preop labs on a patient and the phone report came back showing a high white blood cell count and multiple smudge cells. I pondered further and came up with, "A smudge cell is... a cell that has been smudged," and started giggling. (Today's been a long day.)

    "Oh, thanks a lot."

    "Let me Google it and see what I can find." I found a site and started reading out loud:

    Patients often see a reference to smudge cells in their complete blood count (CBC) reports. Smudge cells are cells that are probably damaged during the CBC process. The cell walls rupture, and when seen under the microscope, they look like a smudge; hence the term smudge cells.

    Smudge cells are not unique to CLL. However, they are seen much more frequently and in much higher numbers in CLL than in any other condition. In patients with acute leukemias, there may be as many as 1 to 3 percent, but in CLL patients, smudge cells can be up to 20 percent of all cells, or higher.

    Halfway through the second paragraph I realized that I had clicked to a site giving information about chronic lymphocytic leukemia - CLL. V. suddenly said, "Oh. His white count's 35." (High.)

    "What's his differential?"

    "I don't know, I'll have to get the full report and call you back."

    Fiteen minutes later I found a message on my voicemail: "CLL, I'm sure of it. Shoot."

    All I Wanna Do
    Is Check my Netflix Queue

    Last weekend two things happened: my new sofa was delivered and I got my first shipment of Netflix DVDs. That's why I haven't been posting. Yes, I know I'm late to the party, but - whoo hoo! - Movies! That come to you in the mail!

    Here's what I watched: Hellboy, Chronicles of Riddick, and Van Helsing. It was a blood and thunder weekend. A quick roundup:

    Hellboy is definitely the best of the three. If you haven't seen it, get it. It's a pleasure to see Ron Pearlman get to play a leading role, and he does a really good job here. The character of Liz, the firestarter, could have used a little more energy and a lot less Thorazine, but overall I was happy with this one. I saw it in the theater last year and enjoyed rewatching it.

    Riddick was a pleasant surprise. I wasn't expecting much and really rented it because Colm Feore was in it, but Vin Diesel is not bad. He's got a fair amount of screen presence and looks good in a wife-beater shirt. Apparently his character has a wicked case of cataracts - he has cloudy eyes that allow him to see in the dark. The best sequence in the movie deals with a prison breakout on the planet Crematoria, where it's 700 degrees in the daytime and 300 below zero at night: Watching the characters try to beat the sunrise made for a suspenseful chase. And Feore, of course, is great fun to watch. He gets to wear cool armor and a cape and play the charming bad guy and is clearly having a blast. My favorite line of his: "It's been a long time since I've seen my own blood."

    The big surprise in this one was Judi Dench. Yes, that Judi Dench! What the hell was she doing in this? I amused myself wondering what she'd bought with her paycheck for this movie - new dining room set? A trip to Bermuda, perhaps? She played an Elemental - some sort of neutral observer who can become invisible, tell the future, and various other things.

    Last was Van Helsing. Not good, this one. It was watchable but so incoherent I still have no idea what the plot was. Dracula was involved, also werewolves and the Frankenstein monster. Hugh Jackman is Van Helsing, with some sort of mysterious past that is never revealed (we're led to believe that his memory has been wiped). He roams to and fro killing monsters for the Catholic Church, assisted by some woman in a bustier and high heels (in19th-century Romania... yeah, that's authentic. Not.) and a friar named Carl who appears to be a cross between Q from the James Bond series and Marty Feldman's character from Young Frankenstein. Lame, but nice photography and special effects.

    I may be subjecting you to many more of these reviews... I went wild listing movies in the queue.

    Tuesday, February 08, 2005

    More blogging later. Probably this evening. (No, I haven't forgotten you all.)