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, March 29, 2005
    Photoshop Part II

    Longmire presents more photoshopped romance covers. Just click, and giggle.

    Sunday, March 27, 2005

    Here, because I love you, is my mother's recipe for Deviled Eggs. (And by popular demand, and because it's Easter.)

    A caveat: it isn't "her" recipe; it's actually the "Better Homes and Gardens" circa 1960 recipe. Let me just say here, if ever you have the chance to snag one of those classic checked-red-and-white covered cookbooks, DO SO. You won't regret it. They have all kinds of great recipes, including one for chicken baked in a homemade barbecue type sauce that I'll have to post someday.

    One more warning: Should you ever come in contact with a deviled egg recipe that requires sugar, RUN LIKE HELL. This is a recipe tainted by Satan and should not be attempted. (Unless you live north of the Mason-Dixon line, in which case, anything goes.) Yes, my mother is from Tennessee, and yes, I have a deviled egg plate, in case you were wondering; we take our deviled eggs seriously 'round about here.

    So anyway, here is the recipe, per six (1/2 dozen) eggs - makes 12 halves:

    Hard-boil eggs (about 22 minutes). Halve, remove yolks, mash or shred (I find a box grater works well). Mix into the yolks two tablespoons Real mayonnaise (yes, it makes a difference), one teaspoon each vinegar (distilled is fine) and mustard (French's - that would be regular yellow mustard - is fine), dash white pepper (this is important. Black cracked pepper doesn't look right in an egg), 1/2 teaspoon salt or less - less is probably better, and 1/4 teaspoon paprika. To stuff eggs the easiest way is to grab a Zip-Loc or other sandwich bag, shovel the yolk mess in there, cut off a corner of the bag and use it like a makeshift pastry tube to fill the eggs. Sprinkle the finished eggs with extra paprika for decoration.

    Show up at any party with these things and, I promise you, they will disappear in a flash. I have used them for Christmas, New Year's, Easter, Fourth of July and Thanksgiving functions with the same results. Extra points for the deviled egg plate (I got mine at the Rose Bowl).

    Once Upon an Easter

    I finished residency more than ten years ago, so I think it's safe for me to tell you this story.

    Way back when I was a third-year resident in San Francisco, my brother had just moved to SF a few months before and we had decided to attend Easter services at Grace Cathedral. (I was what is politely known as a "lapsed Christian" at the time. This would have been my first Easter church service in several years. My brother, well, I won't speak for him.) I was up and getting ready when my phone rang - at 7:30 am. I assumed it was my brother and answered. It was not my brother; it was my chief resident. We will call him Bill. Here is the conversation verbatim.


    "Hi, Alice."

    "Hey, Bill, what are you calling so early for?" (beat) "Oh, shit."

    "Alice, I need your help. [Resident X] has called in sick and I really need someone to cover today."

    "Look, Bill, I know you need help but isn't there anybody else you can call? It's Easter Sunday, I'm supposed to go to church with my brother and this is the third time you've called me in this year!" (Fact. It was.)

    "Listen to me. If you will help me out, I will see that you get an extra week's vacation this year." (Totally illegal and against all the rules of the National Board of Internal Medicine. We are talking Animal House territory here.)

    (Two-second pause) "Okay."

    I said not another word, called my brother and canceled, showed up for work and gave a hundred and ten percent that Easter Sunday. Bill was as good as his word. I got that extra week. He told me later, "Alice, one thing I've always admired about you is that you know the value of a bribe."

    And I knew what he meant. I just grinned and told him that was why we got along so well. I still cackle every time I think about that episode (and I still haven't told my father to this day, though I'm sure he'd get a kick out of it). It was probably the most rebellious thing I've ever done.

    Saturday, March 26, 2005
    "More Wine for Polythemus!"

    I recently received the following email from a friend who shares my love of old movies. He's right, there aren't enough sword-and-sandal epics on TV anymore:

    When I grew up, particularly in New Jersey, the local television stations filled the week preceeding Easter with Bible/Gladiator movies. With the exception of "The Ten Commandments" which aired Saturday last week, there are no Gladiator movies on LA television or our satellite service!

    What would qualify for this genre? Any movie where you might see Victor Mature wearing sandals. Any movie where a character claps and says, "More wine for Polythemus!"

    If they are showing them where you live, please look out for:

    1) The Robe
    2) Demetrius and the Gladiators
    3) Ben Hur (Charlton Heston)
    4) The Silver Chalice (Paul Newman)

    I can't believe I missed "Ten Commandments" this year - I thought it was this weekend. I do have to say, if you've never seen "Ben-Hur," see it if only for the chariot race scene which absolutely rocks. And I love the "More wine for Polythemus" line - I'll have to use that the next time I'm in a bar. (I'll be going to Vegas in two weeks, might try it out there.)

    Thursday, March 24, 2005
    Bodily Functions in the Comics

    A possible first: a character threw up in Mary Worth a couple days ago. No, it isn't related to binge drinking or bulimia: it's a plot point! Yes, after a whirlwind Vegas marriage and a mere three weeks of agonizing over her "infertility," Mrs. Anna is pregnant. Apparently all it takes is a few weeks of obsessing, a couple of agonized soliloquies, and a chat with Mary and everything is fine. Yeah, I can see infertile women all over America really empathizing with Anna. Not.

    I didn't used to read Mary, or Apartment 3-G, or any of the other serial strips; when I was a kid I thought they were boring and as an adult, well, I thought they were asinine. In recent years the original artists have died off or retired and the replacement artists apparently are drawing with pencils held in their teeth. At least a couple of decades ago the art was worth looking at. Now the funny pages are populated by grimacing homunculi who look more like they belong on Mount Rushmore than anything else.

    This is all a very convoluted way of telling you that Josh is the man who has made me see the light. Yes, there's drama and hilarity right under our noses on the funny pages - even though it may not be what the artist intended for us to see. Go read Josh! You, too, will become obsessed by Rex Morgan, M.D.! (What is the deal with that secret Indian burial ground on the Morgans' property, anyway? You'll have to read the blog - and the comics - to find out.)

    Tuesday, March 22, 2005
    Red Flag Warning

    You know it's really, truly That Time of the Month when your secretary finds you some Advil and you reply, "Thanks. I'll kill you last." (Fortunately, my staff knows me very well.)

    Really, it's been that kind of day.

    More More More

    Thanks to Ilyka for the link to this CT picture. This study is nine years old and is apparently the only brain image obtained on Ms. Schiavo. I reiterate: get me more studies. I'd like to see the PET and MRI. The cortex looks godawful to my reading, but then I'm not a radiologist or neurologist. And yes, there is cortex present - I expected there to be, actually; I don't think one gets complete cortex liquefaction except in full-on brain death, and it's clinically obvious that this is not a case of brain death. How well is the cortex functioning, is my question. (And, for the record, it is completely medically incorrect to speak of "liquefied brain" or a "bag of water" or "brainstem only" based on this CT, and I chastise the MD's who did so in court. I still think it's highly likely that she is in PVS, and I don't expect her ever to improve, but for God's sake, people, let us be accurate.)

    University of Miami Ethics Dept. has more info on the case here.

    I suddenly remembered a book on bioethics and euthanasia that I once read that I can highly recommend - Dancing with Mr. D, by Bert Keizer. The writer is a physician in the Netherlands, works in a long-term care facility, and has been involved in several cases of euthanasia (with full patient consent, I hasten to add). For the record, I loathe Jack Kevorkian and I would not be in favor of legalizing euthanasia, but this book is excellent. His patients are not just targets to be knocked off. He has well-established relationships with them and in some cases becomes close to their families as well. I think it's out of print, so try the library. It's difficult reading but it's very good.

    Now. Change of subject. Email from V. regarding a patient she saw today:

    There ain't nuttin' like examining a happy boy for a hernia.

    OK, sir, you can pull up your drawers - NOW!!

    And it didn't help that he came in for a nasal cellulitis. I felt like I was groping Rudolph!!

    Saturday, March 19, 2005
    On a Different Note...

    Truly, utterly hilarious. (h/t Tim Blair)

    And if you needed further evidence that the Web has room for everything, I give you... Encyclopedia Brady! (Warning: don protective eyewear before viewing.)

    And the adorable DogBlog. (h/t Jo)

    Friday, March 18, 2005
    A General Rant Inspired by Terri Schiavo

    Well, I guess it's my turn to take a shot at this, because God knows everybody else has, including people who apparently don't know the first goddamn thing about what happens to people in comas.

    Yes, I'm mad. Can you tell?

    To clarify: I think the Terri Schiavo case has been mishandled. The way things are at this time I would not disconnect the feeding tube. However, if Ms. Schiavo had a PET scan and MRI which confirmed that she was in a persistent vegetative state, I would. The sad thing here is that everybody involved in the case is so busy staking out their personal battle grounds that no one is really paying attention to the patient (even though they say they are). Instead of lawmakers proposing dumbass bills for passage or subpoenaing Ms. Schiavo for testimony she can never give - my jaw dropped when I saw that, I couldn't believe someone was pulling that one - the husband and MD should have been legally compelled to get the test that would, you know, ANSWER THE QUESTION of what her clinical state actually is. But no one is interested in getting the test; the husband is afraid that it might show she isn't in PVS and the parents are afraid that it will.

    Here is a link to an info page on coma and PVS.

    Now, let us move from the specific to the general. Let's assume we are talking about a patient with documented PVS, who's had all the right tests, who has been in this state for more than a year. Heck, let's say five years (half of the length of time Ms. Schiavo has been in this state). For the record, as a primary care doctor I have never taken care of someone with PVS, but I have taken care of a lot of stroke patients, dementia patients, and others who are permanently bedbound. Let me share with you what happens to someone who can no longer move.

    • Bedsores. You're going to get them. The human body was made for activity, not to remain supine for long periods of time. I understand in the Schiavo case claims are being made of abuse on the part of the hospice staff. I don't know whether those claims are true or not, but I can say that the presence of bedsores does not ipso facto prove abuse. Exhibit A: Christopher Reeve. If ever a patient got impeccable care, it was he; but he died of sepsis from an infected bedsore. You can minimize them with proper care, but you cannot prevent them.

    • Infections. You're going to get them. This patient can no longer empty his/her bladder properly nor clear his/her respiratory secretions. This means 1) pneumonias and 2) urinary tract infections. Plural. This leads to 3) multi-drug-resistant infections with superbacteria that never really go away, and eventual death.
    • Contractures. You're going to get them. Muscles which cannot move are permanently in a flexed state. Over time, the muscle cells shorten and tighten. Knees draw up. Heels dig into buttocks. Hands curl inward upon themselves until the fingernails dig holes in the palms (I have seen this). "But this can be prevented!" comes the cry. Well, yes. Sort of. To prevent contractures the person's hands, feet, arms and legs must be strapped tightly to splints. 24 hours a day. I have seen sentient patients cry and scream when the splints are put on, so I can assure you this isn't comfortable. For a non-sentient patient that issue doesn't apply, but you still basically have somebody strapped to a rack with no freedom of movement. Did I mention bedsores? And as for physical therapy, it isn't going to happen, at least not in the long run. The main criterion for approving coverage of physical therapy is clinical improvement. I can see a patient with a particularly generous insurance plan getting physical therapy for up to a year after the onset of vegetative state, but certainly not longer than that. That means that if the patient is going to continue to get therapy the family will have to pay for it. Our sample patient would have a bill as long as your arm (therapy six days a week, 52 weeks a year, for 4 years).

    Okay. I hope what I have outlined gives at least a partial illustration of what caregivers and family have to deal with in a PVS-type situation. We aren't talking Sleeping Beauty here. This disease state destroys the body as surely as cancer or diabetes; it's just a lot slower. Now, let's go to the withdrawal-of-food-and-fluids issue. Here is a link to a hospice website; I apologize for the design, it's hideous, but it contains some useful references to studies done on the withdrawal of food and fluids in hospice patients. Honestly, I was surprised to see the level of shock and horror expressed by various posters on this subject. I have news for you, people; this has been happening for years. Withholding food and fluids is not torture. It is not. To alleviate the concerns of family or patients about dehydration, hospices will often run a very slow IV, or even intramuscular, fluid drip specifically to make sure that the patient remains comfortable. They use mouth swabs. There are things that can be done to keep the patient comfortable - that's always the first priority. If you still feel that the withdrawal of nutritional support is untenable, what about removing people from a ventilator? Is it better? Worse? Why?

    This has gone on way too long, so I'll try to wrap it up with a memory. During my medical residency my maternal grandmother died after a massive stroke. She'd never made a living will, but she had been active and functional until shortly before her death. My father (a doctor) was there with my mother and her sister. The doctor showed them the MRI results - no hope of recovery. My mother and her sister declined a feeding tube; my father concurred. My grandmother died peacefully within 48 hours. None of us have ever questioned that it was the right decision. (Yes, I know it's anecdotal, but I thought a firsthand story might be helpful.)

    Sunday, March 13, 2005
    A Learning Experience

    I've been rounding in the hospital for the past week (hence the lack of posts). Our hospitalist quit a few weeks ago, forcing The Firm to jerry-rig yet another system for taking care of patients. The good new is that our senior managed care patients have been taken out of the equation and are being covered by a different hospital group. This means that we now have three different hospitalist groups taking care of different sets of patients (1: Commercial managed care, a.k.a. The Employed; 2: Senior managed care plans; 3: Fee-for-service/PPO/Medicare). It's all quite Byzantine, but considering that we're now covering for thirty primary care doctors it's good to split the load three ways instead of two.

    My rusty inpatient skills are improving. Yesterday I got a crash course in ischemic colitis. I had admitted a woman on Saturday who was complaining of severe abdominal pain and vomiting; CT scan showed no mass or obstruction. She'd had the same symptoms in January '04; the CT done then was likewise negative. What was seen, which I found interesting, was extensive vascular calcifications on the abdominal blood vessels. This woman is a known vasculopath, who's had both legs amputated below the knee. Could this be mesenteric ischemia? I called up two specialists to get some input. Their answer: a unanimous No. The vomiting was atypical (pain yes; blood yes; emesis no).

    I questioned the patient further. Suddenly, she started to complain vociferously about her grandson's wife (the patient is legally blind and the grandson and spouse live with her and take care of her). Diagnosis: stress? Possibly. She'd gotten much better overnight. I felt sorry for her, but solving a home situation problem is up to the patient's primary care doctor, not me. I voicemailed her regular doctor with the information.

    Several hours later I found myself admitting a 93-year-old woman who came in with the complaint of severe constipation, followed by explosive diarrhea, followed by blood in the stool. I phoned our gastroenterologist with the clinical info to see if he wanted to plan a colonoscopy for the next day. His immediate response:

    "This is ischemic colitis."

    "So I was wrong on the first one and missed the second one?" I replied. "Great."

    Give the guy credit, he laughed and kindly went through the symptoms of ichemic colitis with me and, more important, explained what causes them. The colon lining swells when its blood supply drops, blocking the passage of bowel contents. Then when the tissue shrinks down again, the pent up, pressurized contents are released with predictable results (all over the bathroom floor, in this case). The ischemic, traumatized tissue then bleeds, though usually not a lot.

    "Well, I learned something today. Thanks." With luck, I'll remember this next time I see somebody with abdominal pain and puzzling symptoms.