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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    Wednesday, January 10, 2007
    This Entry Is for My Family in Denver

    ...who have been hit with three snowstorms in three weeks, with a possible fourth coming up.

    Calvin, Hobbes and the Underappreciated Art of the Snowman

    (favorite line: "Mom and Dad don't value hard work and originality as much as they say they do.")


    Tuesday, January 09, 2007
    Oh, Hallelujah! Thanks, Santa Claus!

    Mary Worth is going to Vietnam! This is even better than the upcoming season premiere of '24'... oh wait, no it's not.

    But it's still pretty awesome. I can't wait to see how this plot pans out, but maybe that's just because I'm sick and twisted. My personal ideal would be something like a frantic Mary showing up in Vietnam, only to find a safe, well and puzzled Dr. Jeff. She tries to explain that she came to find him because she was having nightmares that he was in trouble, puzzling him even more. She storms off back to Charterstone to confront Ella, the psychic who advised her to go find him... only to find that Ella has disappeared and no one in Charterstone has ever heard of her. [cue Twilight Zone music]

    It's weird, I admit, but it's gotta be better than whatever the artist is going to come up with. As an added bonus, Mary appears to be conversing with Presiding Bishop Schori in this panel (the tipoff here is "Mine's the usual! Achieve world peace!").

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    My Answer To the Unasked Question

    ...that question being, what do you think?

    Maybe you have not heard about the intense bioethical debate surrounding "the Ashley case"; I had not until today. Briefly, Ashley is a nine-year-old girl who is severely developmentally disabled (and by "severely," I mean "has the mental capacity of a three-month-old"). No one is questioning the severity or the permanence of her problems. Her parents have committed to taking care of her at home, which includes lifting her, changing her position frequently, bathing her, etc. and have little assistance in doing so. They elected to give Ashley high-dose estrogen to shorten her height so that they could continue to take care of her; this will put her into early puberty and close the epiphyses of her bones. To combat the side effects of the estrogen, she was also given a prophylactic bilateral mastectomy and hysterectomy.

    The parents chose to post about their decision on their blog, and as you may imagine were hit with a storm of criticism. Much of it accused them of perpetrating "child abuse." Other accusations, such as those I'm going to quote here, were directed at the physicians who advised them on their decision as well as at the American health care system: It is the elements of our culture that create an atmosphere where surgery is a solution for care giving. Care giving is traditionally women's work, and therefore it is fraught with social expectations and little appreciation. The care that women provide for their families is unpaid labor, which makes it of no value in a patriarchal, capitalistic system.

    Thanks to Ilyka's blog, I got to hear and read about all this and I posted my answer below.

    Genni, speaking as an MD I recognize your points but I don't think you address some of the issues Ashley's parents are dealing with. For instance, most insurance plans (and Medicaid) simply will not pay for the kind of in-home care this disabled girl would need for the rest of her life were this surgery not to take place. They. Will. Not. Pay. Tube feeding, yes; 24-hour care or home health aides, no. The parents would have to cough up the cash for the kind of care she will need for the rest of her life, and believe me that's a LOT of cash. Or they'd have to scramble continually for grants and city- or county-supported programs, and that's like relying on quicksand. The program that helps you today can (and probably will) be gone tomorrow.

    Is the approach taken by the MD's in her case an extreme measure? Absolutely, and I really have never heard of such a method being tried before. (I should note here that I'm not a pediatrician or an endocrinologist.) I appreciate the chance to read what you've written, because I am not sure I would have heard about this case other than through Ilyka's site. (Work avalanche, I haven't paid much attention to the news recently, I'm afraid.)

    While I said above that I'm not a pediatrician, I am an internist and I do a lot of rounding on geriatric patients in nursing homes, so I have a fair idea of the kind of life Ashley would be condemned to if her parents weren't taking care of her. Personally, I'd pick the surgery if it meant my parents could take care of me at home... but again, that's just me. I'm pretty sure this is the only way Ashley's parents can afford to handle her care themselves. The ugly truth is, most insurance plans would gladly pay for the surgery and estrogen (which is cheap) rather than the cost of in-home care for the next twenty or thirty years.

    I don't see this as a feminist issue. Speaking as an MD, a uterus is just another organ. You can live without it. That doesn't mean you should just whip it out at the first sign of a problem, either; for some women, removal of the uterus can seriously interfere with their ability to have an orgasm, for one thing. But some women really and truly have a better quality of life after hysterectomy.


    Monday, January 08, 2007
    Memorial Service

    He was perhaps the best surgeon I've ever known. (I say this based on my dad's criteria, and believe me my dad knows a good surgeon when he sees one.) I've known him since starting with The Firm ten years ago. At that time he was contracted with us, but not a member of The Firm; he was by far my favorite surgeon of all those we worked with. A few years later, he joined us for real. I was overjoyed, and so was he, I believe.

    He was truly a pleasure to work with. He did great work, always sent consult notes promptly, called with any questions... I think he truly liked and/or respected internists. (For those who are wondering, surgeons and internists are like oil and vinegar in a salad dressing. You need them both, but they don't get along that well, generally speaking.)

    I still remember this one patient: At the time I examined her, she had just had a 'normal' mammogram, but I found a lump on her exam. To play it safe I sent her to The Surgeon. (I do not wish to betray his or his family's privacy so I will continue to refer to him in this manner.) He examined her, agreed with my concerns, did a biopsy. He sent me the results by email - the woman had cancer - then added this comment at the bottom, gratis: "I think you saved her life."
    I read this the next morning and burst into tears. At the time our medical director had the office next door to me. "Is there something wrong?" she asked with concern; "No," I stammered, and showed her the email.

    She was clearly struck by it. "That's really wonderful," she commented. "Have you told him?"

    "No, but I will."

    The hell of it is, I can't remember if I did tell him. This was several years ago. I hope I did; he certainly deserved it and more.

    Anyway. He was found dead on a weekday morning, at the age of forty-nine, four days before Christmas. The entire group, staff and MD's, was knocked flat on its collective ass. We could not believe it; we cannot believe it still.

    The hospital held a service for him on January 5. The service in itself is not so unusual in that we routinely get two or three emails a week regarding Members Emeritus who have, as they say, Passed On. But this guy? No way. No one would have expected it. He was, as I say, 49 and had no medical problems as far as I know.

    I attended not because I looked forward to anything special beyond the usual 'oh, he was such a wonderful guy' but because I wanted to do it specifically for him. I mean if I were to, shall we say, cack it I would like to think that those I had worked with would take the trouble to show up for the service, just to make the gesture and all.

    But so much more happened than I had expected. Our CEO, clearly moved, gave the first speech and then yielded the floor to others. The next speaker was a plastic surgeon whom I have always viewed as something of a hardass, but he shared the most wonderful memories of this gentleman that you could ever have imagined; I would never have visualized Plastic Surgeon Guy choking up on a podium, but that's exactly what he did. It turned out that The Surgeon had been his chief resident when he was an intern (I had not known this).

    The next speaker was The Surgeon's partner who had been signed as a member of The Firm on his (The Surgeon's) recommendation about three years ago. He gave an equally wonderful speech with warm remembrances of him. He's pretty stoic, but he choked up when he shared with us his memory of The Surgeon shaking his hand across the table at the end of a case and saying, "Good job."

    The next two speakers were anesthesiologists - did I mention the oil-and-vinegar simile already? all right, I have - who worked with TS on a regular basis. For me this was the most moving part of the entire service; these two physicians painted such a beautiful verbal picture of their working day and how their association with TS had made it more enjoyable. TS had a regular shift in the outpatient surgical center on Fridays, and they both said that he made Friday their favorite day of the working week. One of the anesthesiologists even said that after hearing the news, "I didn't know if I would ever be able to work on Fridays again." They explained that TS had an "update list" for his co-workers that grew from a few to over a dozen. He'd ask everyone how they were and what was going on in their lives; Assistant One ("the delinquent"), Assistant Two ("E"), one of the anesthesiologists ("Butter")... it never seemed to end. And there was always room for everyone, even the pet of a co-worker. Everybody okay? Yeah, everybody is. Good.

    I didn't know, I thought. Would someone be able to say this about me if I were to die tomorrow? Probably not. I'd like to think so, but probably not.

    Not a bad resolution for a new year; make sure your co-workers would be able to say stuff like this if you were hit by a bus tomorrow.


    Sunday, January 07, 2007
    Restless Legs

    I recently got the following question in comments:

    Is restless leg syndrome real? I've read about it as a side-effect to taking SSRIs, tricyclics, tetracyclics etc. but not related to insomnia.

    It's definitely real. I've had quite a few patients with this problem. While it can be a side effect of certain medications, non-drug-related RLS is thought to be caused by overactivity of the sympathetic nervous system and by deficiency of dopamine receptors in the spinal cord. Ropinirole (aka Requip), one of the medications used to treat RLS, mimics the activity of dopamine in the spinal cord.

    It can be associated with pregnancy, iron deficiency (a common cause, should always be checked), end-stage renal disease (i.e., dialysis dependent), thyroid disease - interestingly, either under- or overactive thyroid, and gastric surgery. I don't know how frequently it occurs after gastric bypass surgery for weight loss but it would be interesting to find out.

    Hope this helps.


    Thursday, January 04, 2007
    Bugger. Off.

    Let me tell you about my New Year's resolution... whether you want to hear about it or not. (Warning, if you are not religiously minded, you may not be all that interested.)

    I have not blogged about this, really, because it seemed too personal, but I have thought about it a lot. The recent sudden and unexpected death of one of my partners (in the traditional sense - one of my professional partners in my medical group) seems to have spurred me on to take action and to write about it as well.

    I will do my best to condense this... after many years of not being interested in organized Christianity, I was encouraged to come to church by a dear friend of mine. "You have to come here, you will love it," he said, and he was right. The church in question was this one, an Episcopal church (for the technically minded, a member in good standing of the ECUSA). I was happy with the beautiful music and services, struck by the formality of Episcopalianism (brought up as what they call a 'low Protestant', this was completely new to me), and in general welcomed into the family. I felt happy there... for a while. I joined that church in 1997.

    But about three years ago, after GenCon 2003 (the greatest collection of highminded bullshit ever seen on God's Earth, second only to GenCon 2006) and after the loss of some dear friends and fellow church members to cancer and suicide, I began to hear this voice in my head. (No exaggeration, I did.) You have to move on, the voice said.

    I don't want to, I said.

    I tried arguing with the voice. I tried ignoring it. I tried shouting it down. Nothing worked. I gradually began to realize that I could not stay with ECUSA. This realization was, shall we say, made easier by online revelations of the stupidities of my chosen denomination which appears to be irrevocably wedded to the cause of Political Correctness over and above the ideal of Christianity. I mean, there's nothing wrong with nicey-nicey goodspeak, it's just that it has nothing to do with Jesus Christ and the Gospel He wanted to spread.

    Whenever I hear or read about this stuff it reminds me of this group of atheists I see every year doing the Los Angeles AIDS walk -- no kidding, they have T shirts and everything. They want to do good for their fellow man (and woman), and that's great. They want to make life better on this planet for other people, and that's wonderful. But if you raised the question of whether God had something to do with their mission they would no doubt have a fit. That is, I think, where the Episcopal Church is today... so far from the basic tenets of Christianity that they would blush in embarrassment if you asked whether they believe the Nicean Creed that we recite by rote every week. If you think I'm kidding, read this. Yes, a canon in the church writing about the joys of taking a good dump, going on to compare it to sex (personally, I think he needs to get out more), then continuing from there to speculate whether Jesus had sex with some of his 'women admirers'. This is what my denomination, with a long and respected history in the US and other countries, has come to.

    So can you guess my resolution for 2007? Oh, you have? That I will shake the dust of this Godforsaken--literally--denomination off my feet and go to find another one ASAP? How sharp of you.

    I'll let you know how it goes.