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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    Sunday, July 29, 2007
    Sick of Them

    I don't know when Sunday morning was designated the official day for Beatles worship, or who decreed it. All I know is that nearly every radio station in Los Angeles (and, I'm sure, lots of other places as well) plays wall-to-wall Beatles music every Sunday morning, and I am tired of it.

    I used to like the Beatles, before they got played to death on the radio. They've become the equivalent of beige shag carpeting. It's always there, you don't look at it or notice it until the day you decide to rip it out because you can't stand it any longer. Can't radio adopt some other group for their go-to music? The Police? Elvis? Shoot, the Carpenters would be better than this. Gah.


    Hot Water: a Good Thing

    A few days ago a patient of mine mentioned in the course of her visit that her hot water heater had recently stopped working and that, as a result, she'd noticed her water supply was slightly darker than normal; was this a problem?

    I told her she could be at risk for bacterial overgrowth in her water supply, due to Legionella and its propensity for colonizing water lines. To rid a system of this bacteria, it must be flushed with hot water. This is why all water heaters have a minimum recommended set temperature on them; the water in the tank must be at least 130 degrees Fahrenheit (to allow for cooling in the pipes). Legionella is a perennial problem in hospitals, since they often use nebulized water for inhaled medication treatments and to humidify high-flow oxygen. Bacteria can also colonize the plastic hosing used in ventilators, if someone is intubated and hooked up to a breathing machine. Another risk in a home water supply that isn't heated might be cryptosporidium, a small cystic parasite that can sometimes colonize water supplies and causes diarrhea in humans.

    Legionella isn't just limited to hospitals; the original outbreak that gave the disease its name was related to the cooling tower in a hotel air-conditioning system. For good measure I explained that there had once been an outbreak of Legionnaire's disease that had been traced to the produce mister in a grocery store. She quickly agreed to get the water heater hooked up again.


    Demotivational Posters for ECUSA TEC

    Somebody's got fabulous Photoshop skills and a wicked sense of humor. Check 'em out.

    And thanks to Stand Firm for the link.


    Tuesday, July 24, 2007
    The Lipid Wars

    Cholesterol: The bane of every internist. If I had a buck for every patient I've argued with about starting a statin to treat their elevated cholesterol, I could probably retire right now. There are a couple reasons for this. First, the guidelines for "normal" LDL levels are getting tighter all the time. This means that my patients who formerly needed to lower their cholesterol 20 or 30 points may now need to lower it by 50 to 60 points. Their lipids haven't changed; the rules have. Second, people don't really like taking statins, even the ones whose cholesterol is close to 300. These medications have the potential to injure the liver, although we prevent that by following patients' blood tests; if the liver enzymes go up we stop the drug. There is no permanent liver injury. A much more frequent side effect of statins is muscle aches. Most of the time when I've had to stop statin treatment it has been for this reason.

    The other issue besides side effects and the cost and annoyance of taking a drug is the overly optimistic view patients have of the effectiveness of diet and lifestyle changes. ("I'll change my diet!" If I had a buck for every time I heard that, I'd be as rich as Bill Gates.) Don't get me wrong: cutting fat out of the diet does lower cholesterol. But to make a significant change such as fifty points or more requires a very strict, usually vegetarian, lowfat diet.

    I have one such diet sheet which I hand out to patients as an example of what it's going to take to lower their cholesterol without drugs. I love to watch their faces fall in disbelief as they read it. Next predictable question: "How long do I have to do this?" I answer: "The rest of your life." High cholesterol is simply not a curable problem. Controllable, yes, but not curable. I have to tell people over and over again that no matter what we do for their cholesterol - medication, lifestyle changes, or both - the problem will never really go away. Most people go off the wagon at some point, which is understandable. When they do the cholesterol profile worsens almost immediately, with the HDL going down and the LDL going up.

    The effects of high cholesterol take years to decades to appear. It's difficult to get someone to buy into taking medication that costs money and can have side effects when they won't see the benefits for many years to come. And it's a negative benefit at that, as in they won't get a heart attack. It isn't about achieving something, it's about preventing something. Psychologically, no wonder this is a struggle.

    I've had patients suggest red yeast rice as an alternative. Sad news, folks: the product as it is currently available does not lower cholesterol. It did in the past because the original formulation contained lovastatin (brand name Mevacor), the same as the prescription drug that lowers cholesterol, just in a lower concentration. The FDA banned it from being sold as a dietary supplement, since it contained an active ingredient that was classified as a drug; the manufacturers pulled it, reformulated it and started selling it again. Unfortunately once the lovastatin was removed, the rice product was useless as a treatment.

    All of this is a leadup to a conversation I had yesterday with a new patient. I had just found out that he has high cholesterol and thought: well, he's young. We can try diet first and I'll check his labs again in three months. I called him, went through the numbers with him, explained what they meant and touted the benefits of a high-fiber, low-fat diet...

    Me: "...and we'll check your fasting cholesterol again in three months."

    Patient: "Do you think I need medication for this?"

    Me: "Well, uh, sure we could do that, and you may need medication. But I think we could work on diet and exercise first."

    Patient: "Are you sure I don't need medication?"

    Me: *head explodes*

    Apparently the negative psychology ploy really does work. Who knew?


    Monday, July 23, 2007
    Metapost: Housekeeping

    I dusted off the links to the left and started a new category: generally useful links. Zip codes, area codes and so forth always drive me nuts trying to remember them. Hope you find these helpful.


    Rain in July

    ...is almost as rare as Christmas in July around these parts. Nevertheless it's what we woke up to this morning. You could see it coming on last night; I left the house just after sunset to go to the grocery store and was greeted by humid air and a huge rainbow in the sky. The weatherman on the radio is calling it "Monsoon moisture," whatever that means. I believe the Southern California climate is classified as subtropical desert -- a phrase I've always found pleasing since it's such a contradiction in terms -- and we're living up to the subtropical part today.


    Wednesday, July 18, 2007
    Book Seven

    Just a few more days until Harry Potter and the Deathly Hallows is released. I'm trying to decide whether to save the book up as a treat or to gallop through it the first weekend; if I save it I just hope I don't run afoul of any spoilers. Unbelievably, someone may already have posted the book's ending online (don't worry about clicking, there are no spoilers in this link). Rowling's idea of setting up the last book as a Horcrux hunt is brilliant, and I like the idea of Harry visiting Godric's Hollow to see where his parents used to live.

    I'm also waiting for an explanation of one scene from the fourth book: a moment at the end of Goblet of Fire I've been puzzling over ever since I read it. When Dumbledore learns that Voldemort has used Harry's blood to gain a new body and become resistant to Harry's touch, there is a "brief flash of triumph" in his eyes. That has to mean something, but I don't know what.

    I'm sure Dumbledore will have some sort of presence in the book, perhaps through his portrait on the wall of the headmaster's office, but I don't expect him to speak from beyond the grave. One theme that has run through all the books is that when you're dead, you're dead. We have seen brief glimpses of Harry's parents, for instance, through old photographs, the Mirror of Erised, Harry's wand duel with Voldemort in Book Four and so on, but Rowling has made it very clear that these are memories or "echoes" and not Lily or James themselves.

    I didn't order the book online this time, as I know it will be cropping up in my local grocery store and Costco within a day or so. Still, I remember the day that Half-Blood Prince came out the delivery guy who came to my house looked like he was having a really fun day at work. He'd probably never had so many people thrilled to see him.

    ADDENDUM, July 19: Apparently the New York Times published an early review of the book - with spoilers. Shame on them. J.K. Rowling has responded as follows:
    I am staggered that American newspapers have decided to publish purported spoilers in the form of reviews in complete disregard of the wishes of literally millions of readers, particularly children, who wanted to reach Harry’s final destination by themselves, in their own time.

    Should you feel like writing a letter of protest regarding this decision, you can email one to letters@nytimes.com.


    Tuesday, July 17, 2007
    What Color is Your Brain?

    Gee, it's like they know me... (Via Dr. Deb)

    Your Brain is Orange

    Of all the brain types, yours is the quickest.

    You are usually thinking a mile a minute, and you could be thinking about anything at all.

    Your thoughts are often scattered and random - but they're also a lot of fun!

    You tend to spend a lot of time thinking about esoteric subjects, the meaning of life, and pop culture.


    A Funny

    How your computer cursor really works. May take a few seconds to load.


    Monday, July 16, 2007
    Teaching Medicine by Video

    An interesting article from last week's Wall Street Journal describes a company designed to bring courses in basic medicine to rural doctors in China. The term "rural doctor" may be misleading, as most of these health care providers have no formal medical training. One doctor interviewed for the article finished school at 17 and learned to practice medicine by training with his mother. There are about one million of these rural doctors, who are also known as "barefoot doctors," in China; in most cases they provide the only medical care available outside cities. Most got started as farmers who were appointed to be village doctors by local officials. (Imagine being told "You're going to be the doctor for this town.") They were sent to hospitals for basic medical training, which was unfortunately minimal in most cases.

    The purpose of the videos is not to provide a complete medical education but to bring the doctors up to date on problems they're likely to see in their local clinics. One doctor successfully resuscitated a baby using CPR techniques she'd learned from the class (she'd never learned how to open an airway or perform CPR properly). Another said he'd learned about drug allergies for the first time. Unfortunately, the instruction is by video only with no doctor on hand to answer questions (the company says it's too expensive to do this except at the end of the course). Nevertheless the feedback has been good. A three-year course of instruction costs 3400 yuan - about $448 - and the cost is partially subsidized by the government.

    The Chinese government, in an effort to improve the medical care available to rural residents, has ordered all rural doctors to earn a basic medical degree by 2010. The video classes sound like a great way to ensure that this happens.


    Saturday, July 14, 2007
    Dynamite in a Bottle

    This week has brought another catfight in the Episcopal blogosphere. It began with a post from Elizabeth Kaeton, a priest in the diocese of New Jersey who happens to be both rector of a parish and head of the Standing Committee in said diocese. In other words, this is a person with administrative experience whom one would hope possessed the quality of good judgement.

    What she wrote on her blog managed to enrage a lot of people. It was directed at another female priest who is married with three young children and a fourth on the way; in her original post (hastily taken down and edited after a few hours) Kaeton compared this woman to Andrea Yates and Susan Smith, two mothers who murdered their children. I'm not going to repost the entire story, which has been covered in great detail on multiple blogs, but a good summary of the episode is here with further analysis in a later post. (Full disclosure: one of the main bloggers on Stand Firm is Matt Kennedy, who is married to Anne Kennedy, victim of Keaton's original post.)

    Kaeton's motivation for this rather appalling act was apparently based on a single blog entry from Rev. Kennedy, from back in March. In it she discusses her messy house and that she's too tired to clean because she and her husband have just found out that she's pregnant with their fourth child. It's not a desperate or incoherent post; it's actually rather cheerful. Read the post and see what your take on it is.

    Now consider this. Kaeton responded to the outrage that greeted her post with another entry in which she apologized. Unfortunately the apology consisted of the following:
    I need to say to you, however, as gently and lovingly as I can, that there are growing numbers of us, lay and ordained, mostly all in "the helping professions" including psychiatrists and psychologists, doctors and nurses and pediatric nurse practitioners, social workers and those whose speciality is in domestic violence and child protection, who grow increasingly concerned and check in on your blog with some regularity.

    Some of us have written your bishop with our concern...
    Many of us have raised the question of our legal responsibility as professional helpers who understand our obligation to report situations like this when we "see" or "hear" them.

    In other words, Kaeton implied that she had contacted the Kennedys' bishop specifically to state that she felt Anne Kennedy might not be capable of holding down her job and implied further that Rev. Kennedy might be an unfit mother, emotionally unstable, or both. Further, she threw in the threat of continuing to watch Rev. Kennedy's blog specifically for the purpose of gathering evidence to this effect.

    And she did all this based on a single blog post from four months ago without ever posting in Rev. Kennedy's comments and, apparently, without even emailing her, a fellow priest, to inquire how she was doing or if she was okay or needed help. (To clarify, I will add here that I've read all of Rev. Kennedy's entries and the blog's comments for the last four months. I find nothing in the blog to warrant this sort of reaction from Kaeton.)

    This is beyond irresponsible and beyond unprofessional. It is unconscionable. Consider the following situation for perspective. Let's say someone who is caregiver for a parent or other relative with Alzheimer's has a blog. In it they write about how difficult it is to be a caregiver, how tired they are, how frustrating it is to try to communicate with and take care of their relative. The blog is their safety valve, if you will, and allows the writer to contact others in the same situation (for instance, anyone interested could post a comment, which most bloggers allow). It is not evidence that the relative is being mistreated. It cannot and should not be used as a warning sign.

    Now let's say that someone who doesn't like this person - perhaps they're angling for the same job, perhaps they're of an opposing political ideology, perhaps it's another family member who wants access to the relative's money or property - uses the information in this blog to call Adult Protective Services and file a complaint against the caregiver. "See?" they say self-righteously, "It's all right there on the Internet! She admits she can't handle taking care of Dad, she said so!"

    Kaeton's "answer" to her critics holds a very real threat to Ms. Kennedy: the potential to destroy her career. Being investigated by CPS is the sort of thing that tends to remain on one's record, and when it comes to applying for a job... would you want to ask a bishop for a recommendation when the bishop in question had been dragged into a messy child-protection case involving your children? No matter how innocent of the charges you actually are?

    Kaeton has set a dangerous precedent here. The appeal of blogging is the ability to write about oneself, one's life and interests, like casting a bottle on the ocean with a message in it. It's disconcerting to think that someone might open the bottle and use the information in it to come after you.


    Wednesday, July 11, 2007
    The Perils of Dye

    A patient came into our after-hours clinic this week complaining of a swollen lip. Cause: an allergic reaction to mustache dye (which he'd used before). He applied it, left it on overnight as per instructions, and woke the following morning with a swelling and itching upper lip.

    Many -- in fact, most -- allergies don't appear until the patient has been exposed to the allergen multiple times. Anaphylactic reactions to bee stings or penicillin, for instance, generally don't occur the first time the person is stung or dosed; the extreme sensitivity is brought on by repeated exposures. This patient's history illustrates that fact. This is the same way vaccines work, actually; this is why we give 'booster shots', to boost the amount of antibodies the body forms in reaction to the protein injected - it generally is a purified protein derived from the virus (as in hepatitis) or toxin (as in tetanus) you're trying to protect against.

    Several years ago I had another patient who had a reaction to hair dye. Hers was much more serious and could in fact have been a chemical burn -- I'm still not sure. She developed a deep ulcer at the top of her scalp, which eventually healed but she permanently lost the hair on that part of her scalp and later required plastic surgery.

    I'm not sure how often people develop reactions to hair dye, but these reactions can be difficult to predict. They fall into the contact dermatitis category (like cosmetics or nickel allergies). The only advice we really have, when a patient develops a reaction to dye or other topical substances, is avoidance. Oh, and Benadryl is helpful too.


    Tuesday, July 10, 2007
    Death and Mondays

    Our monthly staff meetings are always held on Mondays ("Monday Night Meeting" is a dreaded phrase among the doctors in The Firm, and on the rare occasions the meeting is canceled for the month it is known as "Miracle Monday"). In last night's meeting, as a special treat, we had one of our periodical lectures from Risk Management on How to Do Things Properly. This month it was How to Fill Out a Death Certificate. These talks, to be honest, are often useful and we usually come away from them knowing something we didn't know before. For instance, according to law the doctor has to complete the certificate within fifteen hours of the patient's death. This is a practice more honored in the breach than the observance: it's rare that the certificate is actually filled out within that time.

    Weekends are a perennial issue, as patients have an annoying habit of dying on Friday and Saturday nights. In Orthodox Judaism, for instance, the rule is that burial must take place within twenty-four hours after death. At one time or another every doctor in my group has received an urgent call from funeral homes on a Saturday or Sunday requesting that we sign off on a death so that the funeral can proceed on time. Getting access to the certificate is not the issue, as mortuaries serving the Orthodox community are very accommodating. Given their schedules, they have to be. They're happy to send messengers to the doctor at the hospital - or even at home - to get the thing signed. It's a different story when the doctor on call doesn't know the patient, doesn't feel comfortable certifying the cause of death, and we can't get hold of the primary care physician for clarification (most common scenario: the PMD is out of town on vacation). I've spent a few weekends in my time trying to pacify a distraught family by running to the office and ransacking charts, trying to figure out a cause of death that wouldn't involve me in fraud or perjury charges. Most of the time, fortunately, we are dealing with elderly patients with multiple medical problems who often reside in nursing homes, so that you don't have to be Sherlock Holmes to deduce the likely cause of death.

    This brings me to another tradition: the weekend phone call from the police. Oh yes, we get those: "Mr. Smith has been found dead at home. Will you sign the death certificate?" Usually the hapless on-call doc can give only one answer: "No." In this situation we usually have no information at all, meaning we don't know when the patient was last seen by their doctor, what the decedent's medical problems were or whether the death took place under suspicious circumstances. I usually lamely offer, "You can call Dr. X on Monday," but that's rarely a satisfactory answer unless it's 3 a.m. Monday morning.

    "But we'll have to call the coroner then!"

    So call him, dammit. That's his job.

    Assuming the primary care doctor is located, that the patient is considerate enough to die early on a weekday, and all the planets are aligned, we go on to the fun of actually completing the form. The mortuary usually faxes a "dummy" certificate for the doctor to fill out and fax back so that the formal certificate can be typed up and then brought to the office for the doctor to sign. (I have had funeral homes try to cut to the chase by having someone drop by with both the blank form and the actual certificate, asking me to sign the blank certificate and have them complete it later. I always refuse to do this. Never do this. One of the most valuable pieces of advice I ever got during my training came from a hardbitten attending who'd signed his share of these things: "Never sign a blank death certificate. It's like signing a blank check.")

    Stating the cause of death can be like determining how many angels can dance on the head of a pin. If you scroll to the bottom of this sample form here you will see that there are four lines for cause of death. You don't have to use all of them, but in some cases you might need to. This is to list both the immediate cause of death and whatever disease process might be linked to it. For instance:

    Cause of Death: Sepsis
    Caused By: Gangrene
    Caused By: Diabetes

    You get the idea.

    Most people get the hang of this after filling out one or two certificates, but coroners and mortuaries tend to be picky about what they will and will not accept as a cause of death. I myself, sad to say, have often defaulted to "cardiopulmonary arrest due to..." as my standard cause of death. After a few clashes with mortuary directors (and, if I recall correctly, one coroner's office), I lost my will to live. I mean, argue.

    This very issue was debated at our meeting last night, in which we were exhorted not to default to "cardiac arrest" as a standard cause of death. One MD reminded us of the vast amounts of money erroneously (he implied) devoted to cardiac disease research - money that is driven by death statistics, which are determined by... listings on death certificates. He said that when his elderly demented patients die, he lists respiratory arrest due to end-stage Alzheimer's and hasn't had it questioned so far.

    "But how exactly does that contribute to the cause of death?" countered another MD.

    One of my office mates fired back: "They forget to breathe." She brought down the house.


    Friday, July 06, 2007

    So we have had... stuff going on. Quite a bit of stuff, actually. After over a year of planning/anticipation, my practice has moved to a new building. The move was a month ago and we are practically settled into our lovely new quarters, but it still doesn't feel like home to me. It's like missing the tatty, comfortable old bathrobe you used to wear until you were shamed into buying a new one (please tell me this has happened to you too). The most annoying part is that now the office is split into Upstairs/Downstairs, and the lunchroom is downstairs. So are the after-hours clinic, of which I am the director; the blood draw station; and the eye box (containing our rudimentary ophthalmologic equipment) and pulsoximeter. These are items we need several times a week, and to go galloping downstairs or to send a staff member for them holds everything up. I have already suggested to the office manager that we get duplicates for the upstairs office.

    The medical records department is newly set up with one of those Spacesaver filing systems, with the hand cranks on the side that let you roll the cabinets forward and back on their tracks to access charts. No doubt this system minimizes the risk of the shelving collapsing in case of earthquakes, but - as I already have found out more than once - you have to check for occupants before you start cranking. Otherwise you run the risk of reenacting the garbage masher scene from Star Wars with a hapless filer as the victim.

    Plus which, The Firm has decreed that we're going paperless. We are switching to an electronic medical records (EMR) system, which has been slowly rolling out for over a year. My office, now that we've moved, is the latest to undergo this ordeal. Currently we are in the "preload" stage, which involves each physician loading patient information into the system (such as allergies, medications, previous surgeries and so forth). Which is all fine and good, until you realize how many patients need to be preloaded; my list contained over six hundred names. "You can do it from home!" we were told blithely; "you can take the charts home with you and preload there!"

    No thanks, I thought. My computer service is not so great, plus I tend to get very distracted at home. This really doesn't work for me; I do better in the office. So this weekend I have resolved to come in and get a chunk of preloading done. This is the same resolution I have made for the last several weekends in a row, but we're running out of time. I will be coming in this weekend. But if you see several feverish blog posts in a row, you'll know why I was moved to communicate. The truth is, I would rather clean house or write a novel holding the pen in my teeth than load this information.

    On the up side, my house has never been cleaner.


    Thursday, July 05, 2007
    Sometimes It Is That Easy

    Several years ago a co-worker showed up in the break room with a slow cooker filled with the most delicious pork ribs I've ever had.

    "How did you do this?" I gasped.

    "It's really easy," she confided. "The sauce is equal parts soy sauce, sugar and water. Oh, and you need a lot of garlic. A lot of garlic. You can do it with chicken, too."

    "Hmm," I responded. Soy sauce, sugar, and water? The garlic I could get behind, but the rest of the recipe sounded too good to be true. I filed it away in memory, vaguely meaning to try it. I never got around to it until this year's Fourth of July, when I realized that I had some chicken breasts dying of freezer burn that I had to use up. The garlic - nice, fresh, and plump - was on sale in the local grocer's. Soy sauce and sugar - not a problem, I've always got those. What better time to give this "recipe" a try?

    I thawed and skinned the chicken (should be on the bone for this recipe), mixed together equal proportions of the three ingredients - you should have enough to cover the chicken - and chopped up several cloves of garlic and chucked them in. I could not make up my mind as to the proper temp for the slow cooker... low or high? I temporized by alternating between the two settings.

    It worked. I still can't believe it, but it worked. One caveat: despite anything you may have heard to the contrary, it IS possible to overcook chicken in the slow cooker - but perhaps I should have left it on "Low." Be that as it may, it is delicious. It fell off the bone when I looked at it and the remainder is currently sitting in the fridge for tomorrow (and perhaps the next day, if I'm not greedy). Goes well with rice. Give it a try, you won't regret it. Especially if you have freezer burned chicken... as long as you have enough marinade to cover. It will turn out nicely.