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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    Thursday, September 27, 2007
    One of the Good Things About the Internet Is...

    ...that sometimes you just want to know if anyone else has ever posted about one of your favorite stories by one of your favorite writers, and you find out that someone has. It's good to know that some kindred soul out there whom you've never met, nor ever will, had the same reaction to reading something that you did.

    I just realized that the second link I mentioned here containes a link to an essay I once wrote about cookbooks (it's at the very bottom). I suppose this means that if you go chasing about the Internet long enough, you will eventually catch up to yourself. It's a hall of mirrors, I tell you.


    Sunday, September 23, 2007
    Which Harry Potter Character Are You?

    You scored as Harry Potter.

    You can be a little reckless and hot-headed at times, but a more brave and courageous friend would be hard to find.

    Your Harry Potter Alter Ego Is...?

    (Three posts in a row? Yes, it's been a slow night.)


    Rebound Headaches

    The NY Times discusses the phenomenon of rebound headache here. This is news? I've been warning patients about this for years. But I should note that many patients I've treated for headache still don't know that taking medication improperly can trigger rebound headache. So:

    Most pain medications if used in excess, even as little as twice daily, can give you rebound headache. What is a rebound headache? In a simplified sense you can call it a withdrawal syndrome - which sort of implies that the patient is 'addicted' to the pain medication. That description leaves one wondering, how could I get addicted to acetaminophen (Tylenol) or ibuprofen (Advil)? Well, in the same way that you can get addicted to caffeine - think of the ice-pick headache that comes on when you stop drinking coffee all of a sudden. Many medications can do this, including narcotics (codeine or hydrocodone), ergotamines, triptans (such as Imitrex [sumatriptan], Maxalt [rizatriptan] and so forth) and over the counter meds such as acetaminophen and ibuprofen and, of course, Excedrin (contains caffeine - guaranteed to give you a rebound if you use it often enough).

    The answer in most cases is to stop the medication that one is using to treat the headache, grit one's teeth, and sweat it out - or to use one of the prophylactic medications for migraine (but these don't take effect right away, so you will still have to cope with the headache for a bit). These include prescription meds such as amitriptyline, nortriptyline, beta blockers and gabapentin. Some over the counter supplements and vitamins such as Coenzyme Q10, magnesium, vitamin B2 and niacin may also help prevent migraine.


    Conversations with V.

    So last Friday night I sat in V.'s office rehashing the events of the workweek, as we often do. Call it a debriefing session: It allows us to dump our angst for the week and go home to relax.

    "So did I tell you we had a ghost in the office today?" she said dryly after a few minutes' chat.

    "Um... no," I answered, puzzled.

    "A patient of mine came in asking me to write her a letter. She lost her Medicare benefits because the government says she's dead. And I am writing this letter going, I have known this woman seventeen years. Trust me, she is not dead."

    I gaped at her for a second. "Are you serious?"

    "Yes. I've known her longer than I've known B [her husband]. So I felt her and I said, 'Well, you're warm... you have a pulse... I'm guessing you're not dead.'"

    "Geez." I thought for a second. "That might be the least of her problems. She's gonna lose her Social Security benefits."

    "She already has." V. is very good at keeping a dead pan, no matter how pissed off she is. I knew she was more than just annoyed.

    "Did I mention this is why you should never depend on the Feds? For, like, survival?" I demanded, unleashing my libertarian side (which V. is used to by now).

    "Yeah. It sucks."

    "Well, she's got you. And you know her," I said, hoping it would help. "You're willing to stand up for her. I'm sure that will take care of it." And it will. Eventually. But it probably will mean a lot of extra work for V., as it would for me were it one of my patients. This falls into the class of those "annoying but necessary" jobs we have to do. Except it's more annoying but unnecessary - it's due to some bureaucratic foul-up.

    V. sent me a copy of the letter she wrote for the patient, brilliant in its understatement. In it she documented the woman's vital signs at her visit this week and stressed the fact that she had known the patient for seventeen years. Subtext: Do the math, you idiots.

    We anxiously await the result.


    Wednesday, September 19, 2007
    Arrrrrrrr You Aware...

    ...that it's Talk Like a Pirate Day today?

    I loved "Treasure Island" as a kid and I have to confess that I get a kick out of doing this at work every year. But only for half an hour or so, after that it gets annoying. In honor of the day, here's a pirate cat picture for you:

    ARRR! Where's me grog, wench?

    Now go tell your boss to walk the plank or something.


    Sunday, September 16, 2007
    New Orleans 2007

    As the Times-Picayune headlines reminded me incessantly during my vacation last month, it's been two years since the devastation of Hurricane Katrina. I was eager to see how the city would appear since my previous visit nearly ten years ago - I was there for a medical conference then. This time I went with two friends as part of a summer roadtrip.

    I was struck by the dearth of tourists in the city (granted, it was August and hotter than hell, but still I was amazed). The up side of this was a refreshing lack of crowds, and we were able to make restaurant reservations the same day that we wanted to eat. There was no competition for the hotel pool, either. We did a lot of shopping around the French Quarter and Magazine Street and many of the shop owners told us that business hadn't yet picked up the way they hoped it would.

    Structurally the center tourist part of the city is back to normal - the French Quarter and Canal street, where the big hotels are, is fine. The Superdome is up and running again; in fact the Saints' first preseason game took place while we were there. The moment you get out of downtown, however, it's another story. In the Faubourg Marigny section of town, five minutes' drive from our hotel, were homes still bearing floodwater markings and branded with the FEMA spraypaint sign indicating the home had been searched and found habitable after the storm. Heading in the other direction, to Magazine Street, we had to detour time and time again as many streets still were blocked with concrete barriers and choked with debris.

    We approached the city from the north, therefore having to take the Causeway across Lake Pontchartrain, which is 22 miles across. So there we were driving along this raised freeway and unable to see land when we got to the middle of the lake. I suddenly understood exactly why the city had flooded so badly; I never knew how large that lake really is. While visiting New Orleans we met up with another friend who lives in the parish north of the lake; she told us that drivers' ed classes there include a crash course in what to do if you drive off the bridge. (short version: there's not a lot you can do.)

    If it's possible to describe a mood as optimistic but bitter, that's what I'd have to say the mood in the city was. One bumper sticker we saw read "Forget Iraq, Rebuild New Orleans." It's sad to see a place with so much history taking such a hit and struggling to come back. I plan to go there again soon. I love the atmosphere of New Orleans, the beautiful architecture, the food... all of it.


    Friday, September 14, 2007
    Rate Your Blog

    Hmm. This is silly, but fun:

    This rating was determined based on the presence of the following words:
    drugs (1x)

    Oh, the horror! A medical blog that mentions drugs! If you have a blog you might check it out anyway, it's kind of fun.

    (via Dr. Mabuse)


    Monday, September 10, 2007
    Funky Cancerbean, or "What is Wrong with Comics These Days??"

    Back when I was a newly hatched tad just about to graduate from medical school, I agreed in a fit of temporary insanity to co-edit the school yearbook. That year the yearbook committee was in serious trouble because the previous year's class (the senior class was always in charge of the yearbook) had fallen down on the job, badly. Some alumni send checks every year to support this project, God bless them ... and the year before my class graduated they never got one because the damn thing wasn't finished for months and months and months. The administration made it clear that my year had to atone for the delinquency of our predecessors, and in an attempt to do my part I spent the first two months of my internship desperately finishing layout in my apartment when I wasn't taking call. (I also had to try to think up clever captions for the many pictures that were submitted. I solved that by conjuring up an imaginary evil twin, who produced some memorably snarky commentary.)

    In the end we met the deadline and produced a yearbook I'm still proud of, partly because that was back when Calvin and Hobbes and The Far Side were still in print. Clippings of both these comics appeared regularly in the class note service and monthly newsletter to liven things up. (In the third and fourth years when we were scattered among various hospitals for our clinical rotations, the newsletter was the only way to communicate with the entire class.) For the sake of nostalgia I decided to reproduce some of the comics in the yearbook; looking back more than fifteen years later, I'm glad I did. These strips have become classics, and since neither Gary Larson nor Bill Watterson are drawing comics any longer they will always remind us of that time and place. One night recently I ran through the yearbook and these twenty-year-old or more strips stood up well... they did not date.

    I can't think of many, if any comics of which you could make that claim today... maybe Lio. (I worship Lio.) Today's strips, for the most part, are simply not that good. Maybe most of the 'classic' comics we like to think about never were as good as we remember. The drain of writing a daily strip, coming up with a quip or joke every day, is something I can only imagine; it must be like trying to blog every day.

    This is all a lengthy lead-up to my main complaint, encapsulated in the title to this entry. Why aren't the comics fun to read any more? One of the blogs I link to in the side menu is Josh's The Comics Curmudgeon, a man who performs a valuable public service in sieving the wheat from the chaff and snarking on the chaff (this would be maybe 80 percent of the comics page). Favorite targets of his are the soap strips, such as Apartment 3-G and Mary Worth. These strips have always been hopeless, but now at least they're funny thanks to Josh. Their plots move at a glacial pace and the dialogue is usually ridiculous.

    Josh's two biggest targets, though, cordially loathed by pretty much everyone who visits his site, are comics that used to be good: For Better or For Worse and Funky Winkerbean. FBOFW broke a fair amount of ground in its day; it used to be funny and even insightful. The strip's artist Lynn Johnston is retiring soon and seems to be more interested in tying up the remaining loose plot ends than she is in letting the characters drive the strip, the way they used to do. It wasn't enough, apparently, to let daughter Elizabeth go off to teach in Mtgiwaki up north and become interested in native culture, maybe even accepted into the locals' world. No, she had to rush back to Toronto in a fit of homesickness and get tied up with ghastly Anthony, her (now divorced) high school sweetheart. Every strip of Johnston's ends with a feeble pun or some sort of wordplay, no matter how forced, and none of the characters seems believable any more.

    Funky Winkerbean, drawn by a high-school teacher named Tom Batuik, used to be kind of funny in a laid-back sort of way as it detailed the adventures of a bunch of high-school kids back in the seventies. But now it's one big downer. One of the main characters is currently dying of breast cancer (hence the nickname "Cancerbean"), and as if that weren't enough, nothing good ever happens to anybody in the strip. The most gratuitous example of Batuik's pessimism is Harry Dinkle, the former band leader and a man obsessed by his job: A running joke every year showed him selling candy to raise money for his high school band, going door-to-door in full uniform (he was never drawn any other way). Guess what's happened to him? He had to retire because he's losing his hearing. See? Irony. Watching events unfold in this strip is like watching a train wreck in slow motion, but less entertaining.

    There's still some good stuff out there - Sally Forth, Frazz, Zits are all usually funny - but many of the strips have fallen into a pattern of tired repetition. One reason for this is that often when an artist dies or retires the syndicate will continue the strip instead of retiring it and giving new artists a chance. This makes it very difficult for most new strips to get a foothold.

    I'm not really sure how to end this rant, but I do think there's still hope for the comics. When fresh, imaginative strips come along they're greeted rapturously by readers. And newspapers will never be able to get rid of the comics; in a few years they may be the only thing that keeps people buying papers instead of getting all their news online. What we need is a few more strips like Lio and a few more blogs like the Curmudgeon.


    Sunday, September 09, 2007
    Emergency Meals

    Everyone has one or two favorite fallback meals that you make as a reflex when you've got to cook something. Since I am single, my reflex meals are probably more eccentric than most. Peg Bracken, my favorite cookbook writer, did a great chapter in her Appendix to the I Hate To Cook Book on singles cooking; see also Laurie Colwin's chapter "Alone in the Kitchen with an Eggplant" in her book Home Cooking, about her single years cooking on a hot plate in a tiny New York City apartment. At that time she apparently lived on eggplant (which I can't stand).

    I can't hide behind Colwin's impediment: I have a house with a functional whole kitchen and an intimidating family heritage as a daughter of Southern cooks behind me. I just simply don't have time to cook, other than on weekends. I work too many hours. The number of times I have eaten cold cereal or potato chips for dinner would stun you, or maybe it wouldn't - I get the feeling that more and more people are eating like this when they can get away with it. But now I am trying to eat better and more cheaply. The only way to do this, I realized, is to cook for yourself.

    My next realization was that whatever I cook has to be simple, tasty and fast, or I won't continue to do it. For many years in my twenties my fallback meal was vegetable stir-fry; back in medical school when I was doing a clinical rotation in Oxford, England I lived on this for an entire month. I had somehow forgotten about it until a few months ago when I dusted off my nonstick wok and took it for a spin. The results were as good as I remembered.

    This weekend I had some chicken tenders in the fridge that had to be used up, so I decided to do a stir-fry. I usually don't use meat in stir-fry if it's a true emergency meal, since by definition this is a last-minute sort of thing and most of the time I don't have meat sitting around waiting to be used up; however, if you do, try this approach with it. I chopped the chicken into eating size chunks, threw some soy sauce and powdered ginger over it and tossed in a crushed garlic clove, then left it to meditate while I put the water on to cook for the rice.

    Next and most crucial is the vegetable selection. The really nice thing about stir-fry is that you don't have to use expensive ingredients. If you have, say, bean sprouts, fancy mushrooms or red bell peppers, you certainly can use them in your stir-fry but you don't have to. I used chopped onion, cabbage and celery because that is what I had. As a general rule I would say use onion (green onion is great, but now I use regular because I always have it around and it keeps better than green onion) and garlic or garlic powder. For a "base vegetable" I use either broccoli or cabbage and then I throw in whatever else there is. Carrots, snow peas, whatever - it almost doesn't matter.

    If you have meat, cook that first (to sear all surfaces) and then take it out of the pan and keep it warm while you start to cook the veg. Do the heavier ones, such as onion and celery, first and then add the mushroom/cabbage types later. Do the bean sprout and snow pea sort of thing last. By the way, I do think that using peanut oil makes a difference as it takes the heat better and leaves less of an aftertaste; if you're allergic to peanuts, though, canola or sunflower is fine.

    So that's your emergency dinner Number One. Here is another one that I think is good if you are in the mood for pasta. It requires that you find a jarred or bottled tomato sauce that you like (it should be tasty but doesn't have to be really expensive). Cook pasta, heat sauce. Toss together in a warmed bowl and add a few tablespoons of ricotta cheese; mix, but not enough to fully blend ricotta in with the sauce. Serve with Parmesan on the top. Yummy, and will make any jarred sauce taste better.


    Saturday, September 08, 2007
    What Do You See When There Is 'Nothing To See'?

    Have a look at this:

    This is the surface of the sun on a very boring day.

    To quote from SpaceWeather.com: This morning Japan's Hinode spacecraft photographed a blank patch of the solar surface and sent this image back to Earth. The "blank" surface is seething with solar granules. The sun is so hot, it literally boils. Granules are bumps on the boiling surface, much like the bumpy surface of water boiling on a hot stove. One difference: While the granules on your stove are only a few centimeters across, granules on the sun are as wide as Texas. Even when the sun is blank, Hinode shows, there is something to see.

    I find this helpful to remember. Even when things are dull, they are not boring. You just have to know what it is you are looking at.