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, December 27, 2007
    This Snow Thing.

    It's overrated.

    We woke to snow here in Denver Christmas morning and it didn't stop all day. The next day's paper informed us that it was the snowiest Christmas Day in Denver in more than a hundred years. Today more snow was predicted and we got more than was expected. I have not seen snow like this in years, since I lived in Philadelphia back when I was in medical school.

    The kids love it, of course. My niece and nephews got sleds - snowboards? - these sort of foam things that look like boogie boards, anyway, and immediately clamored to go sledding. They've done that a couple of times this week and greatly enjoyed it. Me, I volunteered to shovel the driveway with the boys this afternoon and found out what a chore it is with several inches of snow on the driveway. As we worked the mail truck came by and the nice woman delivering the mail greeted us. Frankly, I can't believe she made it out in this weather.

    "So how's your afternoon going?" I asked.

    "Whoops! Great!" she laughed, nearly losing her balance on the slick surface as she opened a mailbox.


    Friday, December 21, 2007
    Typing Impediment

    I just finished typing the following phrase into a patient's EMR chart: "Sputum culture positive for Serratia marcescens sensitive to ceftriaxone" and thought, well, there's a sentence you wouldn't want to attempt if you had a lisp. Along similar lines, I have developed an annoying habit of typing "tomorrow" as "tomowwow," which makes me feel like a three-year-old. Or Barbara Walters. Or a three-year-old Barbara Walters.

    Forgive the scrambled thoughts: I leave this weekend for a two week vacation, hallelujah. I'll try to post if possible, but I promise nothing as I don't know what my computer access is going to be.

    Everyone enjoy your holidays, and a happy 2008 to you.


    Thursday, December 20, 2007
    Blue Wind

    Sitting here shivering tonight in my underinsulated 1920's-built house (apparently the developer's motto was "Insulation? We don't need no steenkin' insulation!")

    We've had a fair amount of rain this week for which I am grateful, considering the drought year we've been promised for lo these many months. The drought may yet happen if we get a dry January, February or both. But tonight after the rain the wind has kicked up. Oy, the wind.

    We inhabitants of Southern California love to talk about the Santa Anas. If you are a Raymond Chandler fan you will be familiar with his story Red Wind, surely the finest story about weather ever written. But old Raymond left something out: Santa Anas can come at any time of year. Mostly they are associated with hot, dry weather but they come in the winter too, and if you get caught in one then forget Raymond Chandler, we're talking Jack London and To Build a Fire. (Surely the finest story about freezing to death ever written.)

    Damn, there it goes again, whistling through the trees outside. Inching its way past the ill-fitting windows. I have lived in colder climates than this, I hasten to say, and in Minnesota or similar latitudes this would probably qualify as a blustery spring night. But I am fond of saying that all weather is relative, or to quote a greater authority than myself: "The coldest winter I ever spent was a summer in San Francisco." The fact that Mark Twain apparently never said it is beside the point: the quotation was apropos enough to have been repeated for the last hundred-and-something years. I defy the most durable Aptenodytes forsteri from March of the Penguins to stand through a winter Santa Ana in Los Angeles without crying Uncle!

    I have to go now; I'm going to put on sweat pants and three pairs of socks and hurl myself into bed underneath every blanket I possess.

    UPDATE. I woke in the night and realized that the power had gone off and come back on, so as a precaution I set a non-electric alarm clock and opened my garage door (which is electric). It's a good thing I did: power was off this morning and stayed off. I showered by candlelight and dressed by flashlight.

    The power guys showed up with their truck about 5:45 this morning and were still there when I left; I stuck my head out the window to watch their arrival and saw a perfectly clear sky and smelled clean cold desert wind.

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    Thursday, December 13, 2007
    On Why I Can't Fit Into Modern Society

    Several years ago, this would be about the time I started blogging, I went to a party in Hollywood. My hostess had a beautiful black cat darting around the apartment. I scooped it up and asked, "What is your cat's name?"

    "Chandler," she answered.

    "Oh, that's a wonderful name for a cat," I said warmly. "Raymond Chandler is one of my favorite writers and he loved cats."

    "Well, that's not why I named him," she replied blankly. "I named him after the character on Friends."

    "Oh," I replied blankly in my turn (I had not, and still not have to this day, seen Friends).

    'Nuff said.

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    Makes You Give In and Cry...

    ...so tonight I was reading Lileks and came across the following: And I do believe the label. I have to. What else do we have in this ever-changing world in which we live in?

    and some sort of switch went off in my brain: Aha! Live and Let Die!

    Off I went to Napster, and I was right. Found it right off the bat. I really enjoyed listening to these lyrics:

    What does it matter to ya,
    When you've got a job to do you've got to do it well,
    You've got to give the other fella hell

    Somehow it sounds exactly like practicing medicine.


    Tuesday, December 11, 2007
    Calling Vanna White

    This time of year we all get a little punchy. It's the stress. As the calendar year winds down we primary care MD's have to stuff in our Paps and mammograms, our diabetic patients and what have you to meet our Pay for Performance (P4P) benchmarks - I have spoken about this before - not to mention doing preop clearances on all the patients who want to have surgery before the end of the year so that they don't have to meet their deductibles again next year. Under these circumstances, and now that our medical records have gone electronic, I find the contemplation of the typos perpetrated by my staff in their Phone Note messages to be an inexhaustible source of humor. Of course, it's probably funnier if a) you're a healthcare provider and b) you work here.

    Today's example: "Patient requests prescription for Irritable Vowel Syndrome." Ah, but which vowel, exactly? Is it U, O, or even (gasp) the dreaded Y-acting-like-a-vowel syndrome? For which there is no cure?

    This had me giggling like a maniac all afternoon. As I said: it doesn't take much.


    Monday, December 10, 2007
    In Praise of Pri-Med

    Thank goodness for Pri-Med. This weekend I got enough credits under my belt to take care of my requirements for this year. You can earn online CME at home, and it's free; plus, the case studies are pretty interesting.

    It seems like every year I wind up scrambling at the last second to get enough CME to meet requirements. This year has been worse than usual because of the move and then the EMR project, which has kept us all incredibly busy. Next year, though, I'm planning on going to the ACP conference in Washington which should cover me for the year - or close to it.


    Saturday, December 08, 2007
    The Day After.

    The party was a success, I am happy to say, including the Taco Soup. I stayed up late cleaning up and this morning had to pop out of bed early to take my (twelve-year-old) car down for a check; it has been somewhat slow to start for over a week. Several months ago my car guy had warned me that the starter was beginning to wear out, though it didn't at that time need to be replaced. After various other bad experiences with said car in the past, I decided to take it in before it failed to start entirely.

    Well, my suspicions were correct and the starter did need replacement: The car was in the shop for about six hours today. The catch was that I was on call for hospital admissions, so I sent a panic call out to my parents who kindly responded by coming in to town for a visit - they also returned my vacuum cleaner, which had suffered a broken belt, and picked up a jacket my father left behind at my house two weeks ago.

    My father is suffering from a nasty cold, so we parked him in front of the television to watch sports and my mother and I went around the house hanging pictures before settling down to the crossword and Christmas catalogs. (I should explain that I have a bad habit of buying pictures and then failing to hang them. Some of the pics had at one time been up on the wall before my taking them down during the kitchen renovation - which would be six or seven years ago!)

    All in all, it was a nice quiet day, just what I needed after getting ready for that party. I was lucky that I got no admissions today. I gave my parents leftover Taco Soup for lunch, which they liked so much that I sent them home with extra for dinner. Now it's freezing and the word on the weather radio is that Southern California is destined for another storm tonight, which may result in 'thundersnow' in the mountain areas. Seriously, when did thundersnow become a word? I swear I'd never heard it until a few months ago.

    At any rate, I am happily tired, but the party is over and I have a working car and the house is clean. I am blogging and eating leftover M&M's (I bought them for dessert for last night). Generally speaking, life is good. And I just realized it's starting to rain. I am not leaving the house tonight.


    Thursday, December 06, 2007
    So, So Tired

    I have been cleaning. And cooking. And dusting. I volunteered to have the office holiday party at my house this year, and it's tomorrow night (my main rationale for throwing parties is, it forces me to clean the house).

    I'll spare you a complete recitation of what I am serving, if only because I am too beat to type much... but one thing I am serving is Taco Soup. This is another recipe I got from my good friend LA and her family on my recent vacation - I came back with so many recipes! One million, actually (she generously gave me a CD compendium of recipes titled "One Million of the World's Best Recipes").

    Taco Soup is easy and good, better than it sounds (if you dislike the idea of canned vegetables) and it makes a ton. Here is the recipe.
    • 1 1/2 to 2 lb. hamburger
    • One chopped onion
    • Two cans chopped tomatoes (large - bigger than the 15 oz. size, I think it's 26 oz. or something)
    • 1 pkg taco seasoning mix
    • 1 pkg Hidden Valley Buttermilk dressing mix (dry, do not reconstitute)
    • 1 can pinto beans
    • 1 can pinto beans with jalapenos
    • 1 can of Ro-Tel tomatoes and chilies
    • 1 can shoepeg corn (this is not regular canned corn, you may have to hunt for it)

    Brown the hamburger and onion - drain well. Mix the meat and onions in large pan with all other ingredients (you don't have to drain the cans of the juice; just open them all and dump them in). Simmer 30 minutes. It's better the next day, I am told. We'll see for certain tomorrow night.


    Universal Health Care Debate, Medieval Times Edition

    I tend to find McSweeney a little precious for my taste, but I thought this piece was pretty funny.

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    Tuesday, December 04, 2007

    Here's the diagnostic secret about dementia: It's all about faking it. It's about faking your way through life until you don't have enough sense of self left to fake it any more.

    The standard medical joke about dementia is, if a patient comes to you concerned about memory loss, they don't have a problem with it. As with most medical jokes there is a hard core of truth to this; in dementia, the very nature of the disease process means that patients will not notice that they have a problem. It's their friends and relatives who see it, long before they do. Also, interestingly enough, I feel in nearly every case of dementia that I've seen that there is a strong element of denial to this disease: if a patient senses that he or she is losing their grip on reality they will fight like hell to maintain what they have left, denying that there is a problem. It's like the old cliche, "If you can admit that other people think you might be crazy, you're not crazy." It is also because for some reason the social niceties are preserved until a late stage in the disease. It's possible to meet someone who is properly dressed, polite, and can carry on some sort of light social conversation and not realize that they are moderately demented.

    The first real case of advanced Alzheimer's I ever saw was as a medical student: it was in an elderly gentleman who had been admitted for some sort of internal medicine issue. However, the primary MD suspected that dementia was a contributing factor (I can't remember why now) and so my resident did a mini mental status exam, aka MMSE, on the patient in the hospital room.

    This was a well-groomed, mild-mannered, well-spoken man - a former college professor - wearing what looked more like a smoking jacket than a bathrobe, some sort of brocade thing. His wife was sitting by his side. It really hit me that something was wrong when my resident picked a pen out of the pocket of his white coat, held it up and asked, "What is this?"

    "Well, it's some sort of... object..." the patient confabulated.

    He didn't know what a ballpoint pen was. This man, a teacher, could not recognize a pen when he saw one. At the same moment this realization hit me, it hit his wife as well; she started to weep.

    Today I had the same sort of oh, shit feeling in my gut. A patient of mine whom I had not seen in over a year came in for a follow up of her COPD (emphysema) and weight loss - she had not been eating well and had lost twenty pounds in the preceding 17 months. (I don't think she has cancer, I think she just isn't eating.) Partway through the visit her watchful daughter raised the issue of memory loss. I didn't have time to do the full MMSE but knew I could interpose a few questions in the course of the exam.

    "What year is this?" I asked.

    ...long, blank pause... OH SHIT I thought, feeling my heart sink. She was able to name the month and season, and the day of the week, but not the date or the year.

    Then I asked her to remember three words and repeat them back to me. This is a test for short-term memory. The three words I always use are honesty, tree and chocolate. There is nothing magic about these words; I use them because they are not related to each other (i.e., no two are food items, character traits or plants) and because a neurologist once told me that one of the three words I use should always be something intangible. "If one of the words is something they can't visualize, that's the one they'll forget first if something is wrong," he said. I have no data or study results to know if this is correct, but ever since that day one of the words in my MMSE test has been some sort of intangible personality trait.

    At any rate, she was able to repeat the words back to me immediately, but when I returned to the subject a few minutes later she was unable to repeat any of the three words (this after I had explained to her that I would ask her again in a few minutes what the words were).

    OOoookay, we have a problem, I thought, realizing that the patient's daughter was weeping just like the other patient's spouse of long ago. Given this patient's weight loss, withdrawal and malnutrition, however, there were any number of other explanations for her symptoms: depression (I think somewhat unlikely, but possible), paradoxical hyperthyroidism, hypothyroidism, diabetes, B12 and/or folate deficiency, subacute syphilis (the most unlikely of all, but we still test for it). I explained all this to the daughter.

    The tests are cooking as we speak. I await the results.

    Oh, and what do you do for the "worried well" patient who is convinced that they have a memory problem? I once asked a neurologist this and have used her advice ever since.

    Give the patient a MMSE exam, show them their perfect results. Reassure them that they do not have dementia. Repeat as needed (and you can throw in a B12 and TSH just for the hell of it).


    Monday, December 03, 2007
    You Want Me To Write You a Letter of Recommendation?

    My office is losing one of its best receptionists this week; she's moving back East to help out with some family issues. It's always sad when somebody who's reliable and knows what they're doing moves on. I truly want to yell, "What are we going to do without you??"

    Jane, as I shall call her, asked me to write her a letter of recommendation and I was happy to do it. She's been the head receptionist in our after-hours clinic (which I manage) for years and I have relied on her many times to let me know when things aren't working right. This is especially important given that most of the clinic docs are residents and don't always have the hang of how things work in the outpatient setting. (They can diagnose and treat, it's arranging aftercare that stumps them.)

    Anyway. I drafted a glowing letter of recommendation and gave it to Jane to review. She took one look at it and shrieked with laughter, due to the postscript I had added at the last second:

    P.S. -- Jane eats live babies, so I would not suggest that she work in Pediatrics.

    Needless to say the postscript was omitted from the final letter, but I could not resist the opportunity to get a rise out of her.


    Sunday, December 02, 2007
    Spies on the Radio

    Clicking around on Wikipedia this weekend, I came across an article about numbers stations which I found fascinating. Turns out there are several websites, and even a Yahoo! group, devoted to this phenomenon.

    Numbers stations are stations on the shortwave radio band which broadcast transmissions consisting of nothing but strings of numbers being read aloud. They first appeared on radio bands as far back as World War I, were at their highest activity during the Cold War, and have decreased in number since then. The generally held theory is that the numbers stations are used for espionage. Transmissions may also contain tones or data bursts. The transmissions may begin with music, or a set phrase to alert the listener that data transmission is about to begin. The numbers may then be decoded with one-time-use code pads, which have also been around for many years (the one-time pad was patented in 1919). This is all very low-tech, but it's reliable and it works. Interestingly, it's rare that other governments make any attempt to "jam" the stations, though it has been known to happen.

    One of the best known numbers stations is the "Lincolnshire Poacher," so-called because the station uses snippets of music from a folk song by that name as an interval signal. It is thought to be operated in Cyprus by MI6, the British secret intelligence service. There is also a station that transmits messages using the phonic alphabet instead of numbers (i.e., Charlie Foxtrot Tango... etc.), which is thought to be Israeli and run by the Mossad. And there's one located in the New Mexico desert near Albuquerque, which is probably military. This station is known as "Yosemite Sam" because, oddly, the transmissions always end with a clip of the cartoon character Yosemite Sam shouting "Varmint, I'm gonna blow you to smithereens!"

    If you're interested in hearing what the transmissions sound like, many of the links above have audio clips you can download; and for further reading there's an article from Wired magazine here which is quite good. Finally, if you just can't get enough of numbers stations there are even recordings for sale at this site, as well as a T shirt.

    UPDATE: I found a very odd series of stories here about phone numbers, advertised on Craigslist, being used as numbers stations; fortunately it turned out to be a hacker prank. Oh, and Salon Magazine did an article about numbers stations several years ago; it's here.

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    Saturday, December 01, 2007
    Just in Time for The Holidays...

    Yes, once again it's Ugly Christmas Lights.Com. Click and cringe.