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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    Monday, April 18, 2011
    Weekend Off

    This past weekend was my first weekend off in, I calculated, five weeks. Factor in the ACP meeting in San Diego, two weekends in Guatemala and a weekend on call and you will understand why I did a faceplant into my bed Friday night and spent the weekend doing as little as possible. It felt goooood. I did a little cleaning, a little writing (a very little), some office scutwork and began to rewatch Season Five of 24. Man, what a great season that was. Jam packed with great character actors and a star who was generous enough to step back and give Gregory Itzin and Jean Smart breathing room to do what they do best. They stole the show out from under him (and I mean that in the very best way). Part of the problem with the three seasons that followed is that the writers fell back on the Jack Bauer character to do most of the heavy lifting, instead of trusting the other characters and storylines more. Seasons Six, Seven and Eight were not nearly as good. I guess lightning only strikes once.

    This week I'm covering for the medical director and I really don't think I want to do this again. In the past it's been a formality with not much for me to do, but this time the administrative second-in-command has also been out and I am getting snowed with vacation requests and patient complaints to review. Unlike the guys who usually do this job, I don't have any administrative time built into my schedule to handle this stuff. At least it's only for a week.

    Office drama: the Old Doc who moved into my office two years ago had a blowup with his secretary last week and she has cleared out. This means he's now on his third secretary. (The other two were extremely competent, IMHO; he's just an exasperating micromanager.) Number Three is a nice young woman who's worked here for a while, but I honestly don't know how long she's going to last. I wish to high heaven that Dr. Oldguy would retire and leave us all alone. However, I don't see that happening any time soon.

    And lastly, a co-worker has been going through some very difficult changes in her personal life (I won't say more except that I feel for her, and it isn't something that's her fault). She has been needing to take some time off to deal with these issues, and that means I've been trying to cover for her as well. So, it's been busy. We'll see how this week goes.

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    Sunday, April 17, 2011

    I've been meaning to post about my experience with raclette for awhile, but as usual have put it off. At least now I can tell you that I have made it several times and have been extremely happy with the result. If you're in an area with chilly weather, this may still be a useful post for you...

    I came across this post on raclette at Tea and Cookies some time ago and was instantly riveted. I had certainly read about raclette, but had always thought of it as the sort of dish you would have to experience in its native land (in this case, Switzerland). Who knew that raclette cheese was so widely available? And doesn't melted cheese and potatoes sound like the most delicious dinner ever?

    So off I went and found myself some raclette (try Trader Joe's or the fancy cheese section of an upscale supermarket). While I was at it I also bought the cornichons, a traditional garnish for raclette, and some baby potatoes. Tara of Tea and Cookies also suggested brussels sprouts as a side, which I think would be excellent. You really do need something pungent and/or spicy as an offset to the smooth, rich, bland combination of melted cheese and potatoes.

    Raclette in its natural state is a somewhat strong-smelling cheese, though not unpleasantly so. Melted it is deliciously mild. The website recommends heating it in a toaster oven, which I think would work great. Not having a toaster oven I used a lidded glass dish and stuck it in at 275-300° while boiling the potatoes.

    I like the look of the little potatoes, but you can also boil regular sized potatoes and cut them up. When done, put the potatoes on plates, throw on a dab of mustard, a spoon of cornichons and divvy up the cheese. I am here to tell you, this is delicious. Best served with white wine, but any beverage will do.


    Tuesday, April 12, 2011
    Somewhere Ayn Rand Is Cackling With Glee

    The film version of Atlas Shrugged is being released this week on April 15. For those of you not in the US, that's Income Tax Day. How absolutely appropriate.

    Apparently the book has been filmed in three parts; this is Part I. I never have read it, but I have read The Fountainhead, which she also wrote, and found it pretty interesting. I'm probably going to go see AS, unless it gets terrible reviews.

    The book has a long history in Hollywood. People have been trying to film it for decades. According to IMdB, there was talk in the 1970's about turning it into a TV miniseries - and Rand wanted Farrah Fawcett to play Dagny Taggart! Who knows, perhaps Fawcett could have pulled it off. I do think Clint Eastwood would have made a great John Galt.


    "My Knee Hurts When I Meditate,"

    said the patient. "I stopped for a while and it got better. But when I started meditating again, the pain came back."

    "What position do you meditate in?"

    "The half-lotus."

    "Ah. You have 'movie theater knee.'"

    "Uh, okay..."

    "It has to do with the patella. The kneecap. When you hold one position for some length of time, like driving or sitting in a movie theater - or meditating - it gets stiff and painful. The good news is, you didn't tear your meniscus or your ACL or any other ligament. I can give you some exercises to try at home. But you might want to try meditating in a different position."

    The patient accepted the exercises. As I wound up the visit I couldn't resist adding, "I bet Buddha had painful knees."

    The patient laughed. "After fifty years of doing this, I bet he did."


    Monday, April 11, 2011
    To Kindle, or Not?

    My roommate on the Guatemala trip had a Kindle. She loves it. I had never considered purchasing one, but after checking hers out I am having serious thoughts about it. She says the battery lasts forever, and that Amazon has a large selection of copyright-free books which cost nothing to download. It's light and takes up very little room. I can see where it would come in really useful while traveling.

    My inner Scrooge McDuck is telling me, "You don't NEED this." And I could certainly get by without it. But it would be a great gadget to have.

    Any thoughts from the audience? Do you have a Nook or Kindle, and if so, what do you think of it?


    Sunday, April 10, 2011
    Home Again, Home Again...

    jiggety jig...

    I was home for all of 60 hours and then packed up for the annual ACP meeting in San Diego. I am now home from that and am happy to report that it was a great meeting. Basically, you sit in lecture halls all day and listen to talks on various aspects of medicine. These talks begin at 7 am and go till about 5 pm, every day, for three days.

    It is less exciting than it sounds. But you learn a lot.

    In an effort to save money on the trip I shared a hotel room with three of my fellow partners from The Firm. (I'm getting quite used to this whole roommate thing by now.) I am sure I bored the hell out of them by mentioning Guatemala's lack of showers, hot water and working toilets every time someone complained about sharing the bathroom.

    Do I have anything else to say about Guatemala? Well. The clean air regulations we have here, they don't have there, and it shows. The air quality is terrible whether you're in or out of the city.

    Guatemala has great buses. In Antigua we went to the crafts market and while wandering around found ourselves in the bus depot. Their buses are all deactivated school buses from the States, shipped down to Central America and treated to bright, eyecatching paint and chrome jobs. Mostly they run shuttles between Guatemala City and Antigua but they run to other towns as well. "I love these buses!" cried one of my fellow internists (who had a lot of experience in third world countries). "Nepal, Guatemala, Peru - it's all the same bus!"

    We went to Antigua for the last two days of the trip, which is traditional for the group. It's always wonderful to get there after a hard week's work but it was doubly so this year, partly because of our no-water ordeal and partly because we got accomodations at the best hotel in the city. It's called Hotel Casa Santo Domingo and, if you ever get to Antigua, I highly recommend it. Breakfast was included and was outstanding: The best breakfast buffet I have ever been to. They had custom made omelets, fantastic homemade tortillas and pupusas, delicious fruit and great beans and rice. I am all about the beans and rice.

    So now I'm home and making lentil soup. I posted about lentil soup previously, but I'm going to do it again because I have found a better recipe, courtesy of Nigel Slater. To make it, first, you need better lentils than the standard brown grocery store lentils (although they will do in a pinch). I highly recommend ethnic markets for cheap, good quality, fine green lentils. If you're in Los Angeles, Pico Boulevard has a stretch heavily populated with Israeli markets which are a great source for lentils, barley and dried beans. So you've got the lentils. Chop and saute some onion, celery and mushrooms and throw in a chopped garlic clove. Sort, wash and add the lentils once the vegetables are soft. Cover with chicken broth and bring to a boil. Add a splash of Worcestershire. Once the soup is on its way, wash, chop and add some baby broccoli and let cook until done - I usually give it 45 minutes to an hour. It is SO GOOD and is even better the next day. This recipe is cheap, delicious and good for you and makes a lot. It lasts me a week for work lunches.

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    Monday, April 04, 2011
    Life In Guatemala

    I walked in the back door of my house at 1:30 this morning, having left ten days previously. The Friday night of week before last I caught a shuttle to LAX, destination Guatemala City. I last went on this sort of trip four years previously and it had taken a little time for me to nerve myself to do it again.

    Our destination was a town in Guatemala called San Cristobal. I don't know exactly where it is, as I never saw a map. All I can tell you is that it is not the Mixco suburb of Guatemala City; it is about four and a half hours away from the airport by bus. San Cristobal is home to an actual hospital, built in a fit of generosity by the United States government in 1962 back when they were making the world safe for democracy. Sadly, most of it has stood empty as the local government has neither the money nor locally educated providers to staff it.

    I loved the building as soon as we walked in; I am old enough to remember the classic 1950's sort of hospital with green walls, linoleum floors and tile, and engraved plastic placards mounted over the door to tell you where you were. (e.g., "Emergencias.") This building was exactly like that. Hello, Dr. Ben Casey!

    The organization I worked with, HELPS International, emphasizes surgery on these trips. The surgeons (Plastics, ENT, OB/GYN, General) do much more good than we primary care MD's or GP's can do. If you are looking for a cause to support, I can highly recommend them. Despite the relative luxury of having an actual hospital to operate in, this was our toughest year yet - as I was told by several old hands who have been on many more trips than I have. Allow me to demonstrate.

    • A serious water shortage to the point that we were not allowed to flush the toilets or bathe. We were driven to use the bottled water (intended for drinking) to sterilize instruments in the autoclave before the water truck finally showed up.

    • Random power outages.

    • The hospital was host to a local Peds ward and emergency clinic. This meant that we were regularly woken by crying babies in the middle of the night. Let me tell you, those babies can raise the dead at that hour.

    • Our first night there we had a sobering experience: a hospital employee dropped dead of cardiac arrest. The locals threw him into an ambulance and rushed the poor guy into the ward in a wheelchair... I caught a glimpse as he was rushed past and instantly thought that he looked dead. The surgeons did CPR on him and got a pulse back, but he coded again in the ambulance and was DOA at the local "real" hospital. It turned out that he had a history of diabetes and had had a pacemaker placed three months before. In addition, he had been hospitalized the previous week for pulmonary edema.

    • A thyroidectomy patient who couldn't be extubated and needed MedEvac to Guatemala City.

    • This is a minor point, but our chef's skills were off. We were treated to undercooked bean soup, "vegetable lasagna" (veg cooked in tomato sauce without noodles. It would have been fine if they had explained that before we sat down to eat) and cold canned pea salad with mayo, cheese and chopped onion. I will pass over this chapter of the trip without comment.

    All that said, the camaraderie among the staff was outstanding; this is why people return year after year. I shared a dorm with five other women, mostly internists and one pediatrician. We chatted every night about spouses, medicine, the day's patients and everything else you could imagine. We got laughs out of the smallest of things. For instance, in most parts of Guatemala you can't drop used toilet paper into the toilet - the plumbing can't take it. You have to throw it into the trashcan. A couple days into our stay, one of my roommates glanced at the overflowing toilet bin and commented acidly, "I see maid service didn't come today." It sounds like a small thing, but we laughed like maniacs. We slept on cots I firmly believe were designed for Satan's Army - even our inflatable air mattresses didn't really help. After a full day of work they were comfortable to start with, but by the end of the night we were tossing and turning with every muscle in our torsos protesting.

    After the first rush of presurgical clearances was finished we clinicians were subject to, as one of my roommates termed it, "the bullshit parade." Duele todos in corpo soon became the last phrase any of us wanted to hear. Not to mention dolor in cabeza or back or foot pain. Our pediatrician announced one day at lunch, "I saw this lovely baby today, she was really kind of fat. Her mother told me she wasn't eating and hadn't eaten for a month. I'm looking at this Buddha baby and just said to the mother, "I don't believe you." (Not eating is apparently a favorite complaint among Guatemalan mothers.)

    I came up with a haiku one day, in a haze of clinic induced fatigue: Feet hurt all the time/Headache, neck ache and back ache/Gastritis, she says

    Next installment later... I have to get some sleep.

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