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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    Tuesday, September 30, 2003
    MRI: Never Again

    Well, I had an MRI yesterday and there is indeed a fracture. For you docs out there, the radius is fine but the capitellum (the tip of the humerus, or upper arm bone) is fractured. I have also apparently torn the ulnar and medial collateral ligaments (ulnar completely, medial partially). Put another way, I screwed up my elbow big time.

    I see the orthopedist tomorrow; we'll see what he makes of this.

    I had never had an MRI before yesterday; since I'm fortunate enough not to suffer from claustrophobia, I thought it would be no big deal. Wrong, wrong, wrong. To fit my bulky splinted arm in the MRI tunnel, they had to strap it above my head. They then proceeded to take twice the usual number of pictures (because, the tech later explained, the radiologist wanted details of the humerus as well as the radius). Imagine having your arm strapped above your head, bent at the elbow, for 35 minutes and not being able to move... it was excruciating. By the end, I was doing yoga breathing, the Jesus prayer, counting the seconds and begging the tech please for the love of God to let me out, and I'm not exaggerating.

    I hope that I will not need surgery or to be casted for very long, but I'm not sure what to expect since ortho is not my strong point. (Thanks, Allen, for your input!) More updates tomorrow.

    To leave you on a more cheerful note, check out this amusing website put up by Alaska Airlines. It's the airline from hell! I especially enjoyed their Global Baggage Tracker - check it out.

    Monday, September 29, 2003
    Dr. Alice Copes With Adversity

    Good news: this website has broken the ten-thousand visitors' mark in just under a year (Feet First's birthday is Thursday).

    Bad news: I've broken my arm. I think. I'm sitting here with my arm in a splint, typing one-handed. I tripped and fell yesterday with my arm out in front of me -- fortunately for me, it was my left arm (I'm right-handed). The ER doc, a charming gentleman whom I actually used to work with in a previous job, peered at the X-rays and said he thought it was an occult fracture of the radial head, just below the elbow. Since it really wasn't showing up on the films, this means I will have to get an MRI to verify.

    More later...

    Saturday, September 27, 2003
    Life Stories

    When you're on staff at a hospital, one of the things you occasionally get asked to do is to "proctor" physicians who are applying to the hospital for staff membership. This generally involves reviewing a sample of their case notes and history and physical writeups. The goal of this assessment is to make sure that the physician is capable of evaluating a patient, to see whether he or she orders appropriate tests and uses the medical data to create a logical treatment plan.

    Recently I was asked to proctor an internist who works for the hospital's hospice program; since the goals of hospice care are (obviously) different from the usual treatment plan, I reviewed his hospice assessment notes instead of history and physicals. In this case, the doctor was evaluating patients who had already been admitted to the hospital to assess whether they were candidates for comfort care as opposed to aggressive treatment.

    So I started reading the notes. At first, I read rather by rote - diagnosis? is the med list there? the medical history, assessment, plan? All were there, yes, this guy knows what he's doing. Then the drama of these stories started to grip me: a person's entire life, encapsulated on one page. What is this person's profession? Does he/she have any family, and is the family involved in their care? What is their disease?

    And the big question in the back of my mind as I read: is this person still alive? Maybe, maybe not: the most recent of the notes was dated three months back.

    Not all hospice patients have dramatic diseases like cancer, I'm glad to say. I say this because I think hospice should be considered for patients other than those with imminently terminal diseases. Take this gentleman, for instance:

    A 92-year-old man with generalized debility, weight loss, and declining function generally. He has chronic back pain due to disc disease and just doesn't want aggressive medical therapy anymore. Social history is telling - "daughters in conflict about care." No major findings on physical exam.

    This doctor didn't change much about this man's treatment regimen except for stopping one of his medications, but the notes indicate that he spent more than half an hour counseling the patient's daughter about what she could expect toward the end of her father's life and answering her questions. That thirty-minute investment was probably exactly what was needed in this case; I hope it helped.

    Then there was the case I couldn't stop thinking about.

    Patient Age: 36 (36?? Holy shit!)
    Chief Complaint: Metastatic Breast Cancer

    This patient had recently undergone a last-ditch effort to treat her with chemotherapy, but she couldn't tolerate the side effects.

    Social History: 4 children. Spanish speaking only. Family member acting as translator.

    She was diagnosed with the cancer while she was pregnant. The notes indicate that she is withdrawn, depressed and worried about her kids, the youngest of whom is only one year old.

    Treatment: counseling, work on treating her symptoms, get the social worker involved to help the family... there's not too much that can be done. I keep thinking about this woman and her family: that interview was six months ago and I don't know whether she's still alive.

    Friday, September 26, 2003
    Poetic Justice

    I know you're probably getting bored with this, but here's a little more on the telemarketing brouhaha:

    Supporters of the [telemarketing bill] had barely begun to celebrate an overwhelming vote Thursday in Congress to counter a federal court ruling when they learned that another judge had blocked the list from taking effect next week.

    "It puts a little damper on the party," said Ken Johnson, spokesman for Rep. Billy Tauzin, R-La., chairman of the House Energy and Commerce Committee. "But we're still confident of prevailing in the end."

    Tauzin led an effort in the House to pass a bill making clear that the Federal Trade Commission has the authority to enforce the do-not-call registry. The legislation was prompted by a ruling Tuesday by U.S. District Court Judge Lee R. West in Oklahoma City that said the FTC lacked the power to create and operate the registry.

    But late in the day, U.S. District Judge Edward W. Nottingham in Denver blocked the list, handing another victory to telemarketers who argued the national registry will devastate their industry and lead to the loss of thousands of jobs.

    Nottingham said the do-not-call list was unconstitutional under the First Amendment because it does not apply equally to all kinds of speech, blocking commercial telemarketing calls but not calls from charities. "The FTC has chosen to entangle itself too much in the consumer's decision by manipulating consumer choice," Nottingham wrote.

    The list, which would block an estimated 80 percent of telemarketing calls, is supposed to be effective Wednesday, but it's unclear whether legal issues will be settled by then. Even after Bush signs the legislation, the FTC must win in court for the list to move forward.

    West rejected an FTC request to delay his order, saying the agency offered no additional evidence that would make him change his mind. The FTC immediately appealed to the 10th U.S. Circuit Court of Appeals in Denver.

    While it was unclear how West's order would affect the FTC's plans, the second ruling more directly prohibits the government from enforcing the do-not-call list. The constitutional issues raised also may not be solved as easily.

    Since issuing the ruling, West's home and office have been bombarded with calls from angry consumers. His numbers were posted on the Internet and people were encouraged to call.

    Late Thursday, Nottingham's phone numbers began to surface online as well.

    That'll teach 'em.

    Thursday, September 25, 2003
    The Empire Strikes Back

    From Yahoo! today:

    House Votes to Launch Do-Not-Call List

    The House approved legislation Thursday aimed at ensuring the national "do-not-call" list goes into effect as scheduled next week to help consumers block unwanted telemarketing sales pitches.

    The House voted 412-8 after less than hour of debate. Lawmakers from both parties blasted a decision by U.S. District Judge Lee R. West, who ruled Tuesday that the Federal Trade Commission lacked authority to create and operate the registry.

    Will the telemarketers get it now? We hate you so much that our elected representatives couldn't move fast enough to enact legislation to stop you! They knew what would happen to them if they didn't do something -- and we're not talking getting voted out of office; we're talking evisceration and burning at the stake.

    Wednesday, September 24, 2003
    What the Hell Were They Thinking?

    I just found this article on Yahoo!:

    Court Rules Against Do-Not-Call Registry

    A federal judge has ruled that the Federal Trade Commission overstepped its authority in creating the national "do-not-call" list against telemarketers.

    The ruling Tuesday came in a lawsuit brought by telemarketers who challenged the list of 50 million people who said they do not want to receive business solicitation calls. The list was to go into effect Oct. 1.

    Here's my favorite quote:

    Direct Marketing Association Inc., one of the plaintiffs, said it was happy with the ruling, even though it "acknowledges the wishes of millions of U.S. consumers who have expressed their preferences not to receive telephone-marketing solicitations � as evidenced by the millions of phone numbers registered on the FTC list."

    In other words, Screw you, consumers.

    The court found that the FTC did not have the authority to institute such a list, but the article doesn't explain why. I wonder if Instapundit will have a legal explanation... nope, nothing yet. I'm sure though that either he will, or he'll link to someone who does. I'd love to see the court's logic on this one.

    Peace and Quiet

    Well, yesterday was interesting. The telephone lines and computer system went down midmorning and stayed off until 5 pm. Whatever went wrong affected the whole building, not just our phone lines; every office had the same problem. (I bet some fumble-fingered janitor hit the main phone line while cleaning in the basement.)

    To be honest, I was overjoyed. No distractions! It was one of the most productive workdays I've ever had. I was able to make a few outgoing calls using either my cell phone or the emergency phone lines in the office (which use a separate circuit). I scoffed when the emergency phones were first put in - they are red and look like the Batphone - but I must admit installing them was a great idea; this is the second time we've had to use them.

    Today will be hell, but it was worth it.

    In other news, I have a book to recommend. (I rarely recommend books to other people, so pay attention!) It's called The Cunning Man, by a writer and former actor named Robertson Davies - actually the late Robertson Davies; this was his last book. I actually came across it at a nursing home as I was waiting in the day room for the staff to bring out a patient: I picked it off the shelf which functions as their library, could not stop reading it, and took it home with me. That reminds me, I have to return it.

    The Cunning Man impressed me to the point that I'm going to track down Davies' other books. As to what it's about, it surprised me by seeming to start as a mystery novel and then turning into something much less straightforward. You could call this book part fictionalized history of Toronto, part memoir, and part mystery. It begins with the narrator, Dr. Jonathan Hullah, remembering the death of an Episcopalian priest who dropped dead during Mass on Good Friday many years before, but that turned out to be only a small part of the book.

    The medical descriptions are fascinating. Hullah practices as a holistic physician and earns the title "The Cunning Man" for himself (this is an old English village term for the local wise man who could work cures). Long story short, get the book. It's a leisurely read, but it never gets boring.

    Friday, September 19, 2003
    Sort of Pirate Related

    For you armchair travelers out there, I found a nice site called Islands.com. I particularly liked the description of the Whitsunday Islands, which turn out to be off the coast of Australia near the Great Barrier Reef. The diving looks spectacular. No information on buried treasure is provided, however.

    And now I'm off; see you next week, ye scurvy dogs.

    Ahoy, Me Hearties....

    It be Talk Like a Pirate Day, and Cap'n Sawbones had to pick today to be down in the bunk with a sinus infection. arrrr. But all is not lost, they say the ocean spray be a powerful reliever of blocked sinuses. (Okay, it's actually saline solution.)

    Yer cap'n be off to landlocked Palm Springs for a company retreat - wait, do pirates have retreats? Why not? Every profession needs to get together once in awhile and swap sea stories, learn to be more efficient plunderers, and so forth.

    Anyway, sorry about the light blogging this week and I hope to have better things next week. Now it's back to the Augmentin and the Sudafed.

    Wednesday, September 17, 2003
    Dipshit Day

    Yesterday on my first day back every dipshit in my practice decided either to show up or call me. Either way, it was their mission to make my life miserable and they succeeded. Ah, medicine... tell me again why I decided to commit to you, you cruel bitch of a higher calling.

    However. Let's get past my personal issues and review The Wedding, shall we? For me the best part was where we stayed. The wedding was in Vermont, where the bride spent a large part of her childhood; very beautiful, but it meant that everyone in my family who attended had to travel cross-country. My mother had the forethought to rent a house for us instead of making hotel reservations, and there were ten of us there - seven adults and three kids (five, three and one year of age). The adults were me, my parents, my sister and her husband, and her husband's parents (who came along to help with the kids and because my niece and nephew were a flower girl and ring bearer, respectively). Breakfast became a luxury - coffee and conversation! I'm so used to living alone that I didn't realize how much I've missed meals with other people. I told my mother that it felt just like the Waltons, but she was not amused by my comparison.

    The weekend was straight out of the Preppy Handbook, if you remember that. At the barbecue Thursday night that kicked off the festivities, there were men wearing blazers over aloha shirts. (Yes, people really do dress like that!) The reception was at the local country club, founded over 100 years ago. All the bridesmaids were slim, attractive and athletic... except me. I never do well at these things; I never feel that I know the proper bridal etiquette, that I'm not feminine enough, etc. Nevertheless, I made it through in one piece and it really was a lovely service. The reception was great, too.

    Now, back to regular posts as soon as I get a chance; I now have my Boards recertification coming up in six weeks.

    Tuesday, September 16, 2003
    I'm Back

    Yep, we got the kid married off. Came back to find piles of charts and messages from patients screaming "Help me!" - so I gotta go. Will post more later.

    Sunday, September 07, 2003
    People Who Need Serious Help

    What with the upcoming wedding (my brother's), I've been a tad frayed at the seams. I leave Wednesday, incidentally, so no blogging for about a week. Lately, though, I've run across a couple of articles that have restored my faith in myself. As an act of humanity, I'm going to share them with you:

    1. The Disneyland Zombie Fan Army
    Now, I grew up near Anaheim in Southern California, I've been going to Disneyland since I was two or three (that would be the late sixties), and I remember The Way It Used To Be. I like to go about once a year. In short, I am a fan of Disneyland - but I've never seen anything like this. Opening lines of the article:

    Benji Breitbart doesn�t go to Disneyland every day.

    �I wasn�t here last Thursday,� he says as we walk down Main Street. �I usually come six days a week.�

    2. The Man Who Kept a Pony In His Bathroom

    A Danish man who was inspired by a children's fantasy movie about a pony which lives in a flat has incurred the wrath of his neighbours - after attempting to copy the film.

    Police say they were stunned to find a Shetland pony in Palle Brinch's apartment after his neighbours alerted authorities about a "rumbling ceiling and a manure-like stench".

    There's not much you can add to that, really...

    Friday, September 05, 2003
    Weekend Surfing

    Check out McSweeney's list of lists; I ran across this today and it's addictive. Specific recommendations would include this one, this one and this one, but don't stop there.

    For crafting taken to its illogical extreme, check out this article at GetCrafty. If any of you ever catches me decoupaging labels from bean cans onto notebooks, journals or anything else, feel free to have me committed involuntarily.

    Have a good weekend, me hearties.

    Hurricane Who?

    I certainly hope that everybody on Bermuda gets through Hurricane Fabian in one piece, but my first reaction when I heard the name of the storm was: when do we get Hurricane Tab Hunter?

    Public Announcement

    Good Lord, they've changed the Blogger setup again. I wish they'd make their minds up.

    I just tried to sign into Blogger and it signed me into somebody else's blog. Let's see what else goes wrong today... still, it's free. You can't beat free.

    And For Gary Coleman, It's a Taquito

    Got this out of Newsweek this morning: Taco Bell is running an "in-store gubernatorial Taco Poll" in California.

    A crunchy beef taco counts as one vote for Arnold Schwarzenegger, and a soft chicken taco counts for not recalling Governor Gray Davis. If customers want Lt. Governor Cruz Bustamante, they should order a chalupa.

    My sources tell me that a chalupa is "sort of a combination" of the above.

    Thursday, September 04, 2003
    Ahoy There, Ye Landlubbers!

    Talk Like a Pirate Day is on the horizon! Start practicin', ye useless sons of barnacles, or ye'll be lickin' me fish-gut-covered boots!

    (Can you tell I'm really into this?)

    Dave Barry has done his bit for this valuable national holiday by supplying some hints and tips for talking like a pirate. (My favorite: "Turn your head and cough, me hearties!") Go there or get a taste of the rope's end! Arrr!

    Tuesday, September 02, 2003
    Bridget Jones Don't Get No Respect: A Literary Critique

    I recently ran across this rant against chick lit, and though this sort of thing usually doesn't stir my blood enough to respond, I found myself roused to action for once. Let's begin with the money quote:

    The doyen of chick lit, the Brit �migr� currently ensconced in LA enjoying all things razzle and dazzle, Helen Fielding herself, the Darth Vader of Chick Lit - she responsible for B****** J**** (I�m sorry, I can�t bring myself to say the words - it�s like actors and Macbeth - Fielding and her scatty heroine are the benchmark for all that is horrible in the world of books) - she has a new book coming out. [snip] Speculation is mounting as to whether she has written a �James Bond in tights . . .� I believe Charlie Brown put it best when he said �Good Grief . . .� Picador are paying Fielding seven figures for this stuff. What a world . . .

    Now, apart from the fact that this guy is way too fond of ellipses, I have several objections to his comments.

    1. Since when is it illegal for a Brit (or anybody else) to move to L.A. if they strike it rich? I live in L.A., thank you very much, and I sure as hell would rather live here than in England. Nothing against England, but it's incontestable that we have better weather, for one thing. If Ms. Fielding decides to pull up stakes for a bit, who are we to quibble? And what does this have to do with her writing ability?

    2. "Fielding and her scatty heroine are the benchmark for all that is horrible in the world of books." Come again? Look, I'm the first to admit that Bridget Jones is not exactly Shakespeare, but I found it an enjoyable read. I would even argue that "chick lit" as a whole -- my, you can almost hear the sneer in this guy's voice, can't you? -- is a not unworthy genre. People like to read about themselves. Single women like to read about single women. If the writing is good enough, lots of other people will like to read about single women, too. I realize this will probably mark me as a intellectual lightweight, but I've tried your Serious Literature, and you can keep it.

    3. The writer of the comments above is a guy. Big surprise.

    4. I've been trying to track down the exact source of this quote, and I can't, but somewhere in Jane Austen's oeuvre is the following ladylike rant:

    "'Oh, it is only a novel!' says the young lady, tossing it aside; 'It is only Camilla, or Pamela'" - and then comes something to the effect of how tired the narrator (Ms. Austen) is of hearing novels demeaned and "serious writing," such as essays or scientific writings, extolled. I think Jane knew quite well what it was like to be pigeonholed as a "chick lit" writer in her day. It's especially ironic when you remember that Bridget Jones's Diary was based on Pride and Prejudice.


    Blogging will be light for awhile, as I have a wedding coming up (my brother's getting married next week) and the Boards are looming over my head with two months to go.

    I spent this weekend studying, shopping for clothes for the rehearsal dinner and seeing nursing home patients - fun, no?

    I do have a few minor events to tell you about. Last week, on my half-day, I was looking forward to a quiet afternoon of phone calls and leaving early. However, fate intervened in the form of an elderly, demented patient of mine who had come in to see our dermatologist; I had seen her for a routine visit at the nursing home the week before and noted an early skin cancer on her right cheek. In came the secretary, Barbara (a.k.a. She Who Must Be Obeyed), thundering, "Why'd those nursing home people drop off that patient without anyone to watch her? She's in the waiting room throwing up and she's about the color of that wall." [i.e., stark white]

    I dashed off down the hall to find the patient indeed diaphoretic, cool, BP 80/50 and vomiting. My best guess is that she got syncopal strapped in the wheelchair, fainted, and threw up. I was afraid she had aspirated (choked), so as soon as the dermatologist had removed the skin cancer (holding her nose all the while), we took her over to the emergency room across the street. Since our hospitalist was tied up with a bunch of other admissions, I finished her exam and took care of the admission orders and history and physical - I took her off the hands of the ER docs as well, since she was basically just sitting there being monitored and waiting for a bed. And that, kiddies, is how I spent my "afternoon off."

    In other, vaguely related news, I noticed this article on Yahoo! today:

    Future Doctors Favor Lifestyle Over Money

    An increasing number of medical students are picking their specialty based on the lifestyle it permits, including more time to spend with family, rather than such traditional factors as pay and prestige, according to a study published on Tuesday in the Journal of the American Medical Association.

    The finding points to potential shortages of doctors in specialties such as family practice, surgery, and obstetrics as medical students shun fields where they are required to be on-call during many off hours, the report said.

    "We're going to have person-power shortages in the next 10 years in critical areas. Where are the primary care doctors going to come from?" said Rutecki, a physician and professor at Northwestern University.

    Where indeed? Why go into a field where you have to spend a lot of time away from your family, get called out in the middle of the night, and don't get paid for your time? In some ways I think this is a good thing as it indicates a healthier attitude toward work and the value of the family... but it may leave the patients up the creek.