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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    Wednesday, October 29, 2003

    On a lighter note, check out Dilbert today on the subject of cholesterol. Made me grin.

    And as I was going through board review questions last night, I found a case history giving the patient's name as "Dil Cubicle." I guess somebody at MedStudy has a sense of humor.

    Tuesday, October 28, 2003

    Today I was seeing a patient with a lot of complaints - bowel problems, irregular menses, trouble sleeping - and she said that she was sure stress had a lot to do with it. I asked was she under particularly severe stress, and she said yes.

    What was the stress? I asked.

    A friend had recently died, her boyfriend had walked out on her, and then - dear God, I don't want to write this - she told me that her sister's abusive boyfriend had attacked her two small children with a knife. My patient said her niece was dead, and her two-month-old nephew had been stabbed in seven places but would survive. He had required reconstructive surgery on his arm.

    What do you say when someone tells you something like that? Besides "I hope the bastard rots in hell," I mean.

    I tried to take more time than usual, talked her through things, and told her to call me if she was getting worse or needed any help. I hope it gave her some relief to talk to me.

    E-Mail Trouble: A Cautionary Tale

    Herewith the transcript of an actual email from last week. Heed the warning.

    First, perhaps I should explain that my friend V. and I have a habit of emailing each other back and forth at work. One of our favorite things to do is to take one of the mass administrative emails that we're sent every day, alter it in some disrespectful fashion, and forward it on to each other. It's our act of revenge upon these useless announcements that pad our computer memories like foam packing peanuts.

    Original email:

    Please join us at a farewell reception for
    Sr. Vice President, [generic administrative title]
    on Tuesday, October 21

    etc., etc.

    I appended the following comment:

    Will there be food and booze? If not, forget it!

    and forwarded it on to V. At least, that's what I thought I did. Until I received the following response:

    Uh, no.

    I then looked at the address in the heading and realized that instead of forwarding it, I had hit Reply and sent it right back to the exchange administrator!

    I did the only sensible thing: looked her up in the Microsoft Outlook directory program, called her, and apologized. Fast. She was quite understanding about the whole thing: "We occasionally get these. I usually just send a little message back so that people know they went to the wrong place."

    "It was a joke, I swear. Just a joke," I explained about four times. I could tell she was amused about catching a doctor stooping to this sort of immature behavior.

    But the story's not finished: I sent the whole thing on to V. with this explanation:

    I'm an ass. I called to apologize, fortunately she was very nice about it. I meant to send it to YOU.

    And got this back:

    Hey, you made me laugh out loud. Not bad for a post-call Monday!

    Monday, October 27, 2003
    The Mystery of the Disappearing Calcium

    Sorry, again; busy again. I spent the weekend studying and freaking out about the fires, the Boards, then the fires, then the Boards... ad infinitum. I actually was looking forward to Monday and the discipline of work, hoping it would get my mind back on its tracks.

    We shall see.

    Presented here is a post from Paula, an internist like myself; it's all about her experience of acute hypocalcemia and tetany during a colonoscopy. It's very well written and I'd like to take this opportunity to recommend her blog in toto, but the other reason I'm linking to it is that thanks to this post I finally understand calcium metabolism.

    Briefly, Paula is a vegan (at least, she was for a while. I don't know if she still is after this experience) who went for a colonoscopy as a regular screening procedure. Prior to this sort of test, you must ingest a "colon cleanser" (read: extremely powerful laxative) so that the MD can see what he/she is doing and whether there are any lesions in the colon. Most colon cleansers are heavy on the phosphate. Phosphate binds with calcium and precipitates it out of the bloodstream. If you have normal calcium levels, this is not a problem - but if you are vegan, meaning you don't eat dairy, and you work from dawn to dusk and never see the sun (and therefore don't have any Vitamin D in your system), you wind up with osteomalacia or "adult rickets." And then, after ingesting lots of phosphate in the colon cleanser, your calcium goes into the basement and you get tetany or cramps and spasms all over your body.

    Thanks, Paula. I get it now.

    Thursday, October 23, 2003
    Poison Hangman??

    So I have this patient who may have cognitive dysfunction due to a toxic exposure of some sort, and I went on the Web to search for info about poison control centers so that I could talk to someone about this problem and get more information about testing and treating her.

    What do I find?

    Poison Hangman!

    Yep, that's their idea of educating the public. Quote: "Don't forget, all the words are poison related!" Which is a total lie, by the way, because the first word I got was "failure." (Yes, I played it, and I got the first word in under thirty seconds. I rock.) Will somebody tell me how the concept of failure relates to poisoning? Mommy failed to keep the toilet cleaner away from the baby? The ipecac failed to do its job? I don't know, I'm just asking.

    Monday, October 20, 2003
    Hi, It's Monday

    I've been working on a long post which I've just deleted because I realized it was nothing but a boring, whiny epic. Therefore I will spare you the story of the Demented Patient With Two Dueling Relatives Who's Now a Ward of the Court, But She's Dying, and Can I Make Her a No-Code? She's on Hospice for Crying Out Loud, and the Patient's Attorney and Temporary Custodian Both Say Sure You Can, But We Can't Put It in Writing, and One of the Relatives Has No Freaking Clue and Wants "Everything Done," God Help Us All.


    Boards in three weeks. Bleah.

    Arm is better - I can get my left hand up to my nose again, which is useful if you're trying to blow your nose. I can't brush or style my hair with my left arm yet, though, so my hair continues to look weird - but not as weird as it looked the first week when I had to sleep on my back, because side positions were too uncomfortable. I wound up with the worst case of Bed Head you've ever seen; I thought I was going to get a bald spot on the back of my head just like babies get.

    I can't think of anything else to share at the moment. This blog will probably become more and more incoherent over the next three weeks. Just thought I'd warn you.

    Friday, October 17, 2003
    Urgent Dave Barry Update

    There's a whole string of posts at Dave's blog linking to real estate salespeople with names that could possibly be construed to have a crude double meaning. (It started with Gaye Males and just snowballed from there.) It's funnier than it sounds; after looking at six of these in a row, you start snickering helplessly.

    At least, you do if you're me.

    Thursday, October 16, 2003
    "I'm Sure Everyone Who Made This Game [Space Invaders] Is Dead by Now"

    This is a great article from Electronic Gaming Monthly about the reactions of a group of 9- to 12-year-olds to some classic early electronic/arcade games. Wait'll you see what they have to say about Pong.

    (via Ernie)

    You Learn Something New Every Day

    "I thought I knew every expression existing in the French language for self-gratification, including the crudest ones known to man."

    (via Dave Barry, who is celebrating the Marlins' win by coming up with anagrams of the name of their pitcher Tim Spooneybarger)

    The Life You Save May Be Your Own - Or Your Mom's

    MedicMom has a great post you ought to read, especially if you have health problems or have an elderly friend/neighbor/family member who may need to call 911 some day.

    Check your house and mailbox today and make sure your house number is clearly visible from the street. It makes things much easier for the paramedics when they're trying to locate the person who made the call.

    (via GruntDoc)

    Wednesday, October 15, 2003
    Somebody Give This Poor Woman Some Iron, STAT!

    From the Ananova news service:

    Chinese Woman Eats Dirt

    A 78-year-old Chinese woman has reportedly eaten approximately 10 tons of soil over the past 70 years.

    Hao Fenglan, from Zhangwu county, northern China, began eating mud and dirt at the age of eight.

    She says she feels physical discomfort if she does not eat dirt at least once a day, reports the South China Morning Post.

    The diet has done her little apparent harm and she is in good health.

    This phenomenon is called "pica." It is a symptom of anemia. I'd be willing to bet this woman has been anemic her entire life. I don't even want to think about what her parasite load must be after 65 years of eating dirt in China...

    Tuesday, October 14, 2003
    Patient Complaint of the Day

    "Kicked in chest by horse."

    The patient came in today although the injury happened three days previously. She was still having a lot of pain and wanted to make sure she hadn't fractured anything; I was more concerned about the possibility of cardiac arrhythmia (she'd taken two hooves to the sternum and was thrown across the horse's stable).

    "He didn't mean it," she said. "He's just six months old, he's still a baby!"

    "You sound like Sigfried and Roy: 'He didn't mean it!'" I replied. She grinned.

    Fortunately, nothing was fractured, she didn't have a pneumothorax and she denied any palpitations; her heart exam was normal. I gave her some codeine and sent her out. Happy ending.

    Ralph Nader, Get a Life
    or: Why Hasn't He Protested the Cookie Monster?

    Take a look at this. Then tell me why these people are listened to, or even employed:

    The Public Broadcasting System's Sesame Street has come under attack from a Ralph Nader group demanding that the popular children's show cease airing McDonald's corporate-sponsorship message before and after each program. (emphasis mine)

    So they weren't airing footage of Bert and Ernie feeding each other Big Macs, or Big Bird eating fries... just a typical corporate sponsorship message. Meanwhile, Cookie Monster is stuffing down partially-hydrogenated carbs on a daily basis and this is OK? Where is the outrage?

    Worrisome News from Rarotonga

    A few weeks ago I posted a link to a series of stories in the L.A. Weekly about a couple who moved from Los Angeles to Rarotonga, a small island in the South Pacific, with their two young children (the youngest an infant).

    They're not on that island anymore; they've moved on to New Zealand (the baby got very sick with the flu and needed better medical care). Read these stories in order:




    Sigh. This is why you can't go around the world in 80 days with young children - the risk is too great if they get sick. I think the baby is going to be OK, though.

    Sorry, again, about the light blogging. It's very busy in the office and with the boards coming up in three weeks my contributions will continue to be few and far between. I do have an idea or two for some longer posts and hope to get to them later this week.

    Monday, October 13, 2003
    Google Calculator Function

    Thanks to Richard Winters who points out that you can use Google for lots of things other than web searches - I was not aware of this!

    Saturday, October 11, 2003
    I Really Like the Concept

    The new $20 bill, folks.

    (via Dave Barry - of course)

    Amusing Comic

    This week in Bizarro Dan Piraro has been experimenting with using the same punchline in every comic strip. (These actually appeared about three weeks ago but they are only now becoming available online.)

    The scenario is always the same: at a funeral, two mourners are viewing the body. The quote is: "He/she looks so natural." The only thing that varies is the appearance of the coffin depending on the job of the deceased (the Invisible Man's funeral, magician's assistant's funeral, etc.) At first I thought it was carelessness on the part of either Piraro or his editor, but as the week went on it got funnier and funnier. I don't recall a comic artist doing something like this before. Hope you enjoy.

    Wednesday, October 08, 2003
    Scary News?

    Bookmakers Drop Odds on Arnie Becoming U.S. President

    The article does not quote odds of Mr. Schwartzenegger winding up in the Senate, however.

    Now that Arnold is in Sacramento, I have a great idea for his first project. How about an early morning exercise program, hosted by Arnold, broadcast daily all over the state? Ideally we'd have monitors installed on our TV's to ensure 100% participation (remember the scene in 1984 when Winston Smith gets bawled out by the woman leading the exercise program?)

    In five years there wouldn't be an obese person in the state. I can see it now: "Drop and give me fifty! I mean you, Dr. Alice!"

    Tuesday, October 07, 2003
    "Bloody Sticky Wicket" Indeed

    That was the title of an amusing article in the Wall Street Journal last week (sorry, no link) that caught my eye. The subhead read: "The Urge to Fit In Can Leave Real Britons Chortling." Subject of said article: fake British accents acquired by Americans resident in Britain. (Exhibit A would be Madonna.) It seems that Americans who stay in Britain for a prolonged period of time often wind up either voluntarily or involuntarily developing what is known as a "mid-Atlantic accent" which doesn't please anybody who hears it.

    This quote is what really caught my eye:

    The irony, says Khalid Aziz, a British communications specialist, is that "the British actually quite like American accents and find it quite highly associated with success in business." His company recently completed a survey that found that 47% of British business directors interviewed considered executives with an American accent more successful than those from many British regions. "What we advise Americans to do is not try to give up their American accent but stick with it," he says.

    The moral of the story? It's nothing new: Be yourself.

    Sunday, October 05, 2003
    Forty Wooded Acres and an Old Train Car

    This sounds like exactly the sort of place I'd love to own someday: not too far from the city, not crowded, with its own source of water and a neat relic from the past thrown in. My idea of a "vacation home" is not some condo at the beach. It's somewhere quiet without TV, where you can kick back and relax, and you don't spend a lot of time or money getting there.

    What I enjoy about this series of articles is the down-to-earth stuff like finding and installing a new pump motor for the well, and the GPS survey of the property lines. And cleaning the rat droppings out of the railroad car. (I enjoy reading about it, not doing it.)

    Friday, October 03, 2003
    Cat Town

    Ernie, whom I have never met but I speak of him as if I know him, has a positive genius for finding really, really freaky web sites. To back up this assertion, Exhibit A would be Cat Town. Please do go and view this. It's quite disturbing, not to mention hilarious.

    Thursday, October 02, 2003
    Various and Sundry Items

    Ooh, I just found out how to Googlesmack somebody. Inflicting passive-aggressive insults on one's fellow bloggers sounds like a frighteningly good time to me; I plan to give it a try. The posts above the Googlesmacking post are also eminently worth reading, as they refer to a new chick-lit book called Jemima J which is apparently absolutely horrible, and from the readers' comments on Amazon I believe it. It's a story about an overweight British woman who has no life until - magically! - she goes on a diet, goes to the gym, and loses 80 pounds just like that, at which point life becomes perfect and she gets a sexy new boyfriend! I love to defend chick lit (scroll down for previous post on this subject), but I have nothing to say here: The author should be put in the stocks for this one and pelted with copies of Bridget Jones.

    While on the subject of female writers, apparently somebody is planning to trademark Jane Austen's name for the purpose of selling Jane Austen brand teas and coffees: an odd idea. Yes, yes, it's an insult to our dear Jane to do this, but looking at it from the capitalist point of view it really doesn't make a lot of sense to me. I don't infallibly associate Jane Austen with tea and coffee, do you? I don't see her as a selling point. Maybe it's one of those British things.

    Happy Blogbirthday To Me

    Yep, it's been a year. I am greatly enjoying myself writing Feet First and hope you're enjoying reading it. This week I was thinking how many better blogs than mine there are out there, but reminded myself that there are many worse, too; there's always room for improvement and I hope to get better in the coming year. Also, I have been lucky enough to find some regular readers who have become friends.

    Blogging has already changed the world and I think it will continue to do so. Who knew there were all those talented people all over the world dying to share their lives, opinions and experiences with other people? It's like getting fifty pen pals all at once, and you don't have to pay for postage.

    So here are some links, as my birthday present to you:

    Cartoons: Bizarro

    I love this one-panel comic, written by Dan Piraro. The artwork is outstanding and his ideas are pleasingly off-the-wall. He has a great, detailed website.

    Timewasters: The Lego Treasure Hunt

    Starring Jim the Lego Pirate. Arrr!

    Humor: Dave Barry

    Blogging is the reason Dave Barry was brought into the world, IMHO. This site is hilarious. Where do you think I get all my wacky links from? Currently there is a hot debate going on at Dave's site regarding urination and men's underwear. Go see for yourselves.

    Wednesday, October 01, 2003

    The orthopod took me out of the splint today. I don't need a cast, nor do I need surgery. He wants me to do range of motion exercises and call him back in three weeks. (As I said to my boss, "He's one of those holistic orthopedists.")

    I am thrilled to get that klunker of a splint off my arm and to be able to wear clothes without having to wrestle them over it. My range of motion is about thirty percent of normal right now, but I hope and expect it will improve.