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“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, December 31, 2003
    If You Eat Sushi...

    which I don't, by the way... you might be able to use this handy Sushi Finder.

    Don't say I never did anything for you.

    (Via Kate)

    Tuesday, December 30, 2003
    Mister! Tambourine! Man!

    Shatner To Release New Album

    'Nuff said.

    It's About Time

    And on a more medical note:

    U.S. Bans Ephedra, Drug Linked to Deaths

    I. Hate. Ephedra. The stuff should have been taken off the market before this. It's also known as ma huang, the original Chinese name of the herb. It's a powerful amphetamine-type drug, which will curb the appetite but will also increase one's blood pressure and heart rate. I've seen people come in with full-on atrial fibrillation and sky high blood pressure due to this stuff, and that's if they're lucky. Some have had strokes and heart attacks.

    Remember, people: just because it's a "supplement" doesn't mean it's safe. Same goes for anything "natural." (A well-remembered med school professor of mine used to have a favorite riposte to this argument: "Poison ivy's natural, but that doesn't mean it's good for you!")

    If the FDA doesn't pass it, I don't trust it. Granted, that's not a perfect safeguard either (anyone remember Baycol?), but it's a hell of a lot better than nothing.

    Jean-Luc Picard Fans...

    And you know who you are... click here.

    And it's all done in ASCII characters!

    If you find this interesting, you can find plenty of others at ASCIIbabes.com.

    (via Ernie, again)

    Monday, December 29, 2003
    After Hours

    Well, the cold-and-flu season is definitely upon us. Tonight the after-hours clinic overflowed into the hallway, and I stepped over to see a few patients with the residents and keep traffic moving. Everyone I saw had the same thing: upper respiratory infection, congested, paroxysmal cough till you gag. I prescribed a lot of decongestants and codeine.

    One thing about this time of year, you may be busy but it's not that difficult. At least sixty percent of the patients you see all have the same thing.

    Interesting (Achoo!) Website

    I just found a website dedicated to the common cold. A company called CommonCold, Inc. seems to be behind it, but I can't find any pharmaceutical sponsors. It appears to be meticulously researched and there's a lot of information there - but I can't help wondering who would spend that much time researching colds.

    Pediatrics 101

    How not to check a baby's diaper, via Ernie.

    A Christmas Poem

    ... from Dave Barry that is worth reading. Also, Best of Tim Blair 2003 - but don't start this unless you have an hour to spare, because you won't want to stop.

    Uh, Sorry, Guys

    It's been a whirlwind holiday season. I was out of town from the 23rd to the 25th (and, yes, air travel is hell right now). Came back to find I'd been made acting medical director because everybody else is out of town. This means I get to keep my beeper on 24 hours a day instead of only twelve.

    But the POWER! Muhaha! I've been promising my staff raises and extra time off; fortunately they realize that this is delusional and I need my medication.

    More later. Hope your holidays are wonderful.

    Thursday, December 18, 2003
    Heartwarming 1950s Christmas Stuff

    Ah, good. Blogger is finally accepting my posts again. What was the problem this time? Who knows? Anyway, I thought to get you in the Christmas mood you might like to take a look at some cute, old-fashioned holiday decorating ideas. Most of them come from McCall's magazine, in the days before Rosie O'Donnell got her big mitts on it and sent it spiraling into bankruptcy.

    Quick bit of history here: for decades there were seven main women's magazines published in the US, known as the Seven Sisters. They were Better Homes & Gardens, Women's Day, McCall's, Family Circle, Ladies' Home Journal, Good Housekeeping and Redbook. They were much alike, consisting of a mix of recipes, crafts ideas, short fiction (these magazines kept a lot of women writers going) and housekeeping hints. This formula worked well for awhile, but the last thirty years or so have been a different story. Still, all seven of them maintained at least a precarious existence until this year. McCall's became Rosie, and now I think it's gone for good.

    Still, thanks to the Internet we can regress for a bit and take a look at what the hot Christmas decorating ideas were for 1952. I liked the mobiles.

    (via Keri Smith)

    Wednesday, December 17, 2003
    Dexter Must Go
    or: Lord, Preserve Us from Awful Children's Sermons

    I may or may not have told you that the rector of my church (I'm Episcopalian) was recently elected the new Bishop of Arizona. He's a good guy and we'll be sorry to see him go, though we're all very happy for him.

    But last Sunday I realized that every cloud has a silver lining. You see, the second Sunday of the month at our church is always "School Sunday," dedicated to the children of our parish school. On School Sunday the adult choir gets the day off, the children's choir sings for the 10:30 service, and many more students and parents attend than on an average Sunday. This means that the sermon is, of course, guaranteed to be a (shudder) children's sermon.

    Remember children's sermons? You know you do. Remember getting called up to huddle on the altar steps, feeling like an idiot, as the minister took the handheld mike, got down from the pulpit and started wandering around like Mike Douglas or Dr. Phil? Too often, children's sermons get sappy ecclesiastic leftovers instead of, you know, some intelligent theology. I swear to you, I still remember my former minister declaring, from a kid's sermon in the 1970's, "How do we know God has a sense of humor? Look at zebras! Look at giraffes!" Oh, the horror...

    Well, I've heard some good children's sermons from time to time, but last Sunday's wasn't one of them. You see, our rector has a secret weapon that gets him through those times when he has to preach a children's sermon. That weapon's name? Dexter. Dexter is a ventriloquist's dummy.

    No, you didn't misread that: a ventriloquist's dummy. And our rector is many things, but he is not a good ventriloquist. He also isn't very good at telling jokes, and a Dexter sermon is guaranteed to start off with two or three jokes usually involving really bad puns. Exhibit Number One would be Dexter's name. The rector uses his right hand to animate the puppet: Dexter. Get it?

    Last Sunday I was verger again, so I had other things on my mind. When the sermon started I was actually relieved, because it meant I had ten or so minutes to relax - then I noticed the director of the children's choir exiting rapidly into the side hallway where I was. He's a good friend of mine, I've known him for years, and we both hate Dexter. When I saw the expression on his face, I knew what was coming.

    We stood in the sacristy, hearing every word, cringing at Dexter's smarmy puppet voice and every lousy pun. "At least this is the last time we'll ever have to hear this," I said, suddenly feeling much happier. As we waited, we recalled the plan we'd concocted about a year ago to kidnap Dexter and leave his charred, smoking frame in the parking lot. Why we didn't go through with it, I'll never know - too chicken, I guess. But knowing this was Dexter's last stand made up for it.

    The one thing that worries me is this: what happens if the rector decides to bequeath Dexter to one of the other priests? If that happens I will find some way to destroy that loathsome creature. Better dust off the parking-lot plan.

    Morning-After Pill

    Looks like we're getting closer to having "Plan B," one version of the morning-after pill, sold over the counter. I don't have concerns about safety with this - it doesn't contain estrogen, just norgestrel (a progesterone). This means that the drug doesn't have the risks of blood clots and other estrogen side effects. However, I am concerned about the possibility that women will attempt to use it at other times than within the 72-hour period that is recommended. I do get questions about this from patients even now: "But are you sure I can't have it?"

    If this goes through, the marketing campaign will have to emphasize the importance of timing. It has to be used within 72 hours of unprotected intercourse, and sooner is better even within the 72 hours (i.e., it's more effective at 24 hours than at 48).

    Updating the Classics

    Apparently, the newest entry in the Lord of the Rings film trilogy has a really awesome car chase scene.


    Monday, December 15, 2003
    Some Guy Named Hussein

    I think it's a federal mandate that if you have a blog, you have to comment on Saddam Hussein's capture. Well, first, I'm late, and second, there are hundreds of bloggers who have done so and done it better. But I'd like to post one quote that I really liked, from Josh Chafetz:

    Brokaw on Saddam: "He was literally a rat trapped in a hole." No, he was figuratively a rat trapped in a hole. He was literally a former dictator trapped in a hole.

    Yes, yes, yes! I hate it when people misuse words like that. This guy is a national journalist and he doesn't know what literally means? Give me a break.

    (via InstaPundit)

    Patient Etiquette

    GruntDoc has some great tips for patients who wind up in emergency care. I'd like to add that these apply to your primary care doc, as well.

    The General Synopsis at Midnight

    (Isn't that a wonderful phrase? I just love it.)

    There's a British sitcom currently rerunning on PBS called As Time Goes By which stars Judi Dench and Geoffrey Palmer. It's an understated romance between two middle-aged people, and I find it really enjoyable. One of the characters in the series, Mrs. Bale, is an eccentric housekeeper (like Mrs. Danvers in a way, but more user-friendly); her hobby is listening to the BBC's Shipping Forecast. She has a habit of breaking into unrelated conversations to inform her hearers of gales off the coast of Iceland, and so forth.

    I bring this up because I have a confession to make: I, too, am a weather geek. I watch the Weather Channel to relax; I have the NOAA weather site bookmarked on my computer; and, yes, I too read the Shipping Forecast. On particularly stressful days, I even listen to it (you can play it right off the site). In fact, the title of this post is taken from the Forecast. Mrs. Bale's hobby seems completely reasonable to me.

    Why do I, who live in Los Angeles where the climate almost never varies, fixate on weather? I have come to believe that it's a combination of reasons: the fact that I am not responsible for it the primary one, no doubt (so restful! It's not my fault!), but the sheer drama of it all playing a part as well. Floods, tornadoes... it's the Old Testament come to life. Then there's the pleasure of reading weather forecasts for places I used to live and congratulating myself that I don't live there any more. Severe weather alert in Philadelphia, eh? Gee, too bad.

    The announcers read so nicely, too. No matter how fiercely the gales may blow or the rain come down, their voices never vary. You can't tell from their tone whether we're in for another nice day or a hurricane warning. One could doze off, soothed and comforted, in front of the Weather Channel, snug in the realization that the bad stuff is all happening to somebody else, and in fact I have been known to do exactly that.

    And, lastly, I must say that if I ever write a novel, the title will undoubtedly be "The General Synopsis at Midnight," no matter what it's about.

    Tuesday, December 09, 2003
    Tired Doctor Rant

    So you wanna know how my day went? I'll tell you how my day went:

    I get a 7:30 am page from the doctor on-call that one of my patients had presented to the ER at 2 a.m. with a seizure, and his wife was throwing fits because a) she didn't like the hospital and b) he was too agitated to get into the CT scanner, and "how are we going to know what's going on if we can't scan him?"

    There was nothing I could do about the hospital; it's flu season and the guy's contracted hospital (let's call it Big Tertiary Hospital) was closed to ambulance patients. It's full, not a bed available. So we had to keep him at Community Hospital. I tried to reassure the wife that Community Hospital was, indeed, conversant with 21st century medicine and that they would not try to trephine him to let the evil spirits out of his head.

    So I call the hospitalist (I also had to explain to the wife that we have a hospitalist who sees our patients) but, being a busy guy, it takes several hours for him to get over there, during which time the wife calls me AGAIN. He's still in restraints but his vitals are stable, etc. so I keep trying to reassure her that he's being observed in the ER and things are OK.

    Now, this guy has some medical problems. He has vascular disease and diabetes; it's possible he could have had a stroke. So I understand the wife's concern, it's just that there really is nothing different to be done. If the patient is too unstable (or agitated) to scan, he's too unstable to scan, and that's it.

    Finally the hospitalist gets there and proceeds to tell me that the patient is a boozer and had had about eight beers with his brother the previous weekend! (He'd denied heavy alcohol use to me, and his liver function tests were OK when I'd done a checkup on him.) Oh, and he had a urine test which was positive for marijuana, too. And he was threatening to walk out against medical advice. Fortunately, he waited till his wife showed up at the hospital to leave.

    So that's how Mr. Party Boy ruined my ENTIRE DAY. Hmmmph.

    Yum Yum

    Check out this article for street food recommendations in NYC, San Francisco, Chicago, Philadelphia and Austin, if you happen to be in any of those places. (Sadly, no Los Angeles recommendations included.)

    (Via Philly LunchBox)

    Monday, December 08, 2003
    FDA Alert

    Here's an interesting piece of news from PDR.net regarding food dye:

    FDA Alert Issued for FD&C Blue No. 1

    The FDA has issued an alert for healthcare professionals regarding reports of toxicity, including death, associated with the use of FD&C Blue No. 1 (Blue 1) in enteral feeding solutions. In these reports, Blue 1 was intended to help in the detection and/or monitoring of pulmonary aspiration in patients being fed by an enteral feeding tube. Episodes of blue discoloration of the skin, urine, feces, or serum were reported, as well as serious complications such as refractory hypotension, metabolic acidosis and death. Seriously ill patients, particularly those with a likely increase in gut permeability (eg, patients with sepsis), were reported to be at greater risk for these complications. A causal relationship between systemic absorption of Blue 1 and the reported serious and life-threatening patient outcomes (including death) has not been definitively established.

    Now, for those of you who don't know, use of the blue food coloring in enteral feeding (tube feeding solution) is absolutely routine. As the excerpt states, it's used to identify the feeding solution in case the patient chokes or you have reason to think they are aspirating chronically. My question is, with use of this stuff so ubiquitous (at least in California) wouldn't this have been picked up sooner if it were truly a problem? And the article itself states that no definite association has yet been established.

    In addition, this population is extremely ill and at higher than average risk for having complications to start with. The tube itself has the potential to cause problems (insertion site infections and so forth). I'd really have liked to be able to see the data on this. That said, even a low risk should be avoided if there is an alternative. (Green, anyone?)

    If anyone has more info on this, I'd be very interested to hear it.

    Save This For Your Lunch Hour

    It's time once again for the annual Dave Barry Gift Guide.

    Friday, December 05, 2003
    Make Mine American Cheese, Mushrooms and Onions

    This article may have limited appeal, but I found it charming. Having lived in Philadelphia for nine years, I am an avid cheesesteak fan - how could I resist an article about an eighteen-year-old whose senior project became a quest to find the best cheesesteak in the Philadelphia area? If you like cheesesteaks, Philadelphia, and/or food writing, give it a look.

    (Via Philly LunchBox.)

    Interview With The Scammer

    From Tim Blair comes this interesting piece about one of the perpetrators of those Nigerian emails promising millions of dollars in windfalls. The writer interviwed a mechanic who was recruited by a friend of his to participate in the scheme.

    Personally, I can't believe people are still falling for this, but apparently they do.

    Thursday, December 04, 2003
    "Oh, the Herbanity!"

    The Goodyear Blimp has crashed into a plant nursery in Carson, CA. No one was seriously hurt, thank goodness.

    Wednesday, December 03, 2003
    More Random Non-Medical-Related Links

    First 2 via Ernie... third one is via Jack.

    1. Take a couple of these to bed with you and you won't need to turn the heat on all winter.

    2. For the computer geek who has everything... except maybe good taste.

    3. Well, I take it back. This one is sort of medically related, but it's really weird.

    What She Said

    I completely agree with this:

    You know who I don't get? I don't get the people who say, "Oh, I love when Lileks goes on about Target and Gnat, but I hate when he gets political." Or the opposite--"I love when he gets screedy, but I hate all that girly shit about Target!" Personally, I love both. I read Lileks because I want to "hear" Lileks. Imagine if you went out with some friends and the minute they branched off into a discussion you didn't care for, you said, "You know, I really like when you talk about work, but I hate when you talk about your girlfriends. You're really boring me." Your invitations out would dwindle pretty rapidly if you kept going around doing that.

    Read the whole thing. This is why I don't write about medicine only (I know, sometimes I don't write about it at all); there are other weblogs that do that, and they do it much better than I do. I don't have time to analyze and write long, thoughtful articles; I wish I did. You get what I have at the end of the day or between patients. It's Short Attention Span Blogging. Many times I can't think of any medical topics that I find interesting, or by the time I get around to writing something (like Medicare, for instance) it was covered by somebody else days ago.

    So I write about other stuff. Something I find funny, or that I heard that day, or whatever. Vodkapundit mixes political commentary and recipes. It works for me.

    So there you have it. Ilyka verbalized my position much better than I did.

    A Phrase I Could Go a Lifetime Without Hearing Again

    "Given the number of eggs there, there's about 300 hookworms in my guts."

    I'll give this guy credit - he's studying himself. Dr. Alan Brown, the man quoted above, claims his hay fever completely disappeared after he became infested with hookworms while traveling in the Third World. This article also mentions a woman with ulcerative colitis who is voluntarily drinking a solution with worm eggs in it to control her colitis symptoms.

    The gist of the article - and it is interesting - is that since humans evolved with a chronic level of parasite infestation, and that parasites in developed countries really have only been eradicated in the last fifty to sixty years, the lack of parasites may explain why our immune systems are turning on us to cause diseases like asthma and autoimmune problems. It's quite an argument.

    The article also discusses the toxoplasma parasite, which usually infects the central nervous system (i.e., the brain) and is thought to control behavior in some animals which get infected, like rats. I quote:

    The main way we get it is by eating undercooked meat (which is why 80% of the French are estimated to have it, with their love of rare meat).

    Well, that explains a lot...

    For years scientists thought it had no effect on our behaviour, but now the parasite's changing their minds.

    AIEEE! Toxo is turning scientists into zombies! Oh, wait, it's just a badly constructed sentence. Anyway, read the article.

    The Bad Sex in Fiction Award

    No, it's not going to Jacqueline Susann. It's still worth reading the article, though; and Sting is presenting the award! Priceless.

    Tuesday, December 02, 2003
    Thanksgiving Dialogue

    I staggered into the kitchen at 7:00 Thanksgiving morning to find my mother and sister already busy cooking and their pecan pies in the oven. My niece and nephew (ages five and three) were standing on stepstools, peering into the sink, raptly contemplating the 21-pound turkey resting therein.

    As I absorbed some coffee, I listened to their commentary:

    "Is this his neck? Aunt Alice, look!" (Waving turkey neck in the air.) "How'd they cut it off? Did it hurt?"

    My nephew lifted the wing: "What's under there?"

    "That's his armpit," said my niece, knowledgeably.

    "Is this his bottom? Mommy, does he poo? Which end is his bottom?"

    "Well, honey, he doesn't have his guts anymore, so he can't poo," I tried to explain. "They took them out, see?" At which point the bag of giblets came into play.

    Let's just say these kids will never join PETA. They were having a great time.

    Ivan Denisovich, M.D.

    So we're back at the gulag today. I wish I had more time to write, but I just don't. I'm getting sandbagged with physicals and strep throats. So here's a little filler for you, and I will try to do better later this week.

    First: here, via InstaPundit, is a really interesting article about Bill Watterson (remember Calvin and Hobbes?)

    And second: a funny and vaguely obscene picture of Dick Gephart, via Dave Barry (of course).