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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    Friday, June 27, 2003
    Malawi Update

    A sobering post from Chuen-Yen. She finally fell victim to malaria:

    Maswera! It's been a surreal week. Here's your memoir:

    �You must have malaria.�

    -- Every Malawan, on my condition

    I now know malaria first-hand. Fevers, headaches, fatigue, sweats, myalgias, nausea�these are the classic symptoms. I had them all.

    Initially I dismissed my illness as a viral syndrome, mayhap flu. After all, malaria season is ending. Forget that I had ceased sleeping under a mosquito net two weeks ago; that I spent last weekend being attacked by vectors at the lake; or that I have been careless about my Larium prophylaxis. Malaria shouldn�t happen to me.

    But it did.

    My few days of constitutional symptoms, punctuated by hallucinations, were extraordinary. As I lay semi-lucid in bed, the book on my nightstand was dreadfully far away. I couldn�t reach it, let alone ponder the words. Transferring from one room to another was an insurmountable task. When impulses toward productivity transiently flitted through my cortex, I would move a millimeter and then resume listlessly contemplating blemished curtains qua friendly apparitions, barking dogs trying to control my mind and the nauseating glass of water that persistently stared me down. The neighbor�s barbering was my mother grinding coffee in the morning. Gift�s clatterings were the footsteps of a beloved lizard. The phone rang, but I couldn�t answer it. It rang and rang.

    Sometime during the second nightfall of my infirmity, a shotgun wielding sentry awoke me. Dr. Kalanda had sent Arinate. Unquestioningly I swallowed two tablets and drifted back to sleep. By morning I felt much better. Twenty-four hours later, I had recovered. So the locals were probably correct. Once again, experience is the best teacher.

    Stay well.


    Thursday, June 26, 2003
    Match Made In Heaven?

    Wanna find out who your blog matches with? I got matched with Sore Eyes.

    (via WhackingDay)

    Malawi: The Servant Problem

    As promised, another post from Chuen-Yen. In case you're not sure, this post does indeed contain sarcasm.

    Greetings! Here are this week's liberating thoughts:

    In commemoration of Malawi�s Freedom Day, I enjoyed an irenic lakeside weekend of privilege with friends. For en route convenience, we toted along a household work-servant. James guarded our belongings while we sipped tea at Kaboodle�s. On rutted thoroughfares, he periodically examined the tires. He removed obstacles from the road as needed. When the windscreen was soiled, he cleaned it. When beggars approached, he shooed them. James performed many bothersome tasks.

    Nonetheless, James himself was sometimes a nuisance. He emitted an offensive odor. His rucksack occupied space in the vehicle. Though we piled luggage atop him, he filled a seat. He had to be fed and watered. Once James even left his post to use the toilet. All of these things were slight impositions on our other wise peaceful journey.

    The cottage staff proved no less troublesome. One of the cooks developed Malaria. He requested 150 Kwacha to buy medicine. Assuming him to be lying � possibly true since the pharmaceuticals actually cost fifteen Kwacha � we purchased the Fansidar ourselves and supervised his consumption of it. After treatment, Thomas overcooked our eggs and didn�t portion vegetables properly. He also pilfered used olive oil for his own purposes.

    Thomas wasn�t the only annoying worker. The garden-boy interfered with our view by watering while we relaxed on the khonde. Housekeeper Mai did a poor job cleaning concealed nooks and crannies. Most vexing of all was that a lovely retro tea set placed in the lounge for decoration was immediately picked up, washed and returned to the cupboards.

    Overall, we were quite dissatisfied with the help. The problem with servants is that they are people too.


    One Track Mind

    To Dave Barry, everything is a great name for a rock band. Even medical terminology.

    Tuesday, June 24, 2003
    Sensurround Code Blue

    I had a rather surreal experience in the intensive care unit this evening. I had the unfortunate duty of meeting with a son to explain that his mother was not likely to survive more than a few days (she has a huge colon tumor and is in multi-system organ failure). After that sad interview I sat at the nurses' station to return a page, which I should confess wasn't medical but had come from my sound-system guy.

    As some of you may remember I am in the middle of an ongoing home-improvement project, creating a rec room from the unfinished basement space under my house. Currently, the plans for the house are still in the Purgatory of City Hall awaiting approval, but in a few weeks I expect to be back to full money-hemorrhaging mode. Well, I want to move my TV downstairs, put in some speakers, get a DVD player (I shamefully confess I still don't have one), maybe even TiVo... you get the idea. My architect put me in touch with a guy I'll call Eric who specializes in this sort of thing. Eric called me from his cell phone and I had to get back to him ASAP, so I thought a quiet spot on the far side of the ICU would be just the place. I was wrong:

    As I began to describe what I was looking for in a sound system, one of the patients in the unit went into cardiac arrest. (Not mine.) I found myself putting Eric on hold to answer the phone calls coming into the unit, as the entire nursing staff was crowded into the small patient room running the code. (If you're wondering why I didn't drop the phone and rush to the rescue, this is why. I wasn't needed.) I finally flagged a nurse on break to answer the phone and print out the tape from the cardiac monitor. I then had Eric in one ear, detailing the virtues of surround sound, and medical terms floating in the other ear: "epinephrine... We'll need to get her on the bed board... suction..."

    In the middle of a discussion about satellite TV, I had to clamp my hand over the receiver as the nurse next to me started yelling: "She's in v. tach! V. Tach!" Worse yet, I was starting to giggle. I brought our discussion to a close as the patient's heart rate returned to normal ("for now," as one nurse grimly put it.) It felt like a strange episode of ER.

    Malawi Update

    Let me make up for depriving you of Chuen-Yen's ongoing experiences as an expatriate internist by supplying you with the following. We will be hearing a lot from her this week as I make up for my ten days' absence. (For those of you who do not know, Gift is Chuen-Yen's houseboy.)

    �If I have too much money, someone might eat me.�
    -- Gift, on financial success

    In an effort to launch a nationwide survey, Gift and I have been stuffing envelopes late into the evenings. Thus I�ve been treated to countless hours of his life philosophy. During last night�s vespertine musings, we discussed the trials and tribulations of becoming wealthy.

    According to Gift, Malawans cannot and should not ascend the socioeconomic ladder for a plethora of reasons. First, there is nepotism; bosses preferentially hire people from their own tribe. Then there is the general sentiment that labor should beget immediate gratification. As I explained my project, Gift asserted that no Malawan could do research given its ambiguous returns.

    Jealousy is the most serious impediment to prosperity. Malawans won�t allow their countrymen to be successful. When achievement threatens, they sabotage their comrades by witchcraft. Exceptionally envious adversaries may even resort to cannibalism.

    Gift, who religiously allocates 30 minutes per day to thinking, articulated several astute insights. He noted that President Muluzi is poor role model; pettiness is stifling social progress; and that lack of forethought precipitates penury. He vehemently advocated education as a means of advancement. After this bout of wisdom, I rhetorically asked Gift how he was planning to break the cycle of poverty and oppression. He responded, �Madame, I cannot do that. I am Malawian.�

    Why would Gift want to be rich anyway? Money is wrought with perils, the worst of which is that you might be eaten.

    Take care,



    Medrants has an excellent post on depression and primary care. I especially agree with his comments as follows:

    Many patients do not want to see a psychiatrist or psychologist. Many health care plans do not allow appropriate mental health referrals. We can manage much depression in our offices. For many patients, the generalist is indeed the best (and sometimes only) choice.

    One thing I still hold against my med school and residency training, which focused on primary care, is that I was never told how much mental health diagnosis and treatment I'd be doing. My psychiatry rotation in med school consisted of a series of lectures interspersed with six weeks on a locked psych ward at the VA, and two or three shifts in the ER on the psych team. Now, these were indeed learning experiences, but they held no relevance for any mental health issues I encounter in the course of my day as an internist. And as for my residency experiences... my teaching hospital also had a psychiatry residency program, which meant that the psych residents saw every patient who had any sort of mental health problem, and we were not allowed to prescribe any psychotropic drug. The psych residents had a lock on all pharmacologic orders. The upshot is I was let loose into the world of medicine with no idea of how to prescribe antidepressants - any antidepressants - at a time when Prozac was at its peak and new serotonin reuptake inhibitors were being developed at a rapid pace. I consider this almost criminal.

    Generalist programs are spending more time considering depression diagnosis and management every year. The residents that I work with are clearly better at considering the diagnosis of depression than their predecessors from 5-10 years ago. They also are becoming more comfortable with pharmacotherapeutic options.

    Good! They won't have to spend ten years making up for lost time, as I have been doing. The good news is that now I'm pretty good at figuring out who needs meds, who doesn't and what might work best for them. I just wish it hadn't taken so long.

    Monday, June 23, 2003

    Yes, I'm back. I had a lovely time, thanks. But it's been hard to get back to writing again, especially now that I'm the hospitalist for this week... in fact, I'm only here because I swore an oath to myself that I couldn't read another blog until I posted something.

    So. Las Vegas. I hadn't been to Vegas for about two years, and wasn't sure what to expect when meeting a clutch of women I'd never met before - all friends of my brother's fiancee and all of whom will be in the wedding party. But we got along fine, and had a great time. Vegas was hot - about 104 degrees - but none of us minded all that much because the spring in California and on the East Coast has been so cold and overcast. We stayed at the Bellagio, which I highly recommend - if you saw the remake of Ocean's Eleven, you know what it looks like. I kept hoping that Brad Pitt or Matt Damon would pop up, but no such luck.

    We spent a lot of time at the pool. Did I say "pool"? It's actually a series of four or five pools spread over a huge area - looked like about two acres. It's jammed at noon, and too hot for me, but I went down at five pm and really enjoyed it. It was plenty warm enough then and there was almost nobody there. So that's my travel tip - don't go to the pool until four-thirty.

    The first night we went out to dinner at the House of Blues, thanks to Vic's cousin who got us into the Foundation Room. (Vic is my future sister-in-law.) It's very lovely, very expensive. We all stood out on the patio looking at the view and waving our "Vic on a Stick" party favors. Yes, one of Vic's friends cut her face out of a photo, copied it 15 times, laminated it and glued the resulting images to tongue depressors and paint stirrers! What are friends for, if not to humiliate you in public in this fashion??

    The next night came what we had all been waiting for... the inevitable... The Thunder From Down Under. Yes, every bachelorette weekend involves seeing male flesh at some point, and this was it. Let me just be frank and say, I had a blast. When is the concept of Australian men taking off their clothes not a good idea? Answer: never. Yes, the choreography left something to be desired; yes, all the dance numbers were more or less the same; yes, watching them prance around in drag at the end was more than a little reminiscent of "Benny Hill." But who the hell cares? And the show got bonus points from me for its location: the Excalibur, the tackiest place I've ever EVER seen. Sherwood Forest Cafe, anyone?

    When we arrived for the show, we were 45 minutes early but already there was a very long line of eager females. (Where are all the guys?" asked one of our group, sarcastically.) Our fellow audience members were not exactly dressed for a night on the town - I saw lots of ripped jeans and tank tops. Standing next to them in our pseudo-medieval surroundings, our semi-dressed-up group felt like we'd wandered into the wrong place. But we weren't in the wrong place. I kept staring around and muttering, "This feels like the Renissance Festival from hell." We were surrounded by the Excalibur Shoppe, The Dragon's Lair (another gift shop), Sir Galahad's Pub and Prime Rib... oh, and a caricature booth. It was like being at Fantasyland, only much tackier.

    To sum up, when in Las Vegas, DON'T stay at the Excalibur. DO stay at the Bellagio. And always drink beer before going to see an all-male strip show; the whole experience is easier that way.

    Next: Alaska.

    Thursday, June 12, 2003

    I am going on vacation and will resume posting after I return. It'll be about ten days. I will be in Vegas for a few days for a "bachelorette" weekend with my future sister-in-law, about eight of her closest friends, my sister and myself... then up to Alaska for six days.

    I will bring you all the degrading details when I return. (I'm talking about Vegas, not Alaska. But you knew that.)

    Feline Humiliation, Part 3 or 4

    There seem to be a lot more funny/weird websites out there for cats than for dogs. Or maybe it's just that I enjoy the cat ones more.

    This webpage has lots and lots of cat outfits and/or hats. The pictures are funny enough, but the language is truly creepy (it's a Japanese website with poorly translated English):

    Ever imagined dressing up your lovely cat into a fabulous beauty? You don't have to dress her everyday, in fact she might not feel comfortable with a dress on for days. Just dress her up only on special occasions like her birthday, takes (sic) a photo and that should leave you lots of memories and fantasies.

    "Fantasies"?! I don't really want to know...

    Don't miss the "Anne of Green Gables" hat/wig combo, which is truly hideous:

    Let her play the leading role in the masterpiece "Anne of Green Gables"! Isn't her coquettish red hair cute? Let's give her a broom and this lady with little red hood, is likely to start cleaning up your room.

    Now I've read Anne of Green Gables, though not recently, and I don't remember anything about a red hood - although I do think she had red hair. Perhaps they were thinking of Little Red Riding Hood?

    (via LittleYellowDifferent)

    Tuesday, June 10, 2003
    Missive from Malawi

    In Chuen-Yen's latest email, she details her tour of a tea plantation in Malawi.

    Anticipating entertainment along major thoroughfares is a favorite Malawian pastime. Rubber-neckers savor vehicular accidents, near misses and loud noises. In addition to catastrophes, passage of government officials, whose motorcades are inevitably heralded by sirens, flashing lights and highway closures, is another popular attraction.

    During a recent drive through Thyolo, pullulating spectators, women clad in telltale UDF (United Development Fund) chitenges and sentinels lounging by the wayside presaged President Muluzi�s approach. Cognizant that roads are always cleared for aristocracy, we opted to linger at a tea plantation rather than joining queues in designated holding areas.

    On Satemwa Estate�s dirt road, our lone car was the most contemporary, and most unsightly, object in the ken of vision. From a vantage point overlooking vast hectares of lush crops, we relished an irenic panorama of slaving workers, many encumbered with back-borne infants. Having sighted White people, children too young to labor, but able to walk, neared in hopes of a biscuit. One explained the logistics of tea harvesting � pill-roll the peripheral stems to garner bright green leaves; avoid dark inner pieces as they are bitter. Collection baskets can be filled within a few hours.

    Some time into our tutorial, sirens heralding the presidential entourage became audible. A few minutes later, the flashing beacons passed. We subsequently joined Muluzi�s obligatory motorcade on the main road. All the while, hordes of locals stared steadfastly at the uneventful automobile parade.

    Once home, I laid a handful of tender green leaves out to dry. Even sans hot water, they effuse warmth. Like so many important matters, my tea experience was not announced with bright lights, bells or whistles. It quietly transpired on the road less traveled.

    Til next week,


    Monday, June 09, 2003

    Haloscan is down. Comments will return, but I'm not sure when yet. (I'm posting this in the no-doubt-mistaken assumption that you're all dying to say something.)

    Movie Review

    So today I'm flipping channels at the gym and strike gold - Breakfast at Tiffany's (1961). I know you've all seen this, so I will just say a couple of things:

    1. This is one of my favorite movies. Ever. I don't know how many times I've seen it, but a lot.

    2. I tuned in just in time for the marvelous party scene in Holly's apartment. Men in suits, women in dresses, Henry Mancini's blasting party music, and total chaos! Sublime. I remember reading somewhere that Blake Edwards got a bunch of people in the room and just told them to improvise... don't know if that's true, but it's great fun to watch.

    3. George Peppard. Wow.

    Neighborhood Update

    I have some sad news for you, I'm afraid.

    You may remember my posting a couple months ago about the woman in my neighborhood whose house caught fire (she was smoking in bed) and who was taken to the hospital. If you don't you can scroll back to March/April if you like, unfortunately the links are not working. Well, my neighbor Norm across the street told me recently that she had died - the smoke inhalation was too much for her, I guess, and she asked to be taken off life support. Her house continues to sit, boarded up, a sad sight. Since she apparently has no relatives to inherit, the city will probably acquire the house when the property taxes come due and are not paid.

    Norm himself has finally sold his house and will be moving to Palm Springs shortly. I'll miss him when he goes - he's the sort of guy who knows everyone on the street (he's an entire Neighborhood Watch program in himself). He's a retired military guy; when my next-door neighbor Debbie's house got broken into two years ago, he dashed over with a gun stuck in his shorts to help. Fortunately the house was empty by then.

    Norm initially tried to sell the house himself, but then gave up and got a realtor. This weekend, shortly after the "In Escrow" sign went up, I was puzzled when the "For Sale By Owner" sign reappeared on his lawn. A closer look, however, made everything clear: in the center of the sign was a small flyer reading:


    Norm doesn't miss a trick.

    Friday, June 06, 2003
    More Bad News

    Los Angeles County is planning to cut 800 jobs from its hospitals within the month. Hardest hit will be King-Drew Medical Center (one of the county hospitals), which will lose 79 physicians and 152 nurses. (Note: link is time sensitive.)

    The hospital staff is concerned about the effect the cuts will have on its pediatric and obstetric programs. It also has an excellent trauma center; I can't help wondering what's going to happen to that.

    Tragedy in the Making

    If this trend continues we will be seeing a bunch of overweight, diabetic squirrels. This must not be allowed to happen.

    (via Dave Barry)

    Finally, Research I can Understand

    This is the most refreshingly honest study result I've ever seen.

    (Thanks to Medpundit)

    Thursday, June 05, 2003
    Leech Update

    I talked to my partner today and asked how the colonial medicine presentation went. The leeches were a wild success; the kids loved them. "I had enough leeches for everybody!" she exulted. However, last night one of the leftover leeches, which she was keeping in the refrigerator, escaped from its Tupperware prison and attached itself to the wall, where it greeted her when she opened the fridge this morning.

    "I'm not squeamish," she said, "but when you open the refrigerator you don't want to see a big, hanging leech!"

    Reason #4757 to Love the Internet

    Look at this: daily photos of the surface of Mars! These are created by thermal imaging from a satellite called "Odyssey 2001." There's a new photo posted every day. Pretty cool.

    Wednesday, June 04, 2003
    They're Finally Starting To Get It

    Last night at the store the latest edition of Time Magazine caught my eye: The cover story, The Doctor Won't See You Now, beckoned to me. You may have read of some of the physicians' demonstrations and walkouts protesting escalating malpractice rates that have been taking place in various states this year. Well, folks, it's worse than you may have imagined. In Nevada there are women who have to drive for hours to find an obstetrician who can deliver their baby. Docs are quitting medicine in droves, or moving to states where they can afford to practice. Click the link and see for yourself.

    This link gives a list of some of the most frequently proposed solutions to the malpractice crisis: capping lawyers' fees; increasing screening and reviews of suits when filed; capping awards. No doubt many will object to the financial caps because they restrict victims - true victims - of malpractice from getting the money that they need to live (if permanently disabled, requiring equipment, etc.). And they would be right; bad things do happen and genuine malpractice is committed. Unfortunately, the vast majority of cases filed are not about this kind of malpractice and do not provide justice or appropriate financial restitution. From my vantage point, most cases are filed because "hey, everybody else is doing it. And I've got nothing to lose - my lawyer won't charge me if I don't win!" or "that son-of-a-bitch doctor really pissed me off. I'm going to punish him/her." or similar half-baked motives. Not to mention that the public at large does not seem to have grasped the fact that bad outcomes sometimes happen without malpractice; interventional medicine is not risk-free.

    When "everybody does it," costs go up. There is no such thing as a free lawsuit. The health care system in this country is a good one (I think) but the malpractice issue truly has become a crisis. I think at this point the only way to control it is financial capping and rigorous screening of individual claims. I would also love to see plaintiffs and their attorneys fined or cited for frivolous lawsuits.

    Basil Fawlty lives!

    Tuesday, June 03, 2003

    This week I have been frantically trying to get enough credit hours to renew my radiologic supervisor license; the great State of California imposed an new requirement of several hours' worth of educational credits without telling anybody. Ah, I love surprises. Fortunately one can obtain said credits online, but this has resulted in five hours' worth of staring at my computer and listening to lectures about imaging studies in low back pain, breast disease, etc. until my eyeballs are about to pop out of my head and roll across the room.

    This explains the scanty blogging this week. (Thank God for Chuen-Yen.)

    But I do have a story for you. One of my partners volunteers at her children's school every other Wednesday. Often she will put together a presentation with a medical theme for the kids: this week it's colonial medicine. She found this book to be a great resource, and she plans to pass it around during the presentation, but she went further than that: she bought some leeches.

    Yes, leeches. She's been on the phone trying to purchase them for a week. It turns out the leeches which are used for medical purposes are difficult to get and rather expensive, but she's been able to get another species of leech which is used for fish bait. She says the kids will be able to pass these around as this species has no teeth which will allow them to attach to humans (I immediately started calling them "declawed" leeches). She also has a smallpox poster, distributed courtesy of the Center for Disease Control, which she will be exhibiting since smallpox was a real scourge in colonial America.

    Incidentally, so was yellow fever. Yellow fever is a viral disease carried by mosquitoes, rather like malaria, which causes liver damage and jaundice. It was eradicated from North America sometime during the nineteenth century, but for many years outbreaks in the summer killed a lot of people. The worst yellow fever epidemic in U.S. history was in Philadelphia in 1793, when over 4000 people died. Washington Square, one of the five open spaces planned in the city by William Penn, served as a mass grave site (when I lived in Philadelphia, I thought of this every time I walked through the square).

    But back to the talk. My friend was also trying to get some maggots (these were used to debride wounds), but I don't think she was successful. When I walked into her office yesterday she was on the phone with her nanny: the leeches had just been delivered. I told her she'd be voted Mother of the Year by the kids after the talk was over. What child could resist leeches and gross-out pictures?

    Sunday, June 01, 2003
    More from Malawi

    In this week's email, Chuen-Yen nearly lost her beloved pet tortoise Enigma (which she rescued from a food market several months ago). We see that the hospital's physical plant supervisor is no doubt mumbling about those crazy Westerners and their pets...

    Mr. Katundo, BAH�s maintenance supervisor, is exasperated with me. On this halcyon Sabbath, I phoned him with an emergency � Enigma had crawled into the plastic piping that drains water from our decrepit patio to the dirt garden below. My neighbor, several friends and I had attempted to push her through the system with a rubber hose. But the drainpipes� external second story location hindered our success.

    To retrieve Enigma, the labyrinth would have to be dismantled. Mr. Katundo was nonplussed when I explained this situation. Eventually he sighed, �I�m coming.�

    For a small audience of security guards, hospital staff and snickering cronies, Mr. Katundo scaled his ladder, opened several critical apertures and located Enigma. After contemplating potential rescue techniques, the group concurred that we should maneuver her horizontally to a vertical conduit, via which she would free fall into my hand. As the plan was executed, spectators contemplated why one might keep a tortoise. They also worried that her shell would crack should we fail to cushion her rectilinear descent through six meters of PVC tubing. Fortunately, there were no complications.

    Afterward, one bystander commented, �Kamba (tortoise in Chichewa) will still be tasty.� Others agreed. It seems nobody would perform such shenanigans for a useless pet. But food is another story.