“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






Email Dr. Alice

 
Neato

It's Ugly Christmas Lights.com. Enjoy.

posted by Dr. Alice at #

 
Friday Night in the ED

I recently started taking hospital call again after eighteen months' grace - hospital call pays more and I'm trying to pay off some of my expenses from the basement project. (Which, by the way, is done. Hallelujah!) Last Friday was a busy night, with four admissions in a row (MI, pancreatitis, cellulitis, compression fracture of thoracic vertebra/pain control).

I don't really mind hanging out in the emergency department, though - you meet such interesting people. For example: I was writing admission orders in the back room when two paramedics brought in an unconscious man on a stretcher. I overheard the mumbled diagnosis and poked my head out to stare:

"He drank an entire fifth of vodka?"

Uh huh. Suffice to say that Mr. Binge Drinker was intubated a short time later - he basically wasn't breathing.

Then there was the matter of the progress note I overheard one of the ER docs dictating:

Patient complains of recurrent epistaxis [nosebleed] which he
claims was caused by a curse from his ex-wife. Patient states he prayed to
Our Lady of Guadalupe to remove the curse but epistaxis did not improve.
Patient therefore presented for treatment.

Our eyes met and he grinned. Not much you can add to a medical history like that. I voicemailed V. excitedly (she was on call, too):

"If I stayed here all night I'd have enough material to write for a month!"

posted by Dr. Alice at #

 
Good Show, Mr. Laurie

OK. A day late and a dollar short, but like every other good medical blogger, here I am weighing in on House. I spent this weekend recuperating from bronchitis and catching up on all the shows I've TiVoed but haven't watched. One show in, I decided: screw The Avengers, Hugh Laurie is the way to go.

If you've ever watched Jeeves and Wooster or Blackadder, you know who Hugh Laurie is. What the hell, not only is the guy funny, he can actually act. And he does a flawless American accent to boot - the only convincing one I've ever heard from an English actor. He makes the show: I could not stop watching it. To illustrate how incredible that is, I should inform you that my sentiments about medical TV shows are simple: they suck. I've never watched ER, for example. My Dad the Retired MD recently reminisced about the only time he ever watched Dr. Ben Casey years ago: "This patient comes into the ER with a headache, and this intern Ben Casey thinks he should be admitted. So his resident asks why and he lists severe headache, light sensitivity - all vague symptoms. His resident overrules him and they send the patient out. A few hours later he's back vomiting, and he turns out to have an aneurysm, and the intern was the only one who got it right, and that's the last time I ever watched Ben Casey!" My sentiments exactly.

That's not to say the show is perfect. No way would any teaching hospital have an MD with three docs assigned to him and nothing to do but spend morning, noon and night figuring out what's wrong with one patient. In one episode, the medical team performs CPR on an infant - none of them are pediatricians. Wrong, wrong, wrong. Another blatant error: in the third episode, a patient is given IV thyroxine early in the episode and then a day or so later the team decides to recheck his thyroid function tests, which have now been rendered meaningless because he just got thyroxine. I could go on, but I don't want to bore you and in any case it doesn't matter: House is damn good TV.

As you doubtless know by now if you've paid any attention to the show, Dr. House is fascinated by pathologic processes (that is to say, diseases) but hates interacting with patients. For my money, the best scenes are those set in the walk-in clinic where House is required to work every week by the terms of his contract. His interactions with patients and their illnesses are scathing, to say the least: I would bet that somewhere in the writers' room is a disillusioned primary care physician. Dr. House says the things we all wish we could say: he calls one patient "the idiot who didn't know how to use birth control," for example. (I know this sounds harsh, but trust me, there are a lot of idiots out there who don't know how to use birth control.) Hugh Laurie is good enough in this role that you empathize with Dr. House while seeing how rude and abrasive he is. The crusty-but-loveable senior doc is a well-known cliche. Hugh Laurie infuses this stock figure with new life.

The diseases tracked down on House are genuinely interesting: cysticercosis, colchicine poisoning, subacute sclerosing panencephalitis due to measles. I also liked the way the show illustrates the methodical process that goes into diagnosing disease. At least once per show the team runs through the options: Inflammation? Tumor? Infection? Allergy? Endocrine problem? Etc. Also, the audience sees that imaging studies do not guarantee a diagnosis. Every patient on the show gets run through a scanner at least once, and most of the time nothing is found. If House does nothing else, maybe it will demonstrate to the lay public that getting a scan does not equal a diagnosis.

The supporting cast is good, though they tend to follow the tried-and-true Idealistic Young MD type of character. In the later shows, the scripts have tried to flesh out each of the team docs (one went to seminary but dropped out; one of them lost a baby, etc.), which is a good thing and hopefully will contribute to the growth of the show, assuming it lasts past the first season. It should - House is a lot better than your average medical timefiller.

Speaking of medical timefillers, did I mention that Dr. House is a fan of General Hospital? Now that's a nice touch!

posted by Dr. Alice at #

 
Condolences

... are due to Jack, who lost his father-in-law today. Norm sounds like a wonderful person.

Bad news seems to be rife, which is one reason I haven't posted much. One doesn't want to be the spreader of bad news. But I have been brought down recently by the discovery of two patients with advanced breast cancer in the same week (one at age 39.) I'm coping with a higher than average nursing home census, fortunately most of these patients are there recovering from orthopedic surgery and not strokes or similar.

And I've been sick. (I know, boo hoo.) I spent Wednesday home with a nasty case of bronchitis. After spending part of my sick day watching The Saint and The Avengers, I can testify to the healing power of BBC America and Tivo as well as Avelox. Those shows are guaranteed to perk you up.

As we head into the holidays, remember those of your friends and family who are coping with hard times and sorrow. It's even more difficult for them at this time of year.

posted by Dr. Alice at #

 
Christmas Carols for the Psychiatrically Challenged

It's a cheap laugh, but I'm not proud.

Schizophrenia --- Do You Hear What I Hear?

Multiple Personality Disorder --- We Three Kings Disoriented Are

Amnesia --- I Don't Know if I'll be Home for Christmas

Narcissistic --- Hark the Herald Angels Sing About Me

Manic --- Deck the Halls and Walls and House and Lawn and Streets and Stores and Office and Town and Cars and Buses and Trucks and Trees and Fire Hydrants and ...

Paranoid --- Santa Claus is Coming to Get Me

Borderline Personality Disorder --- Thoughts of Roasting on an Open Fire

Personality Disorder --- You Better Watch Out, I'm Gonna Cry, I'm Gonna Pout, Maybe I'll tell You Why

Obsessive Compulsive Disorder --- Jingle Bells, Jingle Bells, Jingle Bells, Jingle Bells, Jingle Bells, Jingle Bells, Jingle Bells, Jingle Bells, Jingle Bells ...

Agoraphobia --- I Heard the Bells on Christmas Day But Wouldn't Leave My House

Senile Dementia --- Walking in a Winter Wonderland Miles From My House in My Slippers and Robe

Oppositional Defiant Disorder --- I Saw Mommy Kissing Santa Claus, So I Burned Down the House on Christmas Eve

Social Anxiety Disorder --- Have Yourself a Merry Little Christmas While I Sit Here and Hyperventilate

posted by Dr. Alice at #

 
Advice for a Worst Case Scenario

I'm posting an email (slightly edited) that I recently sent to a friend whose father-in-law was diagnosed with terminal cancer. (He was kind enough to say he'd found it helpful, which is why I'm posting it.) This is the advice I'd give to anyone with a friend or family member who has a serious illness:

Here's my practical advice: prepare for the worst. (Things will go much better and be less emotionally/financially traumatic if you do.)

[Your relative] may live for several months more, but don't count on that. Start talking to hospices now: That doesn't mean throw your hands in the air and give up, but they can offer valuable support if the patient's immediate family lives out of town. Hospices hate being called in at the last minute, and you can get so much more benefit from them if they get involved early on.

If [the patient's] affairs are in order, that's a great thing and one less issue for you to worry about; if not, start getting things straightened out, STAT. If there is no durable power of attorney for the patient, get one. If the patient has no attorney and no will, get one done while he/she is still competent to do so.

Over the years, I have developed one piece of advice for friends and family of the patient in these cases: when they ask, "When should I go to visit?" my answer is always "now." This is not really based on life expectancy but on the quality of interaction with the person. Better to visit early when they are still compos mentis and able to appreciate the visit than at the end when they're deathly ill and/or narcotized and cannot interact with visitors.

I hope most people won't need to use this advice, but life being what it is, I thought it would be helpful to some.

posted by Dr. Alice at #

 

posted by Dr. Alice at #

 
Wacky Phone Greeting of the Day

I was returning a phone call from a patient who'd left her work number. The woman who picked up the phone said, and I quote:

"Results happen at Positive Changes, this is Venus, may I help you?"

It's difficult to respond to an opening like that, but if I'd had any presence of mind I would have said, "Hi, this is Dr. Neptune."

posted by Dr. Alice at #

 
Back

Thanks everybody for your good wishes. My family and I went to Mexico, near Cancun, for a week. It was great. I did nothing but swim, eat and play with my niece and nephews. And yes, my birthday was Friday. No Thanksgiving dinner, but that was a small price to pay - and my mother loved not having to cook (though my niece was bummed).

And now, back to your regularly scheduled posts, when I have dug my way out from the charts.

posted by Dr. Alice at #

 
Running Out the Door

Sorry for the light posts lately, it's just been insane. I have wanted to participate in the weekly med blogs Grand Rounds, but haven't had anything useful to say or time in which to say it. Anyway, I'm off on a vacation and will be back the week of November 28. Happy Thanksgiving, everybody!

And to Ilyka - congrats on the successful turkey experiment!

posted by Dr. Alice at #

 
Things To Do...

When your co-worker is away.

posted by Dr. Alice at #

 
RIP, Good Dog

Todd died yesterday after a very brief illness. He belonged to V. and her family. V. and her husband found him at the local animal shelter. Back then, he was undernourished and skinny, but his head was huge and looked out of proportion to the rest of him; they dubbed him "Big-Head Todd." (He filled out pretty quickly once they brought him home; he was part German Shepherd, and I'm guessing, part Rottweiler as well.)

Todd was gentle, affectionate and liked people; he was good with kids. The first time I met Todd was shortly after I'd started working for The Firm, when V. invited me for a Labor Day weekend party; shortly after that, V. was pregnant and on bed rest and I dropped by to chat and augment the tedium. Todd greeted me by sticking his head under my dress and throwing my skirt in the air, which endeared him to me immediately. He loved to eat bees, too - either he never got stung or he didn't care, we weren't sure which. And he loved to be petted. In his later years I would sit beside him on the floor and talk to him and stroke him for minutes at a time; the moment I stopped he'd nudge my hand for more.

He got sick earlier this week, with bloody diarrhea and jaundice. Initially V. thought he might have eaten some rat poison, but the vet thought it was more likely cancer. Yesterday morning he was bleeding from the nose and having seizures.

There was only one thing to do. They did it.

We're all going to miss him.

posted by Dr. Alice at #

 
A Tale of Two Interns

Thanks to DB for this link to an excellent article about two interns who were polar opposites - the past and future of medicine.

Oh, and have I mentioned BugMeNot yet? If you don't want to register to read online articles, go here and type in the web address for publications like the New York Times and others. It's simple but ingenious; you pool ID and passwords.

posted by Dr. Alice at #

 
Election Fire Sale

Interesting item up for grabs on Ebay today...

posted by Dr. Alice at #

 
Australia... who knew?

[Got the below off Shauny's website. - Dr. A]

The questions below about Australia, are from potential visitors.
They were posted on an Australian Tourism Website and the answers are
the actual responses by the website officials, who obviously have a
sense of humour.

Q: Does it ever get windy in Australia? I have never seen it rain on
TV, so how do the plants grow? (UK).
A: We import all plants fully grown and then just sit around watching
them die.

Q: Will I be able to see kangaroos in the street? (USA)
A: Depends how much you've been drinking.

Q: I want to walk from Perth to Sydney - can I follow the railroad
tracks?(Sweden)
A: Sure, it's only three thousand miles, take lots of water.

Q: Is it safe to run around in the bushes in Australia? (Sweden)
A: So it's true what they say about Swedes.

Q: Are there any ATMs (cash machines) in Australia? Can you send me a
list of them in Brisbane, Cairns, Townsville and Hervey Bay? (UK)
A: What did your last slave die of?

Q: Can you give me some information about hippo racing in
Australia?(USA)
A: A-fri-ca is the big triangle shaped continent south of Europe.
Aus-tra-lia is that big island in the middle of the Pacific which does
not... oh forget it. Sure, the hippo racing is every Tuesday night in
Kings Cross. Come naked.

Q: Which direction is North in Australia? (USA)
A: Face south and then turn 180 degrees. Contact us when you get here
and we'll send the rest of the directions.

Q: Can I bring cutlery into Australia? (UK)
A: Why? Just use your fingers like we do.

Q: Can you send me the Vienna Boys' Choir schedule? (USA)
A: Aus-tri-a is that quaint little country bordering Ger-man-y, which
is...oh forget it. Sure, the Vienna Boys Choir plays every Tuesday
night in Kings Cross, straight after the hippo races. Come naked.

Q: Can I wear high heels in Australia? ( UK)
A: You are a British politician, right?

Q: Are there supermarkets in Sydney and is milk available all year
round?
(Germany)
A: No, we are a peaceful civilization of vegan hunter/gatherers. Milk
is illegal.

Q: Please send a list of all doctors in Australia who can dispense
rattlesnake serum. (USA)
A: Rattlesnakes live in A-meri-ca which is where YOU come from. All
Australian snakes are perfectly harmless, can be safely handled and
make good pets.

Q: I have a question about a famous animal in Australia, but I forget
its name. It's a kind of bear and lives in trees. (USA)
A: It's called a Drop Bear. They are so called because they drop out
of gum trees and eat the brains of anyone walking underneath them. You
can scare them off by spraying yourself with human urine before you go
out walking.


posted by Dr. Alice at #

 
You Don't Mess Around with Jim

One of the non-joys of medicine is sitting on hold with a pharmacy when you're trying to call in prescriptions. The most painful part of this process is undoubtedly the Muzak they inflict on impatient callers. Once in a while, though, they play something you actually want to hear, and then it becomes even more frustrating...



"Can I help you?" Damn!

"Hi, I'm calling in a new prescription, I need the pharmacist."

"Just a moment." Oh, sweet return to Muzak...






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Requiem

My friend from Down Under writes a wonderful remembrance of his late father-in-law. Read it.

posted by Dr. Alice at #

 
Christmas Present

Santa, I want an Atomic coffee machine.

Gimme.
posted by Dr. Alice at #

 
Links

A field guide to medical specialists - from the Head Nurse. What can I say? She's got us nailed.

Noooooo! Dave, what will we do without you?

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... In Which Dr. Alice Decompensates

So I came home late last night from an emergency school board meeting. (Health tip: never sit on a school board. There. You've just added ten years to your lifespan.) It was raining heavily - here in Los Angeles, we've been hit with the first storm of the season much earlier than usual. I entered the house through the basement door - make that the door to the brand-new, just finished basement - and stepped onto soaking wet carpet.

Yep. It's leaking.

My beloved Batcave is leaking.

The problem was solved fairly quickly. Along the side of the house, next to the driveway, are several bricked-in planters. Into one of these planters empties a rain spout. During the construction the guide at the base of the spout, which was supposed to direct the rainwater onto the driveway, was removed, with the result that about a gallon of rainwater per minute was pouring into a small, boxed-in planter.

So there I was, running around in the rain shoving cookie tins frantically under the spout, trying to bail out the planter with my hands, a Pyrex measuring cup, or whatever came to hand. Not to mention dragging out every towel I had from the linen closet and throwing them on the rug in a futile attempt to sop up the water.

The rain has stopped, at least for now, and I put in a frantic call to my contractor who promptly answered and promised to go assess the leak (we haven't made it to the final inspection yet, thank God, which at least guarantees he's motivated to help solve the problem). But it wasn't the best night I've ever had.

posted by Dr. Alice at #

 
Conversations with an Endocrinologist About Food

Dr. Alice and Dr. V. are chatting in Dr. V's office. Dr. V is trying to finish her phone calls and get out of the office (it's her half day) and has just finished speaking to a patient who needs surgery to resect a thyroid nodule.

Dr. V (mumbling to herself as she writes a consult): Please... evaluate... for surgical resection... cold nodule consistent... with...colloid.

Dr. Alice (apropos of nothing): Did you know mayonnaise is a colloid?

Dr. V (blinks, then recovers): Well, that makes sense, actually, it would be. (pauses) Thanks for sharing.

Medical Assistant (who has entered room just in time to hear a stray phrase): Did you all just mention mayonnaise?

Dr. Alice (trying to rescue conversation): Well, a colloid is droplets of liquid suspended in something. In mayonnaise the liquid is suspended in fat. Egg yolk. In the thyroid it's suspended in protein.

Medical Assistant (eyeing doctors, backs slowly out of room): Oh, okay.

Dr. V (calls after the MA): Don't worry, doctors are just weird!

Dr. Alice: Especially us!

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Hello 1918

Among the tidbits of information furnished us at the monthly staff meeting last night: we aren't getting any Flumist vaccine, either.

Damn it.

posted by Dr. Alice at #

 
Catchup

I haven't had many medical postings lately due to being very busy; I switched call groups at the beginning of the month and am now working with the hospitalist group (which means, when I'm on call, I have to go in and admit patients). Most of my Friday nights are spent in various emergency rooms now. This past weekend, in a fit of insanity, I worked both Friday and Saturday nights. Let's just say Sunday was a day on which very little was accomplished.

Drama abounds here at The Firm. Last Friday, a patient belonging to one of my partners (whom I had just admitted to the hospital two weeks previously) died at home half an hour after coming in for a visit. He was in his nineties and had severe chronic illnesses, but it was still a shock. He was a courtly Hispanic gentleman with a marvelous accent and was still as sharp mentally as he ever was. As he left the office in his wheelchair that last time I'd held the door for him and was rewarded with a warm "Gracias, doctora!" It's hard to believe that somebody so alive could die such a short time later.

Then there was the 75-year-old patient I admitted with acute leukemia not long ago. I sat with him in the emergency room as he stared at me and asked, "How long do I have?" There's no way to answer that kind of question, even if you give them the facts and tell them what to expect over the next few days. How to give hope and a realistic assessment at the same time is something I have still to learn.

As we head into the flu season I am bracing myself for many busy nights to come. I'm taking my vitamins in the hope I won't come down with it myself.

posted by Dr. Alice at #

 
Get Ready for the Flu

It's pretty clear that our group will not be getting a supply of flu vaccine this year, thanks to the Chiron vaccine problem. We're already getting anxious calls about flu vaccine -- hell, my mother called me up asking if we had any. Do you know how it feels to turn down your mother for a flu shot? Not good. Trust me on this.

I think we'll be offering a lot of prophylactic meds this year, like Tamiflu, since nothing else is available. There is another vaccine available - Flumist, which is administered nasally - but since it is a live attenuated vaccine, it is not approved for use in anyone over 49 years of age or who is immunosuppressed.

The shortage has spawned one good joke that I heard: before the third debate, Bush and Kerry flipped a coin. The winner got a flu shot.

posted by Dr. Alice at #

 
How Much Would YOU Pay...

... to get your name carved on a tombstone at the Haunted Mansion?

(According to the article, more than $16,000.)

If you're a Disneyland fan, try going here, here and here.

posted by Dr. Alice at #

 
Great Idea

Lileks for Senate!

posted by Dr. Alice at #

 
Go Here at Once

Magnetic poetry is now online. My favorite is the sexual innuendo kit.

(via Wifely Steps)

posted by Dr. Alice at #

 
Sarcasm and Medicine

Got the following emails - the first from V. (she actually had a patient tell her this) and the reply from our friend the Infectious Disease expert:

Hey Scientists!!
I've just learned of a new test. You spit in a glass of water, first thing in the morning. Don't brush your teeth first. Come back a bit later & if you have germs in your stomach, you will see that the water's become cloudy & there are wormy things floating on the top of the water. Gee, what a great test!! It might just put those ID & GI guys right out of business.

Followed by:

I've been performing this test for years--and charging for it.
Another thing I tell my patients that are concerned about eating sushi (and all the germs that could go along with it), is that if they take a hot bath afterwards, they'll cook the raw fish. Most people find that very comforting.

posted by Dr. Alice at #

 
Unbelievable

Read this, from the New York Times:

WEST COLUMBIA, S.C., Sept. 29 - Katherine Bibeau came here in March, to a red-brick doctor's office tucked between a furniture store and a steel factory, looking to slow her physical decline from multiple sclerosis.

Ms. Bibeau, a 53-year-old laboratory technician from Minnesota, met Dr. James Shortt, who practices alternative medicine. He is, according to a sign on the front of the building, a "longevity physician."

"Hydrogen peroxide would be very good to kill whatever's in there," Dr. Shortt had told Ms. Bibeau over the phone in February, according to a transcript of his taped recording of the call, "because, right now, we don't know what it is."

On March 9, Dr. Shortt administered the hydrogen peroxide, intravenously. Over the next five days, Ms. Bibeau bled to death.

Intravenous hydrogen peroxide. Stupid, stupid, stupid. Why would anyone do such a thing? It's guaranteed to destroy your red blood cells and anything else it comes in contact with - it's a powerful oxidant.

These guys give "alternative medicine" a bad name.
(via Code the WebSocket)

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HOWL

Blogger, what are you doing to me??

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A Brief Review of the Vice-Presidential Debate

Cheney: This is what we've done. This is what we're gonna do.
Edwards: I'm Kerry's bitch.

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Apocalypse Now

VISA has come out with a Thomas Kinkade credit card. Can the end of the world be far behind?

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I Dare You Not To Laugh

Ladies and gentlemen, our next president.

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Housekeeping Announcement

At long last I have updated and reorganized my links. Sorry for the delay. Take a look at the left column; they're all good.

Also, check out these Rules for Residents submitted by the Head Nurse (as in neurology). They reinforce what my dad told me before beginning residency: "Nurses can be your best friend or your worst enemy. Respect them."

And here is a new blog which may interest you if you're an Angeleno: the 4th Floor Blog is an anonymous blog written by somebody in L.A. City Hall. It seems to have quite a bit of information on what's going on. I especially liked their name for former Chief of Police, now mayoral candidate Bernard Parks: "Bitter Bernie."

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Link O' the Week

Have you heard of a web comic called Sluggy Freelance? If not, go there ASAP. It's a scream. Chock full of parodies of Star Trek, Alien, the Harry Potter books and much, much more. Also features a cute, homicidal rabbit named Bun-Bun. What more could you ask?

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Amazon List of the Day

This is hysterical: Books for People You Don't Like

posted by Dr. Alice at #

 
Fashion to Die For

In the parade of patients I get the occasional goth-dressing type in the office. They're generally very pleasant, articulate people. One showed up yesterday, dressed all in black, jet jewelry, heavy eye liner, all par for the course. What threw me was her purse: it was shaped like a coffin. Looked exactly like the one in the link.

Then there's the more annoying fashionista type - the retired woman who comes in dressed to the nines, dripping with jewelry, always talks about her next trip abroad and never ceases to complain about her copay going up. (Not to mention the cost of meds.) Grr.

Then there's me. I am pretty damned hopeless at this sort of thing - I will never win the award for Best Dressed Doctor. I tend to go with what's comfortable (when I was a resident, it took a stern edict from the residency director to get me to stop wearing scrubs). This morning, for example, I got scolded by my secretary. I have a dinner meeting tonight and came in wearing my new ensemble. My secretary wandered into my office, noted the outfit with approval, fingered my earrings:

"Now show me your shoes."

I knew I was about to ruin my good impression. Reluctantly, I extended a foot. I was wearing my flat clunkers - not even my prettier flats, as one of them was lost and nowhere to be found this morning.

"AAAH! I'm going to kill you! You need pumps with that outfit!"

"I know, but I hate them."

"Just little ones! They don't have to be high!"

Ten minutes later she came marching in with a catalog and slapped it down in front of me, to emphasize her point:

"You need these in navy, black, brown and beige."

I cringed. We're going to be debating this one for a while.

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Gee, Thanks, Dave

If you find this challenge frustrating, blame Dave Barry. He's the one who linked it. Interestingly, I found it similar to looking at a microscope slide. (You have to navigate upside down and backwards when you're viewing a slide because it's a mirror image.)

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"You. Are. A. TOY!!"

I just have one more comment on the whole Dan Rather thing. Here it is:

Yesterday when I heard the "fake but accurate" comment on the memos, that's when I had my moment of Woody enlightenment. Dan, listen up:

You. Are. A. REPORTER!! Reporters do not act this way. Your private sentiments do not come into this. You are supposed to be impartial.

But somehow, I know what Dan would reply, and it's this:

"You are a sad, strange little [woman]. You have my pity."

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My Life Is Like a Stephen King Movie

Saturday night, 10:30 pm. I was on call and had to admit a patient, and came into the office to look for a chart. I wandered around the corner into the adjoining office to get some water (our bottle of Arrowhead having gone dry), and smelled... aftershave lotion.

Fresh aftershave.

My God, I thought, there's some creepy guy in here who's going to grab me. I tiptoed back down the hall, glancing fearfully into darkened exam rooms as I went. I saw no one.

Monday morning I went back into that office to chat with the secretary. As I walked in I saw her replenishing her little air freshener, the sort that squirts scent into the air every fifteen minutes or so. It smelled like... aftershave.

"Oh yes," she said, "this is the lavender kind. Lots of people have said it smells like aftershave."

I've always hated air fresheners and now I hate them more. My eyes bugged out as I howled, "Your %^&* air freshener almost gave me a heart attack!"

posted by Dr. Alice at #

 
In Other News...

John Ritter's family has sued the hospital where he was taken for treatment:

Ritter's wife Amy Yasbeck and their four children filed a wrongful death and medical malpractice suit on Thursday in Los Angeles Superior Court alleging that hospital doctors "caused the untimely death ... by misdiagnosing his condition and as a consequence, failing to provide proper treatment in connection with an ascending aortic aneurysm that would have saved his life."

The lawsuit says that Ritter was initially diagnosed with acute myocardial infarction and then with pericardial tamponade. He actually had a large ascending aortic aneurysm.

Sad to say, this isn't the first time this has happened (I don't mean at that hospital; I mean in general). Early this year the Wall Street Journal ran an excellent article about the diagnosis of aneurysms. They're often missed. If anything good comes from Ritter's death, I think it will be that aneurysms will attain a higher profile on the diagnostic list. They won't be the last thing considered any more.

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Today

This morning I started with a long, self-indulgent post about where I was September 11, 2001 and what I did that day.

Blogger ate it. Fortunately.

Instead, I've got a better story to tell you - the aftershock of September 11. It was months later, like the aftershock of an earthquake, and it came packaged in my university's alumni magazine.

Flipping through the pages, I noticed an inset box in the Obituary section:


I hadn't known anyone personally who was killed on September 11. My brother knew someone who was on Flight 93. V., who was born and raised in New York, lost two childhood friends: One in each tower.

I started to read. (Note: I'm going to omit the names for the sake of privacy.)

A 1983 alum: ... a financial consultant with Salomon Smith Barney; Sept.11, at a breakfast meeting at Windows on the World restaurant on the 106th floor, One World Trade Center. His sister said he was the high-energy family organizer, who planned the annual reunions of 70 relatives, ordering Lebanese food; he created a game for these gatherings based on family trivia. "He was pretty much perfect."

A 1989 alum: Sept.11, One World Trade Center. This was her second day at work after maternity leave... [She] did not like working in the World Trade Center tower because she did not like heights, and as her brother-in-law had been in the complex when it was bombed in 1993.

Then the gut clincher: 1985. My year. My school within the university. My classmate.

Eleven others: One World Trade Center. Two World Trade Center. Flight 11. The Pentagon.

That was when I realized I had lost family after all. I sat at the kitchen table and cried for I don't know how long.

posted by Dr. Alice at #

 
Perfect!

Yeah. Perfect.

posted by Dr. Alice at #

 
Pessimists 1, Optimists 0

Hope magazine is going under:

After operating for nearly nine years at a loss, the magazine created to inform and inspire readers to strive to make a difference in their worlds will cease publication in its current form at the end of the year, according to Publisher Jon Wilson.

Wilson launched the magazine in 1996 in an effort to counter the "bad news" journalism he saw every day with stories about people who were striving to make the world a better place.

I never heard of this magazine. It's a great idea, but sadly, I'm not surprised it tanked. Why is it that bad news is more compelling than good news?

posted by Dr. Alice at #

 
Yum!

Here it is: the In-N-Out Burger secret menu! I'd heard that there was one but never got details on it before. The Animal Burger sounds good. For those of you who have never eaten at an In-N-Out, next time you're on the West Coast, go to one.

posted by Dr. Alice at #

 
Hands and Feet

Last week I saw a patient who's been coming in regularly to get some warts frozen. She has two large, stubborn ones on her right hand. That day, she had two other problems: a recent bee sting on the right forearm and a new large ganglion cyst on the right wrist.

"Why is it all on that hand?" she lamented.

"Bad hand karma?" I suggested. She liked that idea.


Then yesterday I saw a patient who came in with the complaint of swelling and pus on a toe. By the time I saw it, he was improving; the abscess had burst the night before. I put him on antibiotics anyway since he has circulation problems. His wife accompanied him on the visit (they are a charming Armenian couple); as I was examining him, he said with a laugh, "My wife put eggplant on it!"

"Whatever works," I replied. "Was it raw eggplant or hot?"

She explained that it was cooked, and a teaspoon of sugar added; it sounded like some sort of homemade poultice. It could well have been enough to get the infection to drain. I said that sounded fine.

His last comment of the visit, with a grin: "Tomorrow we try hamburger!"

posted by Dr. Alice at #

 
Project For a Three Day Weekend

Via Bookslut:

How To Write a Best-Selling Fantasy Novel (it's funny!)

Get cracking. You should be finished by Monday night.

posted by Dr. Alice at #

 
Internet Turns 35

As of yesterday. And it plans to get its own place soon.

posted by Dr. Alice at #

 
I'm Going To Hell

This morning I was calling back some patients, catching up on the messages that were left on my half day out of the office. (Yes, I got out of the office on my half day... but only to go to the dentist. You can't win.) Now, to understand what happened next, I need to explain (briefly) our message system. We use preprinted forms that contain info like time, date, and -- in the upper right-hand corner -- the name of the secretary who took the message. I should also explain that yesterday we had a pleasant young male temp working the front office, whose name I did not catch.

So now maybe you'll understand why, in the middle of leaving a message on the patient's voicemail, I boggled when my eye caught the name in the upper right-hand corner:

"JESUS".

And all I could think was, Since when is the Son of God taking messages for us?

posted by Dr. Alice at #

 
Man

Take a few days off the blog, come back and there's freakin' spam everywhere. Sorry. I have pruned the offending comments.

posted by Dr. Alice at #

 
Botox: Owie!

Interesting report on a lawsuit over Botox here:

Jury selection began Tuesday in the case of a former Tri-Star Pictures executive and his wife who sued a doctor and the maker of Botox, alleging she suffered numerous ailments after being treated with the wrinkle-reducing agent.

Mike Medavoy, a former chairman of Tri-Star, and his wife Irena, claim Beverly Hills dermatologist Arnold Klein gave her three injections of Botox, manufactured by Allergan Inc., in March 2002 to treat migraines.

The couple alleges the headaches continued as Irena Medavoy developed upper respiratory problems, fever, fatigue and severe muscle pain as a result of the treatments.

One of the docs in my group is married to a neurologist. He's apparently seen several patients suffering from severe, recalcitrant burning pain after undergoing several injections of Botox. Apparently you can get nerve inflammation from it. Now, I don't think all her other symptoms are likely to be related to the Botox, but I certainly would think twice before getting injections of this stuff. You may wind up with more trouble than you started with.

posted by Dr. Alice at #

 
Hah!

I'm always telling patients to use sunblock. Perhaps this will convince them to do it.

(via GruntDoc)

posted by Dr. Alice at #

 
Must Read

I AM DONALD RUMSFELD, SECRETARY OF WAR! FEAR ME!

Aah, I love Rumsfeld...

posted by Dr. Alice at #

 
Good Catch

... if I do say so myself.

Hyperparathyroidism is a subtle disease. Once or twice, I've missed early signs of it and the patients were not diagnosed until they became overtly symptomatic. (Yes! I admit it!) It's caused by overactivity of the parathyroid glands - as you might guess from the name, they are located in the neck near the thyroid. There are four of them, two bracketing the thyroid gland on each side. Their function is to control the calcium and phosphorus balance in the body. Parathyroid hormone pulls calcium from the bones and raises the calcium level in the bloodstream.

So a patient who needed minor surgery on her finger came in for a pre-op exam and labs. Her calcium level came back slightly high. I looked back a few years in her chart - it had been creeping up over the last few years. Ionized calcium - elevated. Parathyroid hormone level - over 140! Definitely high. She's off to see the surgeon; hyperparathyroidism is treated by removing the glands.

It isn't often that you see this disease in general practice, but it does crop up every once in awhile. Earlier this year I had a patient who died of it. (Disclaimer: he was 102 years old and the family and I elected not to put him through extensive neck surgery he'd never survive. We put him on hospice instead.)

Just goes to show: you never know what you might pick up on a preop exam.

posted by Dr. Alice at #

 
Here We Go Again

If you saw my office right now you would plotz: Charts, charts everywhere. I was here till eight-thirty last night and I'm still snowed under, but I've got to leave now 'cause I have to go to a nursing home and see one of my patients.

The office happening of the month has been a bird nesting in the tree outside one of the exam rooms (we're on the second floor). We stop by several times a day to watch the mama and papa birds take shifts, feed the babies, etc. Today I watched one of the babies get fed: the parent stuck its beak down the baby bird's gullet and proceeded to regurgitate food for it. Ugh. My comment to the nurses was: "I've got your child support right here - BLURGH!"

The other happening I wanted to let you know about is that I'm moving up to a corner office! YEAH! The MD who's been there for 16 years is moving to a different satellite office across town and I'm next in the pecking order. I feel so special.

More later. Sorry to be so brief.

posted by Dr. Alice at #

 
So Post, Already

Sorry to sound like a broken record, but I've been busy. Let me cast a few links in your general direction and I'll try to do better on the weekend.

Jeanette Winterson has an interesting review of the new version of The Stepford Wives (warning: it's chock full of spoilers, to the point where I'm wondering if this is the first time she's ever reviewed a movie). She's a feminist writer - an excellent one - and this naturally informs her take on the film. She liked it.

Here (via Bookslut) is an article from Flak Magazine reviewing some of the best books of the 1990's, but with a different take: best cover, best use of punctuation, best paragraph and so forth. The writer's explanations for said awards are good, too. In other literary news, via The Captain, a great interview with J. K. Rowling in which, among other things, she reveals the title of the next Harry Potter book!

Lastly, V. contributes this telephone message she received from a patient (V. is known for having some of the wackiest patients in the practice - she's a nut magnet). Verbatim:

Re: I think I'm having a respiratory infection. I just came back from Asia and I'm never sick, it is very unusual, I'm having chronic stomach pain. I could be dying a slow painful death. Please call me.

I told her, "If you ever needed an incentive not to call, it's right here."

posted by Dr. Alice at #

 
For Those Who Want the Details

Here is the CDC's fact sheet on West Nile Virus.

posted by Dr. Alice at #

 
Julia Child Dies In Sleep

Story is here. I'm sorry to see her go. Apparently she worked as a spy in WWII - I wasn't aware of that.

Excerpt:

She wrote, "Dining with one's friends and beloved family is certainly one of life's primal and most innocent delights, one that is both soul-satisfying and eternal."

Amen to that.

posted by Dr. Alice at #

 
Mo' Money

Gaaah. Two twelve-hour days in a row. I've been working shifts in Urgent Care, our after-hours clinic, to help pay off the massively incredible load of debt I've incurred due to the Batcave project (which, as I keep telling everyone, is "almost done"). The carpet is ready to be installed and the painting is nearly complete - except for the part that they're going to have to do over. Enough said.

I didn't intend to work tonight, but one of the doctors forgot that he had been scheduled to be here; after brief negotiation, I took his place. I did not have to have my arm twisted very hard to agree to this, because this afternoon I was regretfully informed by the nice gentleman working on my hard drive that it was terminal and could not be resuscitated. (It's over six years old. I thought computer hard drives would just go on merrily computing indefinitely; apparently I was wrong.) So, I'm going to get a nice new twenty-first-century hard drive, but it's going to cost about $700.

I'm tired. Hasta la vista.

posted by Dr. Alice at #

 
Thunderbirds Are Go!

It's August, and there just hasn't been that much going on. I am coping with calls from anxious patients convinced that they have West Nile (they don't), and enjoying the summer. (No meetings!) The only happenings have been minor - my boss has moved to a new house; one of the secretaries has a new grandkid; the air conditioning in the building has finally been fixed, and now we're all too cold instead of too hot.

This weekend I stopped off at V.'s house to swim - this has become a fairly regular happening - and her son excitedly invited me to watch their newest DVD: a collection of Thunderbirds episodes. Yep, the show with the puppets. A rousingly good time was had by all, it's a surprisingly fun show to watch. I was impressed with the production values and surprisingly elaborate sets.

That's all the news for now. More thrilling updates as they happen (heh).

posted by Dr. Alice at #

 
Hurrah

Christopher Buckley has a new book coming out in September and the Atlantic interviewed him to discuss it. If you haven't read Buckley, you should - he is hilarious. Thank You for Smoking is a classic.

(via Bookslut)

posted by Dr. Alice at #

 
"That's not a Moon, It's a Space Station"

Well, actually it is a moon... one of Saturn's moons, to be exact. But it's hilarious how much it looks like the Death Star.



posted by Dr. Alice at #

 
The Epic of the Irrational Bride

... is a must-read.

posted by Dr. Alice at #

 
Interesting Links

A Microsoft intern has dinner with Bill Gates. At his house.

Austria has issued a stamp of native son Arnold Schwarzenegger.

And a really interesting interview with Dave Barry at the Dems' convention. Turns out he's quite a cynic about the political process.

posted by Dr. Alice at #

 
Back

Sorry about the lack of posts. My home computer is acting up and I'm going to have to take it in to be brainwashed or put to sleep or something. Also, I was hit with a blizzard of work upon my return. In fact, the pattern of the rest of my summer is clear: work work work. That's okay, though, because summer is generally simpler: the school board isn't meeting, work committees are on hiatus. It's practically a vacation (she said, gritting her teeth).

I realized yesterday - payday - that I'm going to be hit with one hell of a tax bill next year due to all this moonlighting that I'm doing, but I'll worry about that later. The house project is almost done (we haven't mentioned the house for a while, have we?) We're down to the carpet and paint part. Hallelujah. Of late, V. has taken to calling it "The Batcave" (as in, "I can't wait to see the Batcave when it's done.")

One thought about Kerry's speech, which I was listening to in the car last night. His mantra was "Help is on the way!" After hearing this about five times, I started thinking: So, the American electorate is Timmy, and Kerry is... Lassie? Oookaaay...

More later...

posted by Dr. Alice at #

 
Vacation, Day Two

So today I'm doing my favorite thing: sitting around the house. Only in this case it's somebody else's house - my brother's. I'm having a lovely time playing FreeCell and watching the fog roll in (it's been so hot in LA lately and this is such a relief!)

My bro has a flat in an old brownstone in the area of San Francisco near UCSF. I can't think of many other cities in the States where people use the word "flat", but they do here. It isn't an apartment in the New York City sense of the term, where there are multiple housing units on each floor of a building: Here you get the entire floor straight through to the back. These flats are quite spacious - I think his square footage is bigger than my house.  My brother bought the place about seven years ago; it had been owned by a family for decades, and the holdout surviving relative was a hermit and had (illegally) split the top floor in half and had rented it out to two different tenants. I visited the house back then and it wasn't in good shape - John put a lot of work into it, and it's in much, much better condition now than it used to be. Drawback: the house is across the street from the local branch of the Fire Department, and it is not unusual for the sirens to gear up and the trucks to roll out about 2:00 am. I asked my sister-in-law this morning if that bothered her and she said, "No, I grew up in New York, but it still bugs John."

Last night after I got in I had dinner with my sister-in-law (takeout Greek salads - she got home late) and we chatted about work and, you know, stuff. She works for Yahoo! (exclamation point obligatory) and I asked greedily about the company cafeteria - were the rumors true? "Yep, it's subsidized and seared tuna and couscous are, like, $3.95." Damn. Needless to say, my Firm does not provide such fringe benefits. (The hospital across the street has free cafeteria food for the MD's but they don't run to gourmet eats there.)

This morning I drove down the peninsula to Menlo Park to visit a high-school friend of mine and admire her youngest child (ten weeks old, and a real cutie), then returned and considered driving across town to a coffee house where I used to hang out back when I lived in SF - but then I realized, hey, I can sit here, drink coffee, read magazines and surf the Net for free! And that's exactly what I did. San Francisco is second only to New York in wringing every last drop of tax income from its tourist population; my motto was "I'm not giving those SOB's an effing cent."

Well, that's not quite true. I did go down the street to get a coffee and some Diet Cokes for tomorrow's drive. And then The Bro called and said he had to work late and why didn't I take the N subway out to the restaurant district for dinner? I almost did but then I remembered this place which makes my all-time favorite pizza and ordered from them instead.

The pizza: the Verdi's Special. Pesto (no tomato sauce), spinach, onion and feta cheese with mozzarella atop. No. Better. Pizza.

On to Mendocino tomorrow.

Oh, I forgot to mention one eye-catching ride: the PimpMobile. It's a hot-pink-and-purple stretch limo parked down the block (it makes me wish I had a digital camera!) I'll see if my brother can tell me anything about the car or the owner.




posted by Dr. Alice at #

 
One Tomato, Two Tomato

Ever driven from Los Angeles to San Francisco? I did today. I took a few days' vacation and came up here to visit relatives. The most direct route, Interstate 5, runs up the center of the San Joaquin Valley through flat farmland. It is a long long drive, if you drive like me; those with lead feet can cover the distance in much less time. Under the best of conditions we're talking over five hours. 

If you make this drive alone it is imperative that you find ways to entertain yourself (a.k.a. stay awake). About halfway through the trip I started noticing tomatoes at the side of the road. They were easy to see - little spots of red fluorescence against the asphalt. Obviously they'd fallen off one of the produce trucks.

I decided to count them. First one, then another two fairly close to each other, then a gap, then another two (they seemed to come in pairs)... then we hit a rough patch of road and holy cow, there's a whole pyramid of them...

I was coming up on a tractor trailer full of tomatoes. Ah, I thought, so it's his fault! Sloppy driver. But no, up ahead of him were yet more tomatoes on the side of the road. I had counted  more than eighty (not including the pyramid) by this time. I was beginning to feel sorry for the poor, split, crushed tomatoes left to rot by the side of the road. Suddenly I visualized an organization that would stand up for discarded produce: PETT (People for the Ethical Treatment of Tomatoes). Their slogan? "Why must the lycopenes suffer?"

At that point I realized I needed to take a rest break.

posted by Dr. Alice at #

 
Dark and Stormy Night
 
The Bulwer-Lytton Fiction Contest results have been released. Here's my personal favorite:
 
Galileo Galilei gazed expectantly through his newly invented telescope and then recoiled in sudden horror -- his prized thoroughbred's severed neck, threateningly discarded in a murky mass of interstellar dust (known to future generations as the Horsehead Nebula), left little doubt about where the Godfather and his Vatican musclemen stood on the recent geocentric/heliocentric debate.

(via Bookslut)

posted by Dr. Alice at #

 
...And He Lived To Tell About It

Only Ernie would have come up with this one:

I Gave My Cat an Enema

posted by Dr. Alice at #

 
Paradigm Shift

Just logged on to Amazon and saw the following, so help me:

My Life was released today (sic); we thought you'd be interested because you bought Garage Sales 101.

Huh?! Other than the obvious joke that Clinton's book is likely to end up at a lot of garage sales, I don't see the connection.


posted by Dr. Alice at #

 
Weight Loss Surgery? I Don't Think So

From American Medical News comes this interesting (and relevant, to us primary care docs) story on weight-loss surgery:

Bariatric Patients Need Lifelong Care (or, as I would put it: "Duh.")

A few years ago no insurance plans would pay for bariatric (a.k.a. weight-loss) surgery, or would do so only reluctantly. In the last two to three years that has changed significantly, as insurance plans have set specific indications for this surgery; in some cases even teens are now being approved (though this is still controversial). Many of the older surgical protocols are no longer being authorized, as long-term studies have not borne out their effectiveness and/or safety. In my practice more and more patients are applying for surgery and are being approved; I'm guessing maybe ten of my patients have had this done in the last year or two.

I still have problems with this approach to weight loss, though for the right patient it is undoubtedly effective. Here's my biggest issue: surgical treatment does not deal with the primary drive to overeat, which is emotional (most of the time, anyway). Patients are supposed to receive psychological screening prior to the surgery, but in my experience this is a joke. My medical director once asked, rhetorically: "Has anybody ever had a bariatric patient turned down by the psych team?" (Nobody had.) I have seen patients regain huge amounts of weight, once they figure out how to "outwit" their surgically revamped digestive tracts. Some patients never lose weight in the first place, at least not much, for the same reason.

How do you outwit a gastric bypass? Well, the commonest way to do so is via "liquid" calories - meaning high-calorie, low-volume foods such as smoothies, ice cream, chocolate and booze. When I tell patients that they'll have to make a conscious effort to avoid such foods after surgery, and that they'll still need to exercise in order to achieve maximum weight loss, their faces fall. I really think people are viewing bariatric surgery as some sort of "magic" effort-free method of losing weight. Speaking as someone who has struggled with a lifelong weight problem, I can empathize with this, but I feel patients need to be warned both about its true effectiveness and about the lifetime consequences of such surgery.

The article emphasizes the importance of continuing dietary supplements postoperatively - this is a lifelong requirement. Unfortunately, many patients are not doing this. The supplements are often not covered by insurance (they're "vitamins," not medications) and can be expensive. For instance, many postsurgical patients will suffer from iron-deficiency anemia unless they take an iron supplement specifically formulated for people who have difficulty absorbing iron. They're also at higher risk for B12 deficiency and osteoporosis, as well as deficiencies of fat-soluble vitamins. Some patients need to be followed with blood tests to check for deficiencies as well. Every managed care doc cringes at the thought of being confronted by a patient clutching a list of esoteric, expensive lab tests ordered by a surgeon who doesn't give a damn how much they cost, because he didn't sign a capitation contract with a lab.

Lastly, as the title of the article suggests, we primary care MDs need to be educated about the type of care such patients need. Do they need to be screened for osteoporosis sooner? How often do they need labs? Will they need to be colonoscoped more frequently? Do different surgical techniques carry different long-term risks? I don't know the answers to these questions. If anyone can recommend a good source of information (Internet or otherwise) I would love to know about it. In the meantime, read the article if you haven't already - I think you'll find it educational.

posted by Dr. Alice at #

 
He's Not Paranoid, They Are Out to Get Him

Just found an interesting new Industry blog (what do you mean, 'which industry'?) via L.A. Observed called A Fly on the Wall. Said blogger is anonymous, at least for now.

Lead article today: Michael Eisner's office has been bugged. The listening devices were apparently found during a sweep of his office over the long holiday weekend. The post goes on to state that

Eisner routinely pays for a security sweep by electronics experts every few months out of his own pocket. This is the first time evesdropping bugs are believed to have been found.

After some apparent internal disagreement, Disney officials decided not to alert the Burbank Police Department about the security breach. Disney is notoriously closed-mouthed with Burbank city officials about studio operations, and Burbank police are not allowed on the walled and gated studio lot unescorted.

As to who may have planted the bugs, the list of Eisner's enemies is slightly longer than the Manhattan telephone directory. Some of his current high-profile battles include an ongoing showdown with Miramax's Harvey Weinstein and also a bitter feud with a Roy Disney faction for control of the company.

I don't know where the guy gets his info, but if accurate, it sure is interesting. If you scroll down you'll find another interesting article about celebrities registered to vote in more than one location. "Vote early, vote often"? Hmmm...


posted by Dr. Alice at #

 
"You Got Your SciFi in My Mystery!"

Scifi mysteries are the Reese's Peanut Butter Cups of literature. (One of the pleasures of having a blog is being able to write sentences like that.) By saying that, I mean that each is such a recognized genre in itself that to combine the two seems a little shocking at first - too much of a good thing? Or, for those who like one genre but not the other, why spoil my good thing with this other stuff? (I admit I've never been that much of a scifi fan.) Nevertheless, I recently have had the good fortune to come across three books that I can recommend for summer reading which fall into this category.

The first two books, Bimbos of the Death Sun and Zombies of the Gene Pool, are by Sharyn McCrumb. She has written many other mysteries which don't involve scifi, but these two deal with the adventures of college professor Dr. James Owen Mega, aka novelist Jay Omega. Dr. Mega wrote a solid scifi novel and had the misfortune to sign with a publisher who slapped the lurid title "Bimbos of the Death Sun" on it, hoping it would increase sales. Half the fun of these books comes from watching Mega cringe every time the title of the book comes up. Interestingly, McCrumb likes to focus on the culture of scifi fandom - in the first book there's a murder at a fan convention; in the second, one of a group of scifi writers is murdered at an authors' reunion. Apparently "Bimbos" has acquired a cultlike status among scifi fans and has been used by actors attending conventions as a sort of orientation tool! It's straight-out funny, "Zombies" somewhat less so, but both are worth reading.

My third recommendation is definitely scifi, albeit filtered through Raymond Chandler's noir sensibility: Gun, With Occasional Music. It's also a lot darker than the first two, happy ending definitely not included. At the beginning of the book, author Jonathan Lethem quotes Chandler stating that a suspect was "as easy to spot as a kangaroo in a dinner jacket": it's clear that this line gave him the idea for the book. It's set in Oakland sometime after 2008. The printed word has been outlawed. Everyone's hooked on a drug called "make" (you snort it), including the detective narrator. The population is now made up not only of humans but genetically modified animals with human intelligence and the capacity for speech. We meet a sheep, a kitten, an ape, and yes, a kangaroo. The scenes involving the detective interacting with the cops (now called Inquisitors) are straight out of Chandler. Strange, nightmarish, and very good.

posted by Dr. Alice at #

 
BINGO!

Last week I saw a patient who was complaining of general pain on the left side of her body, but more particularly of pain in the hands and wrists. No pain in the feet. She felt generally unwell. On a hunch, I checked titers for parvovirus - and hit the jackpot! Her IgM (acute antibody titer) was through the roof.

I see a case like this about every one to two years. It's satisfactory because you can put a name to the problem and reassure the patient that the symptoms will go away and they're going to be fine.

posted by Dr. Alice at #

 
Third of July

Today is the anniversary of one of the most memorable days of my life. It's a day I love to remember. Not that it was important in the conventional sense - no graduation, no proposal or anything like that, but it was one of those days that stands out in the memory years later. I can't remember what year it was - I was about seven - but I know it was the third of July, because it was the day before Independence Day.

One of my father's patients was a strawberry farmer in Orange County (these were the days when Orange County still had large tracts of farmland scattered through its urban areas). It was the end of strawberry season, and he invited Dad to bring his family and pick all the berries we wanted; he was going to plow the field under in the next couple days and plant his next crop.

So that's what we did. We went and picked berries. The nearest I'd gotten to picking fruit before was the lime tree in the backyard, not known for its productivity. I remember a sunny, breezy day, bending over to see the bright red berries on the ground and smelling the moist earthiness coming up from the plants. It was marvelous. We picked and picked, then came home with two huge flats full of dead-ripe berries. After we'd all had a bowl apiece, there were still tons left and it was obvious that we'd never be able to finish them before they rotted - they were just too ripe. My mother thought for a minute, then resignedly picked up the phone, called her mother in Tennessee, and asked:

"How do you make strawberry jam?"

Mom made jam! Better yet - strawberry jam! And it was summer vacation - and the next day was the Fourth of July, with the promise of fireworks. Could life get any better for a seven-year-old kid?

This third of July is different. I'm on call, and just got back from making the rounds of the nursing homes. Earlier this morning, I admitted a patient of mine with severe pneumonia, only to watch him die in the ER. (He was horribly ill, and his friend who had power of attorney agreed to extubate him; it was the right decision.) But every year I think back to the kid who picked berries with Dad and watched Mom make jam, and now I realize that the seed for this year's third of July was planted all those years ago when I watched my father's patient thank him for his care the only way he could: by putting his crop at our disposal.

His name was Tamaguchi. Thank you, Mr. Tamaguchi, for my third of July.

posted by Dr. Alice at #

 
Weekend Roundup

Various unrelated but interesting links for your long weekend:

Via Bookslut, a link to an interview with Alain de Bottoin. Do read it, and I can highly recommend How Proust Can Change Your Life. I haven't read any of his other books, but I intend to.

The Fourth of July is Dave Barry's birthday. Stop by and wish him the best.

L.A. Observed has an excellent post on local writer D.J. Waldie, who first became known in 1996 for his book Holy Land: A Suburban Memoir. Part autobiography, part urban study, it became an instant classic. He's published a new collection of essays that has been well received. I'd recommend anything this man has written, especially if you live in Southern California - but he's worth reading even if you don't. His story is an interesting one. He lives still in the small house in Lakewood where he was born and raised in the Fifties, has never married, and works as a civil servant for the city of Lakewood. I get the impression he lives to write, and specifically to write about L.A. He does a wonderful job.

Via Tim Blair, it's "Rock, Paper, Saddam!" Give the pictures time to load. Muhaha.

And finally, via Ernie, it's the Amazon.com Knee-Jerk Contrarian Game! Here's how it works. Go to Amazon, pick a favorite book or movie, and rank the reviews in reverse order (worst first). It's quite entertaining. Here are a few samples:

On the film Seven Samurai:

Save your money and time by not watching this badly made kung-fu movie. The guys in this movie do not know martial arts at all.

This movie seems to be a scene-by-scene copy of one of my favorite movies-"Magnificent Seven". Magnificent seven is a classic movie that has been copied many times, but I didn't know westerns were popular enough in japan to be copied.

Uh, well, okay, how about Citizen Kane?

"The only good thing about Citizen Kane is that it will put you to sleep faster than any film."

"Please stop the hype on Citizen Kane. It doesn't work. It's like you are trying to convince people that poop smells good."

"Citizen Kane is a hymn to all filmmakers who have ever tried to create something artistic and meaningful and failed miserably every step of the way."

"It was just a bad attempt at a boring story about newspaper tycoon. It's one of the worst movies I have ever seen."


And there's so much more. Enjoy.

posted by Dr. Alice at #

 
Question of the Day

From an anxious patient contemplating pregnancy, this message:

"I eat a lot of sushi. Do you think I should be tested for mercury?"

No. No, I don't. But I do think you should lay off the sushi.

posted by Dr. Alice at #

 
Capitalism 101

Your assignments: Lileks on The Parable of the Steps. The Food Whore on The Parable of Why Catering Costs More Than Doing It Yourself. (You may have to scroll down; it's the "Good Whores Don't Come Cheap" post.)

You'd think people would have figured it out by now...


posted by Dr. Alice at #

 
Worrisome News

Via The Lost Blogs Home:

Thousands of Blogs Fall Silent

Blogging pioneer Dave Winer unexpectedly closed Weblogs.com, his free blog-hosting service, on Sunday, leaving thousands of bloggers without access to their blogs. Blogs affected by the shutdown now redirect to a generic message posted by Winer. Some bloggers are screaming that the shutdown is a serial "blog murder."

I wouldn't go that far, but I can certainly see why people would be upset. Winer is going to try to allow users to save and archive their blogs on their computers by emailing them their files. The controversy here is that paying bloggers are now saying, "Idiots, what did you expect?" or similar.

Is this incident going to separate 'pro' paying bloggers from 'amateur' free bloggers? Is this the beginning of the end for free blogging? Stay tuned to find out!

Oh, and now I'm going to try to figure out how to save my posts, just in case...

posted by Dr. Alice at #

 
Phone Call of the Day

I got a message that "Patient called with allergy question."

OK. Here is what she said: "I have an allergy to cats but I'm about to get one. What can I take?"

Lady, don't get the freaking cat!

Oh, wait. No, that was my fantasy reply. What I actually recommended was for her to try over-the-counter Claritin and keep the cat out of the bedroom.

Nothing against cats, but if you're allergic no medication works as well as avoiding the allergen in the first place.

posted by Dr. Alice at #

 
Warning: Cute Baby Story Ahead

My mother told me this story today and I just had to pass it along:

My youngest nephew just turned two. His name is William, but lately he's become known as Trouble, as in "Here comes Trouble."

Last weekend my sister and her family went to her in-laws' for dinner. Dessert for the kids was ice cream bars. The freezer in which the ice cream bars are kept is in the garage, which has a connecting door to the kitchen.

So dinner was over and the adults were trying to have a conversation, when the doorbell rang. Outside was William, with an ice cream bar in his hand. He'd opened the door, gone into the garage, gotten into the freezer, extracted a bar and gone around to the front door and rung the doorbell to be let in! After discussion, my sister made William share the ice cream bar with his brother, and barricaded the door from the kitchen to the garage.

It gets better: shortly after this, it started raining. My sister's mother-in-law decided to open the front door but leave the screen door closed to watch the rain. They continued with their conversation and soon there came a tapping at the screen door. It was William again, with bar number three in his hand. He'd sneaked out the screen door and gone back to the garage.

At that point my brother-in-law gave up and shouted, "That's it, everybody into the car! We're going home!" (And William was made to put back the ice cream bar.)

See what I mean about "Trouble"?

posted by Dr. Alice at #

 
Thursday Afternoon

Set the scene:

It's my half day. Our Medical Director is out on vacation, as are many other members of The Firm. I, Dr. Alice, your host, have been nominated Acting Medical Director because all of the Usual Suspects who would normally cover this job are also on vacation. This means, among other things, that I have been put in charge of STAT insurance referrals.

I have no idea what the hell I'm doing.

Here we go:

Dr. Alice picks up a chart and reads the message. Message says, [Patient] states her insurance has changed so she needs another prescription called in for her [anti-depressant.]

Dr. Alice: I hate you.

Dr. Alice picks up phone and calls refill to pharmacy because her medical assistant has left early (after all, it's Dr. Alice's half day!)

Secretary appears with armful of faxes.

Dr. Alice: What are those?

Secretary, nervously: These are from UR [Utilization Review]. She called a few minutes ago and said you had to review these.

Dr. Alice flips through pile of faxes, most of which consist of requests for breast reductions and extensions of physical therapy with reams of documentation attached.

Dr. Alice: Oh shit.

Details of chart reviews and decisions omitted, due to risk of stupefying boredom. Assume decisions are made.

Page on telephone intercom: Doctor, it's Generic Geriatric Nursing Facility. One of Dr. X's patients was just admitted. [Dr. X is on vacation and she's in my call group.] Who's going to follow the patient until she gets back?

Dr. Alice quickly consults call schedule, which is hanging on the wall: Dr. Y is on call today, so he gets the patient. (Standing rule. It's the law of the jungle.)

Voice on Intercom: Well, uh, should I tell them to call him?

Dr. Alice: No, it's better if I do it. I'll leave a message on his voicemail and then run like hell.

[Tinny giggle from intercom] They need admission orders verified. Will Dr. Y do it?

Dr. Alice, in resigned voice: No, I will. (No need to add insult to the injury I'm inflicting on Dr. Y.)

Orders verified. Message left (very apologetically) for Dr. Y.

Dr. Alice returns to her previous activity of leaving messages for patients; calls random patient, gets answering machine message consisting of 45 seconds of rap music.

Dr. Alice: I hate you.

And so the long day wore on.

posted by Dr. Alice at #

 
Human Interest

Couple things for you. First, this link to a nice story from the Wall Street Journal about items found in used books. (Thanks to Bookslut for the link.) Second, a recipe. (Time I gave back to the food blog crowd after all my taking from them.)

This recipe is actually from the Sweet Potato Queens' cookbook, which could also be called Eat What You Want and Die Like a Woman (see cookbook post below). It's called "Hal and Mal's Come Back Sauce." It can be used as salad dressing or as a dip for veggies or shrimp.

Put the following in a food processor or a large blender:

3 cloves garlic
2 C. mayonnaise
1/2 c. ketchup
1 C. salad oil
2 tablespoons cracked black pepper (no, this is not a typo)
Juice of 2 lemons
2 tsp. mustard
2 tsp. Worcestershire
2 dashes Tabasco
1/2 onion, chopped

Whiz till it's blended.

I tasted this and thought, baby, where have you been all my life? It's a bit like Thousand Island or Russian dressing, but with a bit more kick to it thanks to the lemon juice, mustard, Tabasco, etc. You can cut back on the pepper but if you're using it as a dip I would recommend using the whole 2 tbsp.

It's not low fat - obviously - but it is good. The recipe makes a ton.

posted by Dr. Alice at #

 
Enjoy In Moderation

Yesterday, I'm not sure why, I wound up doing a web search for TV drinking games. The best two I came up with (closet fangirl that I am) were the following:

The Quantum Leap Drinking Game

The Doctor Who Drinking Game

As always, it's the cliches in the shows that make these so entertaining to read about. (Play at your own risk! hic!)

posted by Dr. Alice at #

 
Somebody Should Get These Kids to Clean Their Rooms

I didn't realize Russia has hackers too:

A teenager who sent an obscene text message to 15,000 cell-phone users has become the first computer whizkid in Russia to be convicted of sending "spam."

The best part of this story was the awkwardly constructed last sentence:

Russia has gained notoriety for its large number of talented and often disaffected young computer experts, whose bedrooms are regularly suspected of spawning major viruses.

posted by Dr. Alice at #

 
Not New, But Funny

The Onion scores again:

EDINBURGH, SCOTLAND - Speaking though her publicist, author J.K. Rowling shocked fans and the publishing world Monday when she announced that she has opted to end the best-selling Harry Potter series because she has discovered boys.

According to Knowles, instead of working on the as-yet-untitled sixth installment in her series, Rowling has spent the past two months sunning herself at the beach, reading fashion magazines, and talking on the phone for hours.


posted by Dr. Alice at #

 
Mal de HMO

Gee, it has been a while, hasn't it... sorry. I could tell you all the excruciating details of what I've been doing the last two weeks, but suffice to say, I've been busy. Also creatively burnt out. But I do have topics to write about and will step up posts this week.

I will share with you a recent bemused email from V. on the subject of How Your Health Insurance Funds Are Being Spent:

I referred a patient to ENT & Neuro for persistent dizziness after a cruise. Ultimately, she had a VAT (Vestibular Autorotation Test). Tne upshot was that she suffers from Mal de Debarquement, "a syndrome defined by persistent sensation of swaying or rocking, particularly following sea travel."

Golly, I'm sure glad we spent the money for that eval.


OK, ok, we documented that she doesn't have anything worse & with this documentation, mayhap the ins. will auth vestib rehab. therapy. I dunno. But, dang!! We had to send her all over creation to make the diagnosis of Mal de Debarquement - when I thought she suffered from some sort of persistent sea sickness. Tres chic!!

posted by Dr. Alice at #

 
World's Best Cookbook Title

Eat What You Want and Die Like a Man.

(As a doctor with some frayed, residual sense of ethics, I cannot recommend this.)

posted by Dr. Alice at #

 
Twenty-One Gun Salute

My secretary brought in a tiny black-and-white TV today and I've been watching the funeral procession all afternoon. It is remarkable to see how many people turned out to see Reagan, both in Simi Valley at the library and now in Washington.

I'm getting eerie echoes of the past here; I was born four days after Kennedy's assassination, and my parents have often told me of the weekend my mother spent in the hospital prior to my birth (she was at bedrest for pre-eclampsia). My father managed to bring in a small TV and get it hooked up. My mother said the nurses were in and out of her room constantly to watch the news (this was well before it was standard procedure to have televisions in hospital rooms). The Kennedy funeral was the blueprint for the Reagan funeral arrangements, so it gives me an idea of what my parents saw that weekend.

I'd also like to leave you with this quote:

[Reagan] was put on earth to do two things: kick butt and chew gum, and he ran out of gum around 1962.

That pretty much sums it up.

posted by Dr. Alice at #

 
Well, That Was Fast

The gentleman I told you about yesterday died at five o'clock this morning.

It's probably the best way it could have happened.

posted by Dr. Alice at #

 
In This Bridal Season...

I can't do better than to direct you to this weblog. It's written by a caterer who calls herself a Food Whore and it's hysterical. The descriptions of the weddings are priceless, particularly this one ("I Won't Even Get Out of Bed For $5").
(via Very Good Cooking)

posted by Dr. Alice at #

 
You Never Know

So I've got another dying patient. We seem to go through cycles of this kind of thing (what V. calls "the thinning of the herd"). This fellow is in his nineties, has severe heart failure and kidney problems, and peripheral vascular disease (translation: his foot is turning blue due to lack of blood). He has lived at home with a caretaker and close attention from his daughter, but in recent months has become weaker, had multiple visits to the hospital, and has had two episodes of pneumonia in the last year. This time when he went to the nursing home for rehab he was too weak to participate in the therapy sessions, and he's stayed there ever since, more or less bedridden. The ulcer developed two weeks ago. The vascular studies I ordered confirmed that he needed surgery (you know it's not good when the report says "critical ischemia").

So I reviewed the report and thought: OK. This man would likely not survive surgery. He'd never consent to an amputation, and a vascular bypass on his leg would require an angiogram to see if he had operable disease; the dye used in the angiogram would likely wipe out his kidneys (which are hanging by a thread). After discussing all this with his daughter, she agreed with me and I referred him to hospice care. We're going to focus on pain control and comfort care.

When cases like this stick in your head, it's usually not the disease process that you're thinking of, it's the patient. So it is here. The case I just described is not unusual for internal medicine - a bundle of disease processes, each playing off against the other, forcing the doctor to choose a treatment strategy. Not that this isn't interesting - it has a lot to do with why I enjoy my job - but I'm remembering something else.

I picked this patient up about two years ago when his previous doctor left the group. His chart was the size of the phone book, and I was too busy keeping up with his meds and his various illnesses to go much into his past history. About two months ago, with the worsening of his illness, the patient became more depressed and I decided to get a psych consultation to see if medication would help. When I saw the consult note, this is what I read:


Patient is a Holocaust survivor. His first family (wife and children) died in the camps. After the war, patient remarried. His daughter Ms. X [who is the one who stays in touch with me] is a product of his second marriage.

Holy crap. I didn't know.

I keep thinking of this man who fought so hard to survive, whose body is now betraying him and falling apart. He has his daughter, and his caregiver, so I suppose things could be worse; but I can't do much now except ensure him a comfortable death.

I will do that. I promised his daughter.

posted by Dr. Alice at #

 
Go Ray Bradbury

In 1953 Ray Bradbury wrote a sci-fi classic called Fahrenheit 451. Michael Moore "borrowed" this title for his documentary, Fahrenheit 9/11. How does Bradbury feel about this?

He's not happy.

(via Tim Blair)

posted by Dr. Alice at #

 
Old Guard Vs. New Guard

A couple weeks ago The Firm held one of its quarterly partners' meetings. These meetings are generally long and dull, as I suppose the meetings of most businesses are. They are enlivened in the first half hour by the serving of dinner ("Pollo Loco again?")and by the chance to chat with one's fellow MDs. The Firm is pretty big, and our members are spread among four or five different offices, so in many cases we only get the chance to talk in person at one of these meetings.

At this particular meeting an issue came up which illustrated - to me, anyway - the changes taking place in medical culture. The topic at hand was partnership. To be more specific, a doctor who has been with us for two years (the traditional length of time before a member qualifies) was under discussion for possible partnership. She works hard, is respected by all the MD's in her office, and is committed to the group. The problem is, she works part-time (though more than 50%) and no one in the history of The Firm has ever been admitted to partnership without working full-time for at least two years. We have several doctors who work part-time, mind you, but all of them worked full-time for years before switching. Thus the debate: could anyone not working full-time even be considered for partnership? Forget prorating benefits, forget her skills or commitment. Would The Firm even be willing to consider a part-timer as a partner?

Three of the senior docs (all male) immediately voted no. They gave various reasons but they all boiled down to a variant on "Can we rely on anyone who isn't willing to commit fully to the group? Do you realize this means that someone working part-time might then qualify to be a member of the board of directors?" (because any partner can run for the board).

You could feel the atmosphere change in the room. Every woman sat a little straighter. All the part-time doctors in the group are female, and they all have kids - this is of course their whole rationale behind working part-time. Hands started going up. "How are we supposed to attract women physicians if we aren't willing to take part-time MDs as partners? You know the demand for female physicians these days, and let's face it, most of them are going to have kids. We've got to do this."

I'll spare you the rest of the debate. Suffice to say that the Old Guard was voted down in a landslide. They looked somewhat taken aback but accepted the situation with good grace. There are lots of details still to be thrashed out, but it looks as if the old mindset of "Forget about your family, Medicine comes first" is changing.

The following week I was chatting with V. and told her about the events of the partners' meeting (she'd missed it, being on vacation). Specifically, I told her about Dr. X, one of the old-timers who'd led the Old Guard in arguing against granting part-time docs partnership. Her response was succinct:

"Who raised his kids?"

posted by Dr. Alice at #