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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    Thursday, December 23, 2004

    It's Ugly Christmas Lights.com. Enjoy.

    Tuesday, December 21, 2004
    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!"

    Sunday, December 19, 2004
    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!

    Friday, December 17, 2004

    ... 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.

    Tuesday, December 14, 2004
    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

    Friday, December 10, 2004
    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.

    Wednesday, December 01, 2004
    World AIDS Day