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The man's a genius. He's also a great writer; check out his site if you haven't already. I do wonder, though: just where did he get all his drug pens?

Raiders of the Lost Lunch

Again with the hospital rounds this week. It's been nonstop work, but I have enjoyed a little free entertainment with it. Eavesdropping on the little workplace dramas playing out around me against the background of admissions and discharges is fascinating. Let me give you an example:

Setting: the nurses' station.
A nurse hangs up the phone: "It was delivered to the wrong floor," she says disgustedly.

Another nurse looks up and asks, "So where's the lunch?"

"It's gone. They ate it. They were happy to get free food."

"They ate our lunch??"

"Yeah. I am so mad at them..."

Oh, the tragedy. No sarcasm intended: it's little things like that that'll ruin your day. I hope the nurses track down their lunch scarfers and collect their money back.

Sears: Art Vendor?

The Wall Street Journal had a wonderful article yesterday about the glory days of the Sears catalog, when the company sold art - genuine works by Picasso, Rembrandt and other artists - by mail. Their spokesperson was none other than Vincent Price (yes, that Vincent Price), an enthusiastic art collector who started his career studying art history before he switched to acting. When approached by Sears, he thought selling art to the public through the catalog was a great idea and worked with their marketing department to develop the Vincent Price Collection of Fine Art. Sears started selling works of art in 1962; the program ran for nine years, and during that time Sears sold some 50,000 artworks. Read the entire story, it's fascinating.

Site of the Weekend

If you like movies, especially opening credits, you'll love this. It's a site dedicated to Saul Bass and contains many examples of credits he designed for films (including Anatomy of a Murder, North by Northwest, Spartacus and many more). The site allows you to pick a film and then flip through the credits frame by frame; great fun. Me, I love movie credits; not long ago I sat watching a film called The Wrong Guy, starring Dave Foley, in great anticipation because the credits (clearly inspired by Charade and other chase films) were so much fun. Unfortunately, the credits turned out to be the best part of the movie - although I'll still give it a limp thumb up for the scene in which Colm Feore (playing a hired killer disguised as a priest) busts out of his motel room with guns blazing. And then somersaults off the balcony onto a car roof. Oh yeah.

Bass worked with master film directors including Otto Preminger and Alfred Hitchcock (in fact, he co-directed the shower scene in Psycho). It has been said that if you go to a movie in which Bass designed the credits, you can walk out of the film after the first three minutes because he shows you exactly what's going to happen. Go to the site and judge for yourself.

Try this online cricket game (via Tim Blair) if you're looking for an office giggle. Tip: play the Brit side first, then the Aussie (aka "convict") side.

Perhaps I should change my blog title to 'The Disenchanted Doctor'. On second thought, no - but I do have a new entry for my sidebar. And perhaps I should be more articulate about HMO's, medical regulations, and other issues that health care providers face. It might provide readers with some useful information. Something to think about for future posts.

This led me on to remember what I like to think of as the "Christmas in July Affair." One hot summer a few years ago a patient came in complaining of a wound on her ear. She'd gotten an insect bite and decided to control the itching by applying ice packs... for a really long time. The pinna (outer ear structure) was blistered and peeling. Diagnosis: frostbite. She did fine, but it still cracks me up to think of someone presenting with frostbite in the middle of the summer.

So now I'm corrupting six-year-olds. What next?

We finished off with a visit to the refreshment tent and headed back to the car. I suddenly realized that I was feeling better as we both replayed our fearless climbs to the top of Mount Hummer and extolled our friend Jason (both his sterling character and his physical virtues). I now know why guys seem to like cars so much... they just make you feel good.

That's it, really - except, READ IT. It was worth the wait.

Let me start off by saying, I could be completely wrong about this. Feel free to vote in the comments if you are so inclined.

Last week I had a patient - young, healthy - who came to our after-hours clinic with a moderate cough that had been going on for about two weeks. No fever. The clinic doc prescribed an inhaler for bronchitis and recommended a chest X-ray. I called the patient next day to discuss. Frankly, because the clinic note and the patient's description of the symptoms sounded so mild I could have flipped a coin, but since the patient had not improved on the treatment suggested by the clinic doc I ordered the chest X-ray. Next day I was called by the radiologist, very excited, who reported a cavitating lesion in the upper lobe of the right lung. The radiologist thought it was TB. Naturally, I informed the patient; naturally, the patient was upset. There was no history of active tuberculosis or of a positive skin test. I reported the case to Public Health and held multiple (three) lengthy phone conversations with the patient, stating that it was most likely tuberculosis but that there were other possibilities. (Fungal or bacterial infection.)

What I'm trying to say is, I spent a fair amount of time on this case. I should also emphasize that the patient looked remarkably healthy, clinically speaking (no high fevers, coughing up blood, etc. etc.). Let me also reiterate that the total amount of time elapsed so far is 48 hours - or less - since the X-ray reading.

Late yesterday afternoon I got a fax from a lung specialist requesting STAT authorization for two tests (a bronchoscopy and a CAT scan of the chest) for this patient. I did not refer the patient to this doctor, I did not know who this even was until I looked up the physician in our on-line database. I had heard nothing about this appointment from the patient and received no phone call from the M.D.

I took no action yesterday because I did not have time. Today I called the patient who stated that he/she (no pronouns here for security reasons) had gone to see the physician in question based on a recommendation from a family friend. "I wanted to get treatment as soon as possible," stated the patient.

"Why didn't you call me? I've been calling you for the last two days. What made you do this instead of calling me and asking for a referral?"

"I was uncomfortable that you referred me to Public Health. The only thing they will do is see if I have tuberculosis. I wanted to find out what was going on, and I don't want to get treated at the county hospital."

"I talked to you about what the other possibilities could be. Remember? We spent a lot of time on this. I want to find out what's going on as much as you do, but I wanted to get the tuberculosis question settled first. If you had been really sick I would have put you in the hospital if necessary - you weren't even running a fever. I've been working with Public Health a lot this month on another tuberculosis case and I thought they could do the job most efficiently."

"Well, I pay thousands of dollars for insurance and I have a right to get treatment I think is appropriate."

Readers, let me tell you something. One way to really piss your doctor off is to pull the "I have insurance therefore you owe me" argument. Every day I see patients who have insurance, patients who don't and patients who used to have insurance but are losing their coverage; I try to treat them all the same. You do NOT deserve Treatment X or Test Y because you have insurance; you deserve it because you are SICK. This patient, with a legitimate problem, just lost all credibility with me based on that one sentence and on not giving me the compliment of a phone call to inform me of their concerns and intended actions. Unfortunately, that took nothing away from the fact that a problem existed here that had to be treated.

On further review, it turned out that the specialist in question did have a contract with us - though it wasn't a doctor that I work with on a regular basis. The tests ordered, I had to admit, were perfectly appropriate in the circumstances. I wrote the referrals - after I made it clear to the patient that I was really pissed off and that I thought he/she had acted in bad faith.

I didn't mark the referrals STAT, though; I downgraded them to "Urgent." Because, yes, I'm just that petty.

Piss a waiter off and you run the risk that he'll spit in your food, unprofessional though that is. Piss a doctor off and... do you even want to go there? We aren't saints. I know that there are many, many docs out there who act like mini-tyrants and treat their patients like dirt. I try really hard not to act that way and not to have control issues (I can't deny that that may have been a factor in how I feel about this). But to put a lot of work in on a case, to try to be there for a patient, and then to get treated like this - yeah, if I were a waiter, at this point I sure as hell would spit in their food.

At the end of last year, my three-year term was up. I wanted to leave then but was talked into staying on by some of the other members. Halfway through this year, I realized the only way I would survive with my sanity was by promising myself to quit at the end of this year. I have done so, and I feel no guilt. Lesson learned: don't be afraid to say "NO!"

(via Ernie) - sorry about all the silly links, I haven't been in the mood to write anything at length. Hope to improve soon, and in the meantime, enjoy the jokes.

To All the Lawyers Out There

Some Advice from your Public Defender

This is excellent. (Via MoebiusStripper).

(via L.A. Observed)

For my friends in the Southern Hemisphere: remember, it only gets better from here.

I'm sure Schiavo's parents are going through a very difficult time. I hope they are eventually able to make their peace with the medical information now available.

I have issued a fatwa for the MD at Valley Hospital. Shoot on sight.

So much for that. Hopefully I'll never have to hear anything about this guy again.

Old-Time Drug Advertising

From Cut to Cure comes this link to a whole bunch of 1940s-1960s drug ads from old medical journals (as a reminder, pharmaceutical companies weren't allowed to advertise to the lay public until just a few years ago). They're hilarious, a little bit scary and very un-PC. My favorites include "Mabel is unstable" and the Thorazine ad ("for the agitated, belligerent senile"). Gee, that would encompass about 85 percent of my geriatric patients...

And I will probably get called again even though I have nothing to do with it. Oh, well, at least I'm getting paid for this.

This One's for V.

...who asked,"When are you gonna blog again? I've read all your links!"

Here ya go. For those of you who, like me, have filthy minds, get ready to cackle with glee. For those of you who don't think much of phallic humor, you have been warned - but give it a try, it's NOT explicit and is actually quite funny.

(Via Calculus Woman.)

that's when you know you're in the hands of someone really, really good.

Thanks to some commenter on Josh's blog; I'm too lazy to go back and figure out who it was.

Thanks to GruntDoc for providing the link to this hilarious article. It's a first-person essay written by a fellow who provides AV services at lectures and has been sitting in on maybe one medical presentation too many. Do read, it's very well written.

via Ilyka it is. (OK, enough of the inverting clauses already.)

Lately the calls have tapered off. Of course - we doctors being a superstitious lot - the mere act of my posting this entry may be enough to bring him back down on our necks, but I will hope for the best. I could not resist telling you about this fellow, though - he is definitely one of the most memorable patients we've had recently.

Never a Dull Moment

Today, Saturday morning at 9:00, I was in church because it's my week to do Altar Guild. I was trimming the tapers on the candle snuffers and inserting new ones, closed the knife I was using to do the job and, in a classic mistake, failed to move my finger off the end of the knife holder. The blade came snapping down and got my middle finger just below the nail bed. After dropping a few choice curses (in the sanctuary!!) I dashed to the sacristy, rinsed it off and decided it might be deep enough to merit a suture. I know I'm due for a tetanus shot, so I headed over to our Urgent Care, just ten minutes away.

I was prepared to get teased by the staff for my clumsiness, but not for what I saw when I stepped off the elevator: the resident whose turn it was to work and three or four patients waiting in the hallway. (It was fifteen minutes past opening time at that point.)

"Nobody's here," explained the resident. Neither the medical assistant nor the receptionist had yet shown up, and she didn't have a key to get in.

After dropping another curse or two (I am so going to hell after this weekend), I let everyone in and started looking up phone numbers after checking the schedule. Ten minutes later, the staff showed up (one had gotten stuck in traffic coming down from Palmdale, the other had locked her keys in the car and had to walk home).

I didn't need a suture. Got my tetanus shot and left. Not such a bad thing I wound up cutting my finger this morning.

i-ii gtt OU TID-AC &HS

I now would write "one to two drops in both eyes three times daily before meals and at bedtime."

Doesn't it just look better the other way?

I gotta start attending services there more often.

Chocolate. Russian. Roulette. (V., I smell a birthday present...)

For what to do with Altoids and their tins, click here. My "favorite" is the suggested recipe for sea urchin sprinkled with crushed Altoids. (But I do like the crafty ideas for the tins.)

(via Instapundit)

Tomorrow ends the week with a bang. It's my last day as hospitalist, plus I'm on call that night. If I drop dead of fatigue they can sack me up and combine my funeral with the First Communion. More later...

This is Just Ridiculous

I'm anticipating Star Wars III as much as the next fangirl, but I think the Lucas marketing juggernaut has gone far enough.

I give you - Star Wars M&M's. Be very afraid.

And More New Links

For caffeine-oholics - see the sidebar in the food section. Pro: Starbucks Gossip, Con: the Delocator.

If I may digress for a moment, I really don't get the "I hate Starbucks" meme so popular in blogs today. You hate them for what - because they're successful? A company that makes money and goes out of its way to do the right thing - offers health insurance to every employee (and let me be the one to tell you I see a LOT of Starbucks employees as patients), encourages cultivation of organic coffees and land conservation (i.e., shade-grown coffee) - sure their prices could be lower, but other than that I don't see the problem. If you don't like their roast, fine, go somewhere else.

Is Starbucks the Terminator of independent coffeehouses? There is no direct evidence that such is the case. In fact, there is some evidence that Starbucks has actually encouraged the growth of independent coffehouses, rather than discouraging them.

How to Make a Business Decision

Christie's uses Rock, Paper, Scissors -- and wins. (via Instapundit)

OK, this puppy is going on the sidebar right now. It's Waiter Rant. Absolutely hilarious. Anytime you click on a new blog and the first post that hits your eyes is something as funny as this, you know it's got to be good.

I do wonder though if Mr. Nicholas, insurance salesman, took advantage of the party theme to hit the attendees up for extra life insurance coverage. Hee!

Mind Control

Every doc has at least one patient who's a certifiable wacko. Not just somebody who rubs you the wrong way, not somebody who has their Own Ideas about what kind of treatment they need, I mean feet-off-the-surface-of-the-planet wacko.

I saw mine today. She is definitely Doctor with a Cutlass material. I do feel sorry for her, but I have no idea why she keeps coming to see me, since she's rejected every conventional medical treatment I have to offer. Briefly, she was diagnosed with breast cancer some time ago, I think about two years. After considerable negotiation she underwent surgery and was told she needed adjuvant chemo and radiation because she was considered to be at high risk for recurrence. Instead, she has spent an unbelievable amount of time and money embracing every alternative treatment known to man, including a "cleansing diet" of raw organic fruit and vegetable juices that supposedly revs up the immune system to attack the tumor, coffee enemas (I wish I were kidding), and the latest treatment she sprang on me today. She has rejected follow-up mammograms because they involve radiation - obviously - and she is convinced that they will cause further tumor formation. Never mind that it took a mammogram to discover the thing in the first place, and the total lack of evidence that mammograms cause cancer.

At least her treatment du jour lightened my spirits a bit - in fact, I found it hard to keep a straight face in the exam room. She had gone out and purchased some relaxation tapes which put the brain into an "alpha state," thereby raising (or was it lowering? I forget) cortisol levels, thereby making the body more able to fight off cancer. Now, I have no problem with meditation or relaxation tapes per se. There is evidence that daily meditation or relaxation techniques can help lower blood pressure, for instance. What nearly caused me to lose it in front of the patient was a sudden thought:

What if these tapes are full of subliminal messages? What if she's being programmed to take over the world? I suddenly recalled the Charles Bronson movie Telefon in which previously brainwashed people picked up the phone, heard a coded message which "activated" them, and headed out to wreak havoc and then off themselves. Just picturing the guy pushing these tapes as a stealthy Donald Pleasence type recruiting a zombie army was enough to give me the giggles. It wouldn't be too difficult - patients who can be convinced to give themselves coffee enemas can be convinced to do damn near anything.

How to Make Vacation Last Forever and a Day

...spend it cleaning out somebody's apartment. Preferably somebody that you don't know.

OK, here we go. The storyline here actually begins back around New Year's, when for some reason I made three resolutions for myself:

1. Visit Vegas this year. (See previous post.)
2. Visit New York this year.
3. Wear different earrings every day. (I buy them, I just don't wear them. I tend to stick to the same pair of studs on a daily basis.)

Well, then skip forward to late January: I was at home one night when I got a call from V. on her cell phone driving home.

"I need to talk."

"OK, talk."

She told me the story of a close family friend who had no local relatives (never married, no kids), who was in the hospital with a stroke. V. held her power of attorney (and had found this out just shortly before). Purpose of phone call: V. needed help - or, to be more precise, she foresaw the likelihood that she would need help. My response: "Well, I made this resolution this year that I would go to New York. Looks like this is it."

The friend, Dottie, died about a month later. We decided to go to clean out her place the week after April 15 (tax day). So, we left the night of Friday, April 15 on the redeye flight and arrived early Saturday am. After a nightmarish trip on the subway - nightmarish because we were each lugging 40 lb. suitcases, and good luck getting those things through turnstiles - we arrived in Queens.

This apartment building was the same one V. had grown up in, and in which her mother had lived until 2000. Let's just say this was not an easy trip for her. Add to this the fact that poor Dottie had clearly been a hoarder and compulsive shopper, and had given up on cleaning the apartment. Clothing was stacked everywhere - the closets were stuffed, clothing was hanging off every doorknob and molding in the apartment, and there was an ironing board in the dining room fringed with hangers loaded with clothing all the way around its perimeter. If it had been me alone, I would have taken one look, turned around and gotten back on the next plane to L.A. But such was not to be.


"Pitch, Pitch, Pitch, That's All You Ever Do"

We spent that first day frantically cleaning the kitchen and bathroom so that we could have a bit of room to maneuver without our feet sticking to the floor (so help me God, I am not exaggerating). I will spare you most of the details, but suffice to say that the glass facings of the kitchen cupboards were covered in a thick nicotine film - though Dottie had stopped smoking at least ten years prior to her death - and that V. found two dead mice in the kitchen. We also threw out untold numbers of cans of food with bulging tops that had corroded their bottoms and from which food had leaked. I recall V. waving a bottle of blackened bleu cheese dressing at me, which provoked an immediate gag reflex. I promoted myself to chief cook and bottle-washer so that V. had more time to go through the papers, photographs and personal memorabilia, of which there was no shortage: it was clear that this woman had never thrown anything away, and she had lived in the apartment for more than sixty years.

On Tuesday, as we were leaving to finalize the arrangements at the restaurant where Dottie's memorial luncheon was to be held later in the week, I found V. wandering around the living room with a trashcan and a stressed look munbling, "Pitching, I'm pitching as I go." I immediately struck an attitude and whined, "Pitch, pitch, pitch, that's all you ever do." I got the laugh I was looking for (my other job for the week: court jester!) Speaking of pitching, rule number one of the week was established early on: never leave the apartment without a bag of trash in your hand. The apartment is a second-story walkup, so you can see why this was so important. It became difficult to approach the door without tripping on the one dozen or so plastic bags of garbage sitting next to it, so every now and then a garbage run or two was required to restore order.


CNN

At the restaurant, there was a TV over the bar. We finished picking the lunch choices and suddenly noticed that there were bells ringing nonstop at the Vatican... white smoke... a new Pope! V. and I hung out for about half an hour, fending off offers of coffee from the owner, to see who the new Pope was. It was amazing to see the crush of people in the square. We drank a toast to Benedict XVI at lunch.

Julius Caesar

I was in charge of entertainment, and naturally left this important issue till the last minute before leaving. Fortuitously, I caught a review of Julius Caesar in the "Wall Street Journal" the week before we were to leave and bought tickets - not because of Denzel Washington, but because of his costar, Colm Feore. The review overall was not positive, but gave high marks to Feore, and that was all I needed to hear. (Fangirl that I am.) He was fabulous, and V. and I both thought the play as a whole was pretty good.

Well, now I'm back and overwhelmed with work, so shall sign off for now. Overall it was a good trip - V. and I both came back with resolutions to clean our homes and throw stuff away!

Oh, and the earring thing - I'm doing pretty well with that resolution, too. Wow, resolutions I've actually kept... what a concept.

Say what? was my reaction, but I was too tired to ask. As I rode up in the elevator, three people wearing aloha shirts, draped in Mardi Gras beads, and carrying Corona beers got on with me. I made eye contact with the most cheerful looking of the trio and asked, "What's a Parrot Head?" Gleefully, he waved an ID badge at me which was emblazoned with a picture of a grinning man on a beach with a guitar slung over his back and the name "Jimmy Buffett." Aha! Let me say that nothing adds to the Vegas experience like having a bunch of fun-loving drunken guys in grass skirts and parrot hats wandering around your hotel.

That Saturday night we took a helicopter flight around Las Vegas. The skyline was spectacular, and as we passed the Luxor, with its pyramid shape and laser beam, I noticed what looked like glittering confetti in the beam... oh my God, those are moths! Yep, hundreds of moths drawn to the Luxor like, um, moths to a flame. Well, if they're frying in the laser beam at least they're not infesting the hotels.

Tonight V. and I are en route to New York for a week. A relative of hers died and she has to clean out the apartment; I said I'd help. (She believed it!) In all seriousness, I'm going to help her get things organized and start dropping things off at thrift shops, etc. We do plan to do some sightseeing and theater as well. If I can make it to an Internet cafe, I'll post; if not, you will hear from me upon our return. Hasta la vista, baby!