“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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Randomly Entertaining Thoughts

Know how it feels when you're clicking around and you find a string of awesome blogs? Here ya go:

I Hate the New Yorker - hate its pretentiousness but love the occasional good writing? This blog is for you. Incidentally, if you're into this sort of thing and you've never read it you should try James Thurber's The Years With Ross. It's great reading. I, for one, never knew that James M. Cain was an editor at the New Yorker for about five minutes, until he decided that his world of homicidal two-timing wives and their paramours was healthier than the atmosphere of the magazine and beat it for California.

The Mrs. Columbo Website. Remember Mrs. Columbo? The best never-seen character of all time? Of course you do. Kate Mulgrew - later to be Captain Janeway of Voyager - really got the deck stacked against her when she was hired to appear as this beloved invisible character. Peter Falk said it best: "It was a bad idea. It was disgraceful." Soon enough the writers folded and said, no, she was the wife of some other Detective Columbo, and then caved altogether and changed her name to Kate Callahan. Feh.

Casino Royale. I am including this because I saw the movie last night and it's freaking awesome. If you like Bond, go see it. If you aren't a fan of Bond in particular but you like action movies, go see it. Daniel Craig is hot, the dialogue is well-written without a lot of cheap double-entendres, the action is gritty and there is no Q nor cutesy-pie inventions. And, for a bonus, Judi Dench as M. What more do you want?

Labels: Pop Culture

posted by Dr. Alice at #

 
Insomnia

I wish I had a dollar for every time I've heard this complaint: "Doctor, I can't sleep." The patient stares at me pathetically. "I'm so tired."

Every doctor suffers from a common complaint that dogs their steps, that arouses all their sympathy when they hear a patient mention it. Fellow sufferer! I feel your pain! For some it's back pain, for some it's migraine, for some it's allergies... you get the picture.

I am a proud card-carrying member of the International Insomniac Association. I've had trouble sleeping all my life; even as a child it was common for me to wake in the middle of the night and stare incessantly at the ceiling, wondering what time it was. (This was back before alarm clocks with digital displays were common, if they even existed.) In high school I was given an alarm clock with a digital display – I still have it - and it changed my life because I no longer had to wonder what time it was when I woke up in the middle of the night; all I had to do was look across the room. I understand that current advice for those who have trouble sleeping is to avoid looking at the clock, lest you obsess about what time it is and how long you've been awake. While there may be some point to this, I have to say that it is even easier to obsess if you DON'T know what time it is. (Speaking from experience.)

Several years ago one of the rectors at my church preached a sermon that reassured me about my crazy sleep cycle, at least to a certain extent. She told us that in monasteries the service of Vigils, commonly sung between one and three a.m., was not a punishment; it came about because monastery routine called for the monks to get up shortly before sunrise and go to bed soon after sunset. Thus they would normally awaken in the middle of the night, because the time allotted for sleep could be nearly twelve hours (depending on the season). In other words, everybody was awake and staring at the ceiling anyway, so they might as well get up and worship.

Somehow I felt better when I heard that. It was nice to know people were able to do something productive with their time lying awake even before electricity or the Industrial Revolution. These days we have the Internet (cue the chorus: what did we do before the Internet?), so on nights without sleep it's very easy to while away the hours surfing around, perhaps blogging, researching some esoteric topic or chatting online with our fellow insomniacs or some bored fellow in an office on the other side of the world. Back in my young days all we had to entertain ourselves on "white nights" was late-night television or perhaps the odd VCR movie we'd rented. Random thought: now that we have the Internet, does anybody even watch infomercials any more? They may soon be a dead art form.

The good news is that in the last few years more modalities for treating sleep problems have become available than ever before. Safer sleep medications are now on the market. The specialty of sleep studies has gained respect and popularity. "Restless leg syndrome" can now be treated with an effective new medication. Somehow, though, it doesn't seem to be enough; patients want their insomnia problem fixed without resorting to pills. I have recently seen a new subgroup of postmenopausal patients who have declined estrogen replacement and as a consequence suffer from insomnia with a vengeance; apparently low estrogen levels will do that to you. Try to tell one of these women that she can either take estrogen or a sleeping pill to solve her problem and she will likely come at you with a deadly weapon, or at least a deadly rant. Tell her to try melatonin or valerian (both natural sleep remedies) and she will give you the "I've already tried that" look.

Physicians still reiterate the basics of sleep hygiene, such as: Don't take naps during the day. Exercise. Avoid caffeine after noon. Cut back on the alcohol. Don't read/watch television/do crosswords in bed. Don't get into bed until you're ready to go to sleep. Etc. But, as always, the lifestyle modifications may not solve the problem entirely, or the patient may be reluctant to change his or her habits. My personal motto is This Is What Pills Are For, and I am happy to practice what I preach. I am not ashamed to say that Lunesta has changed my life. (In case you're wondering, no one asked me or paid me to endorse this medication.) I have tried the samples and I think they work great – although I have had two or three patients complain of a nasty taste in their mouths the next morning. I take it maybe once or twice a week, when I'm desperate. I feel fine the next day and haven't noticed any problems.

Meditation or relaxation exercises will also work for insomnia (I think it's because they get your mind out of the vicious cycle of repeating your pet worries over and over again). Counting sheep never did it for me, but on those nights when the clock dial reads 2:47 and it's way too late to consider even Lunesta, I have a favorite exercise that usually helps. I am working on memorizing the California state highway system. Don't laugh; it's like counting sheep but better. It requires a little bit of cerebral exertion, but not much.

Here is the website that has helped my insomnia the most (it gives information on the location of various highways and freeways throughout the state). To fight insomnia, the rules are you start at Highway 1 and keep going as long as you can. Feel free to adopt this for your own home state or country.

Example: 1. Highway 1. Runs up and down the coast of California, I have driven parts of it. I visualize it, imagine myself in a convertible zipping up the coast on a sunny day past Malibu, relax. Move on.

2. Highway 2. Goes to Glendale and Eagle Rock. In memory I see the intersection of the 2 and the 101 near my high school, back in the good old days of the carpool. Relax some more.

3. The 3 is in the Bay Area somewhere, I think it goes to Berkeley, not really sure.

4. No idea. Skip.

5. Ah, Interstate 5. I remember the old strip of the 5 that used to run to Disneyland when I was a little thing growing up in Orange County. I remember the more recent pleasures of driving the 5 to and from San Francisco when I was a resident there.

And so on, continuing as long as you can. California has a LOT of highways and freeways, so you can go well past 200 if you're really wide awake. Eventually, however, I usually fall asleep or slip into some sort of doze that works almost as well. Zzzz.

Labels: Medicine

posted by Dr. Alice at #

 
How To Date an Egg

(On second thought, perhaps I should rephrase that.)

How To Make Sure an Egg Is Fresh

You may have found yourself in the situation of having part of a carton of eggs left which is past its sell-by date. Perhaps, if you're really like me, several days past its sell-by date. What to do? Bite the bullet and cast the eggs into the garbage, or take the risk of cooking them and finding them unusable?

Simple solution. Take a deep glass of water and gently drop the eggs into it. If they sink, they're fresh; if they float, don't use them. It worked for me today.

Labels: Ingestion

posted by Dr. Alice at #

 
What Happens When You're Febrile...

... is that when you run across stuff like this on the Internet, you think it's hilarious.

Actually, I'm not febrile any more and I still do think it's hilarious. You can find more Family Circus/H.P. Lovecraft crossovers here if you're interested.

What happened is I came down with a horrible case of tonsillitis - bad enough that I failed oral antibiotics. I dragged myself into work on Friday and, no joke, my secretary could see the lymph nodes in my neck from across the room - they were that big. One of my partners shot my gluteus maximus full of Bicillin and sent me home. The Bicillin, ordinary penicillin, worked where the Avelox failed me. It's Sunday night and I finally feel human again and less like Cthulhu.

ETA: See also the Nietzche Family Circus - similar idea.

Labels: Pop Culture, The Doctor's Life

posted by Dr. Alice at #

 
Stalking the Wild Trichomonas

This may sound strange, but I'll say it anyway: Trichomonas vaginalis is my favorite STD.

How so, might you ask? (I'll assume I can hear you asking.) For the following reasons: it's easy to diagnose and easy to treat. Further, it doesn't hang around in perpetuity, as do those familiar and nasty viral infections Herpes simplex and HPV.

Last week, for example, I had a patient who had called several days before asking for a prescription for a "yeast infection." I had prescribed said medication, which had not worked, and the patient then scheduled an appointment for further evaluation. I examined her and my first thought on looking through the speculum was Gee, bright red. My second was Trichomonas. You can often, but not always, make a presumed diagnosis of Trichomonas by looking. The clincher is the "wet mount," or examining the slide under a microscope. The nice thing about this bug is that it is extremely mobile on a slide. Trichomonas is actually a parasite, not a bacteria, and it has lots of flagellae which make it move around quite a bit. Put it in some saline solution under a bright light and you can get quite a show.

There is a catch. Most of the time it takes about thirty seconds to diagnose once you're looking at the slide... But. There is the occasional case where the patient is extremely symptomatic but for whatever reason you can't find many "trick" on the slide. This lady was such a case.

So I scanned, and scanned, and scanned again. "I know you're there," I muttered. "I can feel it." (Fortunately no one was in the lab at the time to see me carrying on a conversation with the microscope.)

At last, there it was: an organism doing the frug in the middle of the magnification field. Aha! Diagnosis made, problem solved... except for the bit about explaining to the patient. I headed back and told the patient what she had and how she got it. She took it stoically, with one comment: "You know I'm going to have to kill him."

"Just don't make me an accomplice before the fact," I shot back. She laughed. I gave her her prescription - a single dose will take care of this thing - and told her to make sure her partner got treated. Happy ending.

Labels: Medicine

posted by Dr. Alice at #

 
Curtains for Aldo?

For those of you following plot developments in Mary Worth, and I know that all of you are--

No, wait. Let's try this again. For those of you who read The Comics Curmudgeon, the latest plotline in Mary Worth has been an endless source of entertainment. I'm actually sorry to see it coming to an end, though the end looks pretty damn spectacular. Or to put it another way, it's the weirdest strip I've ever seen. I'd pay to know what the artist was smoking when they came up with this one.

If you still don't know what I'm talking about, here's some background. Mary Worth is a postmenopausal widowed busybody who lives in the fictional town of Santa Royale, California, in a condo development called "Charterstone." Basically the strip is a soap opera, with issue after issue cropping up. New characters are introduced for each plot, Mary sticks her nose into their business, and when the plot is resolved the peripheral characters disappear, never to be heard from again. The current plot has attracted a lot of attention from readers because a) it's halfway interesting and b) it was presented in a very strange way. Basically, there's a stalker at Charterstone pursuing Mary Worth.

Yes, I said Mary Worth. Our stalker, who bears a strong resemblance to Captain Kangaroo and looks at least twenty years younger than his prey, decided to go after Mary instead of one of the younger women who seem to infest the place as background figures. Why? Who cares? It's Mary Worth-land, where no one makes decisions that bear any resemblance to reality as we know it. Anyway, after making several halfhearted attempts to woo Mary, Aldo was dragged into an "intervention" organized by her concerned neighbors, who told him in no uncertain terms to leave virtuous, meddling Mary alone. Heartbroken, Aldo responded by hitting the liquor store and then going for a drive with his good friend Johnny Walker. In a remarkably poorly drawn sequence, he then missed a turn and sent his car nosediving off a cliff; I assume that means he's dead, but I'm waiting for tomorrow's strip to find out for sure.

What response has this plotline gotten from readers? Suffice to say, there are a lot of people out there who are incredibly creative and have a LOT of free time on their hands. As follows:

• My favorite reader comment from Josh's site: "If Aldomania doesn't end with Aldo shrieking maniacally, a bottle of Bombay in one hand and Mary's head in the other, backlit by the flames of the burning pyre that is Charterstone, I for one am going to be disappointed."
• Two very clever parodies, one a takeoff on Shelley's Ozymandias and the other of Marvell's To His Coy Mistress.
• A Benny Hill- type video you aren't going to believe. See below.

Anyway, it's been fun, Aldo. It's safe to say you will be remembered.

Labels: Comix

posted by Dr. Alice at #

 
Aldo Stalks Mary Worth

Labels: Comix

posted by Dr. Alice at #

 
How to Write Hate Email

This is simply hilarious. As a bonus, it's well-written too! (The best part is, it's Part 3 in a series... the writer must be a masochist.)

Labels: Pop Culture

posted by Dr. Alice at #

 
Sun Tea

This is a minor thing really, but it's improved my quality of life, so I hope you'll forgive my blogging about it. For those of you not from the U.S., iced tea may not be a big issue for you, but if you're from the States -- especially the Southeast States -- it truly is. (My mother is from Tennessee, so I consider myself half Southern.)

I do love me some iced tea, but until the last two months I hadn't made any in quite some time simply because I didn't have the appropriate vessel to make it in. To start with, I will not drink instant tea. I consider it evil and no true beverage at all. You can brew iced tea by making it double strength (twice the normal number of teabags) and then pouring it hot over ice, but I've never really liked to do that. I just feel like it shocks the tea, though I have no rational reason for feeling this way: I think tea is a somewhat fragile beverage and should not be jerked around in that fashion. I prefer to brew my tea in the sun (a.k.a. "sun tea"). It's simpler, for one thing, and does not heat up the kitchen. I also think it gives better-tasting iced tea.

All you do is measure out the water, place it in a glass bottle or jar, add the appropriate number of teabags and leave it in the sun for several hours. You can leave it all day if you want, it doesn't seem to matter (I have heard you can also leave the teabags in water overnight for "moon tea," but I have never tried this). Then strain the teabags out and put the tea in the fridge to cool down. It stays good for several days. I don't sweeten my iced tea, and lately I've even stopped putting lemon in it - if you take care with brewing the tea it tastes good enough that you don't have to. It cools you down like nothing else.

A few months ago I finally found a glass jar the right size for brewing tea; these days, with so many commercial foods packed in plastic jars, this is harder than it sounds. It's a 1 1/2 quart size dill pickle jar. (My first few batches of tea tasted faintly of dill; this may sound offputting, but it was actually pretty good.) On the occasions that I had my act together I would put the teabags (3) in the jar in the morning, fill it up with water, and park it on the patio in my backyard where I knew it would get the full effect of the sun in the afternoon. When I arrived home, voila - iced tea, already made.

The season is getting late for it, but if you have the right-sized glass jar sitting around the house I would encourage you to dust it off and give sun tea a try if you haven't recently. You'll enjoy it.

Labels: Ingestion

posted by Dr. Alice at #

 
Best Chief Complaint Ever

From a patient who presented today with tonsillitis:
"My tonsils look like dead alien babies!"
They sure did. One course of antibiotics coming right up.

Labels: Medicine

posted by Dr. Alice at #

 
"The Glamour of Medicine"

A few days ago I dropped into the hospital cafeteria to grab a quick bite of lunch. I wound up at a table for four with one of my partners, a podiatrist we both know well, and another MD newly on staff. I introduced myself and the talk meandered into personal backgrounds, such as where-did-you-grow-up and how-do-you-like-Los-Angeles. After some gloomy talk about the current state of health care, we started to talk about having doctors for parents (not all of us at the table fell into this category).

"My dad tried to talk me out of going into medicine," I contributed. This is not unusual among children of MD's. Pretty much everyone in my med school class with a doctor for a parent reported that at one point or another, Daddy - usually it was Daddy - had tried to tell them that medicine is a difficult job and that it no longer pays commensurate with the work involved. (I do not include specialists here, though their opinions may differ on this subject. I am speaking of primary care because that's what I know.)

At this point one of the older physicians on staff, a neurologist, joined us and we included him in the conversation. He told us his son had decided to go to medical school. "What did you think about his decision?" we asked, wanting some firsthand input.

"Well, I tried to be honest about it. I told him what I like about being a physician and what I don't like. But he's been doing some volunteer work, and he was attracted by..." he shrugged. "The glamour of medicine."

Simultaneously, the rest of us burst into laughter. The questions came thick and fast:

"Has he ever had to sew up a drunk?"

"Ever done a pelvic exam on somebody with bacterial vaginosis?"

"Has he spent any time in the ER at all?"

He chuckled good-naturedly at our cynicism. "It's what he wants. He's decided it's what interests him, and I said, 'Good for you.'"

This discussion stayed with me the rest of the week. Usually the doctors' dining room isn't good for much except CNN updates and endless pontificating on the state of the world today. If I could vandalize their TV and get away with it, I'd do it in a heartbeat. But hearing what people think about this profession - would you defend what you do to somebody else? Is it worth it to you? - this stuff truly interests me.

I have a standard quip for patients who ask me if I like being a doctor: "It depends on what day you ask me." The truth is, though, I do. I can't think of anything else I would rather be doing, or even of any other job I'd be suited to do. If a friend or relative were to ask me about becoming a doctor, I wouldn't tell them not to do it. Like my neurologist acquaintance, I would try to give them the most balanced picture that I could about what it's like to be a doctor. It might well involve phoning my hapless apprentice at three in the morning to complain about nonexistent chest pain or a UTI, just to make sure they get the full experience... but I'd be sure to include the satisfaction that comes with helping someone feel better or achieve a better quality of life. I feel lucky to have a job that has more meaning attached to it than just a paycheck, that has - for want of a better word - "glamour."

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Google's Advice of the Day

How to remove a hickey. Potentially useful; I'd never heard of most of these ideas.

One of the most embarrassing--although not particularly amusing--moments of my life was the time I had to testify in a criminal case. The charge was spousal abuse, and the plaintiff was my patient who'd been beaten up by her husband. The defense claimed that the patient's bruises, well documented on Polaroid photos, were hickeys. Needless to say, they weren't. I then had to explain to the jury the difference between hickeys and bruises, and how I could tell the difference. (Tip: hickeys are punctate and reddish-purple. Bruises are darker and homogenous, with no little dots in them.)

I never thought I'd be testifying as a hickey expert, but medicine takes you to some strange places.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
Fun with Treadmills


You may or may not have seen this, but it's well worth a view. Better with the sound on.
(via PJ)

Labels: Pop Culture

posted by Dr. Alice at #

 
Zero To Sixty

I had a lovely week off work, but my peaceful attitude was destroyed upon my return... as usual. Even though Monday was a holiday, it didn't feel like one; I dropped in to the office to review charts and suddenly realized I had a nursing home patient who was overdue to be seen (I had conveniently managed to forget about her, probably due to Vacation Brain). At the same time I checked the call schedule and saw that I was scheduled to be the hospitalist this week, AGAIN. I just did this two weeks ago, dammit. It's somebody else's turn. Throw in 300 spams in my inbox and a nasty sinusitis I managed to acquire on the trip back, and you can see that my attitude at the moment is not of the best.

There is good news. After months of limbo, it is now a fact that my office is going to be moving to much posher digs than those we currently occupy. Our management has been wanting to do this for a year, but one thing after another kept delaying us - most notably a recalcitrant landlord who did not want to negotiate. However, at last The Firm has signed the lease and applied for approval of our remodeling plans. We will probably not move before February, but at least we're making progress. Once we have a definite move-in date, my next step will be making arrangements to get my brother's desk from the East Bay locker where it currently resides. (My brother is the proud owner of a beautiful, huge old wooden desk that he snagged when his employer redecorated and bought all new office furniture. I've wanted it for ages, but he was unwilling to part with it until he and his wife had a baby. The home office became a nursery, and the desk is now somewhere in Oakland.)

More good news: since the start of the summer, I have been on a four-day work week. This means that while my Monday, Tuesday, Wednesday and Friday schedules are somewhat longer than previously, I have Thursdays off. It's wonderful. Now if I could just find something to do with my Thursdays other than drinking coffee and staring blankly out the window - though I do enjoy that. What I really should do is clean out the kitchen cupboards. Perhaps that will be this week's agenda.

Now if I can just stagger through the rest of today, I will take my sinusitis home and put it to bed.

Labels: The Doctor's Life

posted by Dr. Alice at #

 
The Heidi Treatment

I stopped by V.'s office the other day along about Phone Call Time (similar to Twilight Time) to find her staring at one particular chart. The annotations on the message slip attached to it were so copious as to inspire a mental comparison to War and Peace... in case you're wondering, this is never a good sign.

"I'm supposed to cure her," V. said grimly. "She's been in the hospital repeatedly, seen every specialist you can imagine, and her neurologist gave her mother my name. Now they're begging me to see her."

I picked up the chart and started flipping through it idly. "What's her problem?" The chart consisted of copies of hospitalization records and studies. It was pretty thick for someone who hadn't even been to the office yet.

"She's got all these neurologic symptoms nobody understands. She's too weak to walk. She was seen by Psych and they think it's conversion syndrome. I've never even seen anybody with conversion syndrome, have you?"

I was impressed. Conversion syndrome was first described, if I recall correctly, by Sigmund Freud. Basically it's a phenomenon in which a person develops a physical symptom or problem for no good reason and no medical cause can be found. The idea is that it's a subconscious psychological defense that allows the person to avoid some overwhelming issue. (Think hysterical blindness, for example.) I've never seen such a case; it isn't a very common problem.

"How long has she had this?" I asked, flipping through the chart.

V. sighed. "A few years." Without going into details, the patient in question underwent some severe physical and psychological trauma while she was a college student and had had the problem more or less ever since. The family was unwilling to accept the diagnosis of conversion syndrome and was insisting that there had, simply had, to be some sort of physical explanation; hence the multiple visits to specialists and V.'s dilemma.

I began to free associate, thinking of ways to miraculously cure someone with this type of problem. "Maybe she needs the Heidi treatment," I suggested as a memory popped into my head.

"And what is the Heidi treatment?"

"If you remember your childhood reading, Clara was Heidi's best friend who was unable to walk. She was stuck in a wheelchair until she went to visit Heidi and her grandfather in the Swiss Alps. A few months of goat's milk, fresh air and sleeping on hay and voila, she was miraculously cured and able to walk again."

V. looked thoughtful. "Yeah, I think I remember that." (V. and I seem to have read many of the same books during childhood. I haven't asked her about The Five Little Peppers and How They Grew yet, but I'm sure that will be next.)

"Well, there you go. Just get her a ticket to Switzerland and you're all set." I left before she could hit me with the chart.

[Postscript: this happened a few months ago. At last report the patient is doing much better.]
posted by Dr. Alice at #

 
"Are There Any Medical Personnel on Board?"

... is a question you never really want to hear on a plane. But like a good internist I hit the call button and identified myself to the flight attendant. She walked me to the back of the plane, where I was confronted by an eleven-year-old boy in the throes of a grand mal seizure.

Here's a dirty little secret. Seizures aren't that scary. Spectacular, yes, but not scary... if you've seen them before. Basically you protect the person's head and airway as best you can and wait for the seizure to end. By the time I got back there, there was an EMT (paramedic) who was restraining the boy and lifting him onto the row of seats. I busied myself trying to get a history from the parents, who were understandably very upset. Briefly, there was nothing wrong with him.

• Personal or family history of seizure? No.
• Fever, stiff neck, rash? No.
• Head trauma? No.
• Diabetes, medications, allergies? No. None.
• What did you do yesterday? "We went touring," they said. (This was a Los Angeles-to-Toronto flight.) "We saw some friends, had lunch."
• Were the friends sick? No.

By this time the seizure activity had stopped but the child was still not really responsive (they call this state "post-ictal" and it's normal after a seizure). Someone handed me a bottle of oxygen and a mask, which I passed to the EMT, and then the airplane medical kit, then asked me my favorite question of the entire experience: "Do you need the defibrillator?" NO. God, no. The flight staff called a doctor who worked for the airline, who reviewed things with me and the EMT. He suggested that we start an IV line in case the child seized again, so that we could give him Valium. This question did not occur to me at the time, but I have no idea how much Valium you would give an eleven-year-old kid. Fortunately, it did not come to that as he remained stable. I discussed things with the EMT, who had basically taken charge, and we decided not to start the IV unless he seized again. This was fine with me. I haven't started an IV in years, and the prospect of trying to do so on a plane at 30,000 feet was not one which made me feel confident.

The flight proceeded to Toronto without further incident. As soon as we landed, the boy and his parents were taken off straight to an ambulance.

I've never before been a passenger on a plane where there was a medical emergency, although I used to work in a medical clinic at San Francisco International Airport and was frequently called out to arriving planes where there'd been an emergency on board. It's a bit different when you're actually on the plane.

I'm writing this from a public library in Stratford, Ontario, so will have to sign off as my time is about to run out. More later.
posted by Dr. Alice at #

 
You're On Notice

Thank you, Stephen Colbert:






posted by Dr. Alice at #

 
Numbers of the Beast

(stolen from a commenter on Tim Blair's blog)

In honor of tomorrow's date, June 6 2006:

666.0000
Number of the High Precision Beast

0.666
Number of the Millibeast

(-666) ^ (1/2)
Imaginary number of the Beast

6.66 e3
Floating point Beast

DCLXVI
Roman Numeral of the Beast

$665.95
Retail price of the Beast

$699.25
Price of the Beast plus 5% state sales tax

$769.95
Price of the Beast with all accessories and replacement soul

$656.66
Walmart price of the Beast

$646.66
Next week's Walmart price of the Beast

666i
BMW of the Beast
posted by Dr. Alice at #

 
Sign of the Apocalypse

At Radio Station KOPA, you'll never guess what they're playing.

("Thanks" to Dave Barry)

UPDATE: link is no longer available... it's all Barry Manilow, all the time.
posted by Dr. Alice at #

 
News That Made My Week

Finally!

"Police Squad!" is being released on DVD November 7. Best. Show. Ever.

"Who are you and how did you get in here?"
"I'm a locksmith. And... I'm a locksmith."

In other news, T-shirt of the week: I spotted a woman outside my office wearing one that said "My pets are not my children. At least that's what their piano teacher tells me."
posted by Dr. Alice at #

 
"I'm Going Out Dancing Tonight!"

Once in awhile a simple treatment change makes a big difference in someone's quality of life. This happened to me just the other day.

I had a patient who'd been having respiratory symptoms for three weeks, whom I had not seen but who had been seen in our Urgent Care. I'd also called in a prescription for her over the phone. She had a known history of asthma but was not getting better despite her meds.

Finally, I got her back into the office. You can only do so much over the phone; when somebody fails treatment, it's time to bring them in and take another look.

She sat there and told me about her persistent cough, her hoarse voice and the pain in her throat. Her lungs were clear and she was not congested. I flipped through the chart and suddenly noticed that eighteen months before she had been taking medication for acid reflux. A lightbulb went off over my head!

I asked more questions. Yes, she had been under more stress recently. Yes, she'd been eating dinner later. Yes, the pain felt like burning and sometimes it was worse at night. The conclusion: her GERD had returned and she was aspirating stomach acid. The acid was irritating her vocal cords, causing her hoarseness and her cough.

I gave her some samples of Prevacid (a proton pump inhibitor that decreases stomach acid secretion) and asked her to call me in 48 hours. The call came before the end of the day; the message slip on my desk read as follows:

"Patient says it is stomach acid and she feels much better. She is going out dancing tonight."

Damn. A cure!
posted by Dr. Alice at #

 
Phones, Down

Our phone system has been f'ed up since last night. We can't call out, and very few patients can call in. This episode follows on the heels of another one two weeks ago, not quite as dramatic as today's - from minute to minute the phones would allow you to call out, then would not. Oh, and my cell phone is dead, so I can't even resort to that option to contact patients. We are lined up to use the red emergency phone in the reception area, which runs off a different circuit, for the most urgent calls.

In other words, I'm having a GREAT day. (Seriously, the silence is wonderful.)

In other news, this week I saw the reappearance of an old favorite illness. A woman in her fifties walked in complaining of not feeling well and having a rash that itched. She stated the rash was on her back and left cheek; when I examined her, I realized that she also had rash on her forehead, right cheek, and chest and shoulders. Staring at it, the phrase "dewdrop on a rose petal" popped into my head from nowhere... then realized it was an old memory aid from med school to diagnose chicken pox. Yep, it was chicken pox, and my subconscious diagnosed it! How cool is that?

Me, I had chicken pox at age seven, and I'm so glad I did. It has guaranteed me protection ever since. I was always the one sent in to examine the varicella and zoster patients all through med school, residency, and during my gainful employment since. I've never had a problem.

More later. I've got to check the phones again.
posted by Dr. Alice at #

 
Funny Link of the Day

Ten Ways Dick Cheney Can Kill You. (Via Tim Blair, or to be more exact, one of his commenters.)
posted by Dr. Alice at #

 
Vignette

As promised.

Each of my exam rooms has a bulletin board in it, usually reserved for unexciting reminders to patients such as "Please Turn Off Your Cell Phone" and "Please Bring All Medications With You At Each Visit." Lately I've tried to jazz things up (and give patients something to read) by posting newspaper articles on health-related issues. Today I walked into an exam room to find my patient standing at the board reading an article entitled "Caring for Ill Spouse Takes Toll on Health."

"You know, this is so true," she said, gesturing to the article. "My stepmother died of a heart attack just a week after my dad died, and she'd been taking care of him for years." She sat on the exam table and continued her story. Her father had been in decline for years with Alzheimer's disease and multiple other health problems and spent the last month or so of his life in the hospital. "She'd walk into the room and he'd throw things at her. At the end he was begging her to kill him."

I told her the story of a patient I'd had years ago, who walked into my office for the first time with a massively swollen stomach; it was clear that she had ascites. This woman's husband had just died of a chronic illness, and she hadn't been to a doctor in years. The moment I saw her I knew something was very wrong. It turned out to be metastatic ovarian cancer; she lived less than three months. She'd been ignoring her symptoms to take care of her husband.

"Yes, yes," said my patient. "My stepmom was running back and forth to the hospital, living on doughnuts and Chinese food! We kept telling her to take care of herself, but she wouldn't. After he died, she told me she felt like she'd lost her right arm and that she didn't have anything to live for. Then a week later - it was the last night of shiva - she'd been saying all day that she didn't feel well and that she felt 'pressure in her breasts.' They found her on the bathroom floor in the middle of the night."

She continued, telling me how guilty she'd felt. "I should have taken her to the hospital. I should have insisted, but she wouldn't do it."

I listen, nod, tell her how coronary artery disease in women often goes unrecognized. "If this ever happens again," I reassure her, "you'll know what to do."

She nods. "I feel better. I've talked about this before, but this really makes me feel better."

Her reason for coming to see me? A minor one - she wanted some blood tests - but the real therapy today was giving her a chance to vent. I'm grateful that I had the time to listen.
posted by Dr. Alice at #

 
Burn Out

Yeah, I know.

V. threatened me with physical harm if I didn't post. I got a lovely email from Jack (thanks, Jack) concerned with what was happening. Or not happening.

It's been a busy month. I had jury duty again - Los Angeles seems to be really churning their jury pool, it's been less than two years since my last stint. Got out of that one by telling the court about the time I was robbed and testified against the guy who did it, and mentioning that my sister is an assistant district attorney (both true; since I was called for a criminal case, that was enough for them to boot me).

I'm in a bit of a rut - not an unpleasant one, but a rut nonetheless. For the first time in over a year I have enough free time to breathe, and I haven't done any of the productive things I promised myself I would do. I have, however, managed to become addicted to 24; I have spent way too much time on the message boards over here. (Another reason why I haven't posted.)

So, anyway, I'm alive and will try to get back to posting more often, even if it's just little vignettes of what happens at work.
posted by Dr. Alice at #

 
Now Here's a Way to Celebrate Easter!

Peep Drinks.

(via Dave Barry)
posted by Dr. Alice at #

 
Vade Darren McGavin

Vampires couldn't stop him. Werewolves couldn't stop him. Zombies? He got the best of them. Even the Bumpuses' hounds stealing his Christmas turkey couldn't keep him down for long. (No one ever better delivered the line "We. Are going out. To eat.") But time eventually caught up to him: Darren McGavin died yesterday at the age of 83.

McGavin was marvelous (if a little overage) as the eccentric father in A Christmas Story, but he excelled as Carl Kolchak, the lead character of Kolchak: The Night Stalker. My sister and I used to watch this in reruns on the late show while babysitting and then turn on every light in the house out of sheer terror. Last year I found Night Stalker on the SciFi channel and have enjoyed rewatching the shows. Seen today, they're quite hokey (Kolchak using a tape recorder and typewriter to write his stories looks positively antique, and most of the monsters just... aren't that scary any more) but still worth watching. The scenes set in the office showing Kolchak interacting with his co-workers are priceless, especially the shouting matches with his editor Tony Vincenzo (played by actor Simon Oakland).

As I watched show after show, it became clear that Kolchak's office was his family: you never saw where Carl lived, he had no girlfriend, and he wore the same outfit in every episode. (Did he ever do laundry?) He lived for his job. And the shows aren't without suspense. The highlight has to be the "Zombie" episode, the climax of which has our hero wedged into a car trunk basically on top of the (dormant) zombie, desperately trying to kill it by filling its mouth with salt and then sewing the lips shut. But before he finishes, the zombie's eyes pop open. Thirty years later, I still jumped in my seat when I saw this.

Darrin McGavin was a gifted character actor who appeared in dozens of movies and several other TV shows, but for me, he'll always be running around in a seersucker suit with a hideous straw hat and a recorder on his hip, trying to crack the latest series of "mysterious deaths" and driving the cops of Chicago crazy. Rest in peace, sir, and I hope you don't rise from your grave.
posted by Dr. Alice at #

 
Sleep, Interrupted

It's always hard to function post call. Last night I got three admissions between 5 and 6 p.m. - good; I didn't get any others. The phone calls, however, persisted all night. I got another ER call an hour after I got to sleep, which destroyed my chance for any quality sleep the rest of the night. I was deeply asleep and it seemed to take forever to realize that the pager had gone off. It turned out to be an "FYI" call only, so at least I didn't have to go back to the hospital.

At two a.m. I got another phone call from a girl who'd been having heavy gynecologic bleeding for a week, so of course decided to call in the middle of the night. Her dilemma: should she go to the ER or call her doctor in the morning? Resisting the impulse to say "How the f*%# do I know?", I mustered enough coherence to discuss her symptoms with her. (She decided to wait.)

I had a meeting scheduled at the hospital today. I was too tired to go, so called in "sick." Bad doctor.
posted by Dr. Alice at #

 
Recipe

So tomorrow's the Super Bowl. (GO STEELERS!)

If you're going to a party, or hosting one, you might need a side salad. Potato salad is one of those things that I always think I'm going to like but often don't. Potato salad needs attention; it can be bland, which I really dislike, but it doesn't have to be. In a cookbook I recently bought called What to Cook When You Think There's Nothing in the House To Eat (I really like this book, by the way; it's out of print but still available on Amazon), I found a recipe for something called "Russian Potato Salad" which has become my recipe of choice. It's easy and delicious, and NOT bland.

First, take a couple of large potatoes and boil (this can take up to thirty minutes). Cool, peel, and dice. Add finely diced dill pickle and onion - the recipe calls for a quarter cup of each but I use more. The onion can be regular or scallion (green onion). Add a cup of peas (frozen are fine) cooked until just done and cooled under running water. Bind the salad with mayonnaise, thinned with a healthy dose of lemon juice. I like to throw some Dijon mustard in as well. This salad does not need salt but does need pepper. You can use white pepper, or fresh-ground black pepper if you prefer. The original recipe also calls for hard-cooked egg, which I usually leave out, but if you want to put it in, hard-boil an egg and finely dice the white and add to the salad; then sieve the yolk over the top of the salad. It does make a nice presentation.
posted by Dr. Alice at #

 
Resusci-Annie

This is one of the funniest things that's ever happened to me, from back in the dim mists of time when I was a resident.

One of the teaching attendings at my hospital had a significant interest in a nursing home in the city (this all took place in San Francisco). In order to make this facility more attractive to potential patients and their families, he decided to offer twenty-four-hour medical coverage. This meant he had to hire slave labor (i.e., us). For reasons which I now forget, I was the resident he picked to organize this program... actually, wait, I think he paid me to get the thing off the ground. Yes, even back then I was a slut for extra work. V.'s favorite nickname for me is "Leather Girl," but we'll go into that some other time.

Anyway. The on-call residents were housed in a room off the physical therapy department on the second floor. It was poorly organized, a large room that was partly office space and partly storage. The staff parked a spare hospital bed in a corner and that's where the on-call docs slept. Next to the bed, behind a screen, was stored a lifesize Resusci-Annie doll sitting up in a wheelchair. That's where it lived between CPR classes; you could see its feet, clad in sneakers, peeking out from under the curtain. The effect was creepy as hell, something like having Talking Tina sitting next to you all night, but we got used to it. It's hard to be scared of anything in a dark room when you're chronically sleep-deprived.

My job was to recruit residents to the on-call program and train them. I organized one or two walk-through orientations, but after a few months I just started phoning it in - I'd have the docs call me on their first visit to Geriatric Manor and tell them what the drill was and what to expect. So now you can visualize what happened during this conversation...

Hapless Resident: "Hi! I'm here and I'm in the call room. What's the routine here? Is there anyone I should round on?"

... about two minutes of boring medical chat..

HR (in a completely different tone of voice) "Wait. What's that?"

Me "Wait! Don't look! Don't look!"

A hideous, high-pitched scream.

I started laughing like a maniac.
posted by Dr. Alice at #

 
Dextrocardia?

Last week our X-ray technician came marching up the hall toward me, waving a set of films. She was somewhat upset: "They won't take this film! They say I did it wrong, and I didn't!"

I didn't recognize the name on the films. "Is this my patient?" I asked.

"No, but it's a pre-op and the radiology department is giving me a hard time. They say I put the markers on the film backwards, or something."

I glanced at the chest X-ray in question and immediately got her point. Normally the heart is situated to the left of center, with the apex pointing to the left. (To the reader's right; the convention is to look at the film as if the person were standing in front of you.) This film showed the heart neatly reversed, pointing to the right.

"Ahh. Dextrocardia," I purred. "I haven't seen this in a long time."

I now had a small audience of medical assistants and office staff staring at the film. "What's that?"

"Dextrocardia," I explained, "is when the heart is on the opposite side of the chest. A guy in my med school class had this." (True.) "Send the film back," I added, "it's OK."

ADDENDUM: I had just posted this when I checked back with the technician; it turned out it wasn't dextrocardia after all, she had just taken the film using a different technique due to the patient's size. We all got confused (including me). Still, I hate to waste a good post, and it could have turned out to be dextrocardia - you do see anomalies once in awhile. Has anybody out there seen dextrocardia or situs inversus on a routine X-ray?
posted by Dr. Alice at #

 
Do Not Be Whipping It Out

If you're a new patient, and you've scheduled an appointment for some completely innocuous reason like a sore throat or a pregnancy check or a bladder infection, and you get me in the room and then PULL IT OUT...

"It" being a two-page pre-employment health clearance form requiring a full history and physical including vision check and multiple blood pressure readings in both arms...

... you will get the bum's rush.

That is all.
posted by Dr. Alice at #

 
One Out of Ten Doctors Recommends It

Got the following email from V. and had to pass it along.


Subject: Ask your doctor or pharmacist...............


Do you have feelings of inadequacy? Do you suffer from shyness? Do you sometimes wish you were more assertive? If you answered yes to any of these questions, ask your doctor or pharmacist about Tequila(TM).

Tequila(TM) is the safe, natural way to feel better and more confident about yourself and your actions. Tequila(TM) can help ease you out of your shyness and let you tell the world that you're ready and willing to do just about anything. You will notice the benefits of Tequila(TM) almost immediately, and with a regimen of regular doses you can overcome any obstacles that prevent you from living the life you want to live. Shyness and awkwardness will be a thing of the past, and you will discover many talents you never knew you had. Stop hiding and start living, with Tequila(TM).

Tequila(TM) may not be right for everyone. Women who are pregnant or nursing should not use Tequila(TM). However, women who wouldn't mind nursing or becoming pregnant are encouraged to try it. Side effects may include dizziness, nausea, vomiting, incarceration, erotic lustfulness, loss of motor control, loss of clothing, loss of money, loss of virginity, delusions of grandeur, table dancing, headache, dehydration, dry mouth, and a desire to sing Karaoke and play all-night rounds of Strip Poker, Truth Or Dare, and Naked Twister.
posted by Dr. Alice at #

 
Oscar Chase

The nominations are coming out this week. In stark contrast to last year, I have actually seen some of the films that are likely to be nominated.

Brokeback Mountain. Entertainment Weekly called this "Edith Wharton with Stetsons," and by God, they got it right. This story of a doomed love slowly but surely draws the audience in and strikes a nice balance between romance and accurately depicting how the relationship between these two men destroys their lives and the lives of their wives/(female) lovers. It's just absolutely outstanding. Ang Lee does a wonderful job of directing, and the scenery is amazing. The attention to detail is remarkable, too; I kept thinking, "Oooh, look at the cars! Look at the hairstyles! Is she doing the laundry on a washboard?"

Good Night, and Good Luck. George Clooney did a really, really good job. The power of metaphor drives this film, re-enacting the paranoia of the Communist hunt that poisoned US society in the 1950's. Apparently he filmed this picture on a budget of $8 million using his buddies and the CBS studio in Los Angeles. GN&GL is an object lesson in how to make a movie on a small budget - it uses only one set, more or less, and a small cast. I must confess that I have a thing for men in white dress shirts with their sleeves rolled up; when I saw this film I thought I'd died and gone to Fetish Heaven. On the other hand the good and bad guys are, like the movie, depicted in black and white. I was reminded of the 2004 Rathergate showdown: That, too, pitted the little guys against the big establishment (oh, exquisite irony! CBS had become the big establishment). That story would make a riveting film... but George Clooney will never make it.
posted by Dr. Alice at #

 
Partner? I Don't Even Know 'Er!

Odd incident in the office this week, which I recounted to two friends during an evening at the movies. They were vastly amused:

I saw a patient of mine a few days ago who had recently had back surgery. While in the hospital she was followed by the hospitalist group we're contracted with. (Yes, I do some hospitalist work, but the managed care plan for seniors has a separate hospitalist contract. Long story; don't ask.)

"So," my patient said, partway through this visit, "the hospital people said this doctor was your partner."

"Well, sort of," I qualified. "She isn't a member of our group, but she is one of the hospitalists who see patients for us."

"No, they said she was your partner. In the vernacular sense."

I stared blankly, then I got it. "Oh, no. I don't think I've even met her." The patient shrugged, and we both laughed; there must have been some lapse of communication there, but I'm not sure what.

By coincidence, the movie my friends and I had just seen as I recounted this story over dinner was this one. (I highly recommend it, by the way. Go see it if you haven't.)
posted by Dr. Alice at #

 
Make Your Own Bollywood Movie

We now return to our usual inconsequential blather...

I call this "Tryouts for Cats."

(Via Tim Blair)

UPDATE: I'm supposed to be catching up on my charts, but this is way more fun:

"Call Night from Hell"
posted by Dr. Alice at #

 
Whoa, Dude

You've heard of In-N-Out Burgers' double-doubles or triple-triples perhaps? Well, feast your eyes on this 100x100. (from L.A. Foodblogging)




Quick, Watson, the Lipitor!!
posted by Dr. Alice at #

 
This Says It All (via Diversion Surplus)




posted by Dr. Alice at #

 
Death Watch

Dr. Oscar London is right when he says "It's the young deaths that kill you." It's hard to lose somebody with good protoplasm who "should" be able to triumph over their disease, or at least could have several years ahead of them (with luck and good treatment). Nothing is more frightening or makes doctors feel more impotent than watching patients like that fail treatment. Right now V. and I are standing on the sidelines watching someone die.

She is younger than either of us. She was diagnosed with cancer six weeks ago. She is in Intensive Care, on a ventilator, in multi-organ-system failure - actually, it's mainly her liver that is failing; it's riddled with tumor. She has breast cancer. She's under forty years old. We are trying chemo, treating her bleeding diathesis with fresh frozen plasma, doing all the things we can to keep her going. If she were ten years older, she'd already be dead, but no one's body can take this kind of punishment for long. Over the holidays I was covering V.'s practice, so it fell to me to tell this poor woman that her CT scan showed tumor in her liver (her initial complaint was persistent abdominal pain). She had only just gotten the results of the breast biopsy the week before. Now two weeks later she's in the ICU.

Lately I've been thinking a lot of a case I saw as a new intern. My first rotation was in the ICU. One day a woman in her early forties came into the emergency room. She was in good health, had had the flu for several days, and came in because of shortness of breath. When I first saw her, she was able to talk and tell us about her illness; she was on a ventilator within the hour; one week later she was dead. It was pneumonia, followed by sepsis and organ failure. The culture results - I still remember this - showed uncomplicated strep. pneumonia as the causative agent. It wasn't drug resistant, it was even sensitive to penicillin, for God's sake! Why couldn't we save her?

We're used to taking action, to implementing plans that work. When cases like this come along they remind me that I don't have the power I like to think I have. I can't fix people. I hate being reminded that diseases are smarter than I am. I hate feeling useless.

I hate watching people die.
posted by Dr. Alice at #

 
Site of the Day

Grocerylists.org - post after post of discarded grocery lists. Why? I don't know, but I think it's pretty neat. It feeds into that universal fascination of seeing what other people are doing with their lives... or is that just me?
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To the Guillotine With Her!

It's the Marie Antoinette action figure... with ejector head!

I then got carried away and found this. Ew.
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Email Aliases

We continue to be besieged with spam at work, although fewer now that we have a new Windows program which is more accurate at sorting the email sheep from the goats, as it were. I have come to admire the writers' ingenuity at coming up with names which slip past the program, and so has V., who emailed me the following:

I got a junk email from Supple P. Apotheosized. I never open them. But anyone who sounds like it could have been a role played by Groucho Marx is highly tempting.

Indeed.
posted by Dr. Alice at #

 
24

So, 24. I had never seen the show till this weekend, though it's up to the fifth season. I know the premise - anti-terrorist guy has a really bad day - but it took Dave Barry's demented recaps of last season to convince me to try it. Fox TV aired two 2-hour episodes for opening weekend, which takes us up to 11 a.m. That means that four hours into his day, Jack Bauer has had his cover as Harmless Oil-Rig Guy blown, has been framed for the assassination of the former president, has kidnapped his girlfriend's sullen 15-year-old son to keep the kid from going to the cops, sneaked into the murder site wearing a disguise consisting of sunglasses and a stolen ID even though the building is crawling with FBI agents, and thwarted a hostage crisis at Ontario Airport. (My reaction: what, Burbank wasn't good enough?) Oh, and managed to bond with the kid.

Midway through the first episode, I realized what this show really is: Hollywood has dusted off the adventure serial format and updated it. That's all this is. Most of the viewing public is too young to have experienced cliffhanger-type shows... unless you remember Batman, a parody of same, which I insist doesn't count. That's why this show is such a success. Throw in a healthy slug of paranoia, computer screenshots, cell phones that can do damn near anything, blood and gunshots and you're all set. If only they'd named Keifer Sutherland's character Jack Armstrong instead of Jack Bauer, it would have been perfect. Once you realize this, it's fun to hear Jack Bauer say code phrases like, "I am in a FLANK TWO position!" and watch it go right over the terrorists' heads, when even I could figure out that he might as well be holding up a cue card that says, "DON'T LISTEN TO ME THIS GUY IS HOLDING A GUN TO MY HEAD."

So next week, return with me to those thrilling days of yesteryear... or possibly in the not too distant future, it's kind of hard to tell... and give 24 a try. Cheer Jack on, hiss the villains and try to figure out what the heck is in those mysterious canisters the bad guys were unpacking at the end of Episode 4.
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"Rodents of Unusual Size? I Don't Think They Exist."

... oh yes they do, and I can prove it.

My family and I went to Mexico after New Year's; the high point was seeing lots of capybaras running around the hotel grounds. My sister's kids dubbed them "rat-rabbits" and they do look like a combination of the two. These things were semi-tame and perfectly happy to eat bread, crackers or anything else thrown to them.

More later, as I am still up to my eyeballs. I did watch "24" for the first time this weekend and absolutely loved it, so will probably spend time ranting about that.
posted by Dr. Alice at #