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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    Monday, February 19, 2007
    Get-a-Freaking-Clue Moment of the Week

    I spent yesterday finishing up my monthly roundup of nursing home patients. One woman I saw had to be fetched out of the day room, where the Patient Activities Session was being held. (The good news is, she's now well enough again to sit up in a wheelchair in the day room.) In honor of President's Day, the director was quizzing the inmates residents on Presidential trivia; all well and good, but remember, most of these people are pretty demented. As I wheeled my patient back to her spot in the day room, the director picked up a mimeographed sheet, smiled brightly around the room and asked, "Now, who was the seventeenth President?"


    "Um," I offered, "I don't know who the seventeenth President was*. How about the first President?"
    *It took me ten minutes to figure out that the seventeenth President was Andrew Johnson - I only remembered this because I finally realized that Lincoln was the sixteenth.


    Sunday, February 18, 2007
    One More for Sunday

    I just found a link to the LAX Live Airport Monitor. This program tracks all planes in the area, and it can give you info about other airports as well; for instance, if you want to check out La Guardia you'd change the "lax" in the link above to "lag."

    (via a commenter at Tim Blair)


    Overheard in Starbucks

    I stopped in to get a coffee this afternoon. Business was a little slow, and while standing in line I heard one barista ask the other, apropos of nothing:

    "Was Helen Keller a real person?"

    Barista #2: "What are you, stupid?"

    Barista #1, shrugs: "I just thought it was a movie."

    Me, butting in: "She wrote her autobiography. It's what the movie was based on."

    Barista #1: (nods, looks interested)


    "Off the Record, On the QT, and Very Hush-Hush."*

    Every year the Academy of Motion Picture Arts and Sciences holds the ceremony known as the Academy Awards. Every year the Academy designs a poster to commemorate this event. If you are a movie quote freak, this year's poster is something you might want to purchase. I didn't know until this year that it was possible to buy these online, but it is.

    Next Sunday I'll be throwing a party to celebrate the 79th Academy Awards, despite the fact that I've only seen one of the movies nominated. (BTW, Little Miss Sunshine is fantastic - go see it if you haven't.) Despite the hype, the gossip, the migraine inducing traffic jams and the boring acceptance speeches, the Oscars remind us of what is unique about this city; how we got started, what put us on the map. In many ways this is still a company town. I think it always will be. And I like that about Los Angeles.

    Oh, and if you're wondering about the source of the quote above, here it is.


    Thursday, February 15, 2007
    Patient Comment of the Week

    Yesterday I saw a patient for a preoperative history and physical. She's had severe problems with fibroids and is having a myomectomy next week (that's when you remove the fibroids but not the uterus). As I was examining her abdomen I noted that her uterine fundus was quite large, nearly up to her navel. She sighed and said, "They showed me the ultrasound results. It looked like Mickey Mouse."


    Award Madness

    ...So the Grammys were Sunday night. (Don't ask me who won, I have no idea.) Every January through early spring Los Angeles is hit with a blizzard of awards ceremonies - they all seem to be at the beginning of the year for some reason. On the one hand, they can make for good entertainment (both TV watching and reading); there are usually several good stories about the restauranteurs who are catering the parties and what they're serving, for instance, not to mention the fabulous gossip that results when celebrities clash at these functions. Unfortunately the accompanying traffic and street closures make life hell for the rest of us, especially those who live in Hollywood. (Hi, Mary!) Now that the Kodak Theatre is the standard venue for the Academy Awards, Hollywood Boulevard is closed off for days beforehand and it's an absolute pain.

    Getting back to my original point, L.A. Observed had a caption contest for this picture, snapped at a Grammy party, showing our fearless leader Mayor Villaragosa chatting with Paris Hilton. The results were so hilarious I had to post this. My favorite: "Why, I'd love to come to your quinceanera!"


    Tuesday, February 13, 2007

    Havidol - when more is not enough! This webpage is a dead-on parody of drug ads.

    (via GruntDoc)


    Friday, February 02, 2007
    MRSA in Los Angeles

    Meant to blog on this a while ago, but I didn't get around to it till now. It's important enough that I decided to dredge up and edit this three-month-old post. MRSA has broken out among the homeless population in Los Angeles in a very big way. (Warning: there are some pretty gross pictures in this article, but it's an excellent read.)

    MRSA stands for Methicillin-Resistant Staphylococcus Aureus. It's a scary bug that used to be seen only in hospitals and nursing homes, but made its escape to the community at large a couple of years ago. S. Aureus is the bacteria that causes most boils and many skin infections; the rule is, if you see pus, it's probably staph. All staph is aggressive, MRSA especially so. In addition, and unfortunately, its DNA is prone to mutate; this means it's managed to develop resistance to nearly every antibiotic we've thrown at it. Back in the 1940's when penicillin was first available, one of the reasons it saved so many lives is that staph had no resistance to it. That lasted about five minutes. As new antibiotics were developed and we became more familiar with the bacterium's resistance mechanisms, many new drugs were developed specifically to attack this problem. For years methicillin was our go-to drug to treat staph. When it became resistant to methicillin, we knew we were in big trouble. Hence the label MRSA.

    The only drugs we currently have to treat MRSA are vancomycin, which must be given intravenously, and two oral drugs. One is an old reliable: the trimethoprim-sulfa combination. One is new (and hideously expensive): linezolid. By hideously expensive, I mean the average wholesale cost is $83 per pill. But if someone is allergic to sulfa or it doesn't work against the MRSA, that is our best option.

    MRSA is a scourge in the HIV-positive population, who seem to be particularly prone to suffer from it. I've seen it in patients with no medical problems as well; last year I admitted a healthy guy with a severe MRSA cellulitis in his hand. He got it lifting weights at the gym. (Most gyms seem to be contaminated with it these days.) The entire Skid Row area seems to be infested with it, and as detailed in the article I linked above it has attacked paramedics, firemen, police officers and shelter workers as well as the homeless.

    I hope the Department of Health gets on this. MRSA has demonstrated its talent for disseminating itself. If it got out of the hospitals, there's no way it will be contained in Skid Row. I'd consider this as dangerous a threat to the public as tuberculosis.


    Great Minds Think Alike

    The doc who writes The Blog That Ate Manhattan recently posted on a method of documenting extremely confidential patient information that I've been using for a long time: the sticky note. I do this a lot. If a patient tells me something that they don't want to go in the chart but is relevant to their care, I've got to remember it somehow. My practice is way too busy for me to trust to my memory. The sticky note (can I say 'Post-It' without getting sued? Nah, better not risk it) is the perfect answer. It's there if I need it but instantly removable if I need to send copies of the patient's records.

    However, our practice is in the midst of converting to electronic medical records, or EMR. This means that the sticky-note confidentiality option no longer works. The MD quoted above is also wrestling with this problem:

    In the EMR, the only option I have is to make an entire encounter confidential,
    so that no other provider in our system can read it. I do use that option for
    the occasional celebrity patient or for the employees who wants their records
    uber-protected. But that does not work as well, in my opinion, for handling
    those little bits of personal information that count.

    The EMR has not reached my office yet, but sooner or later it will. I have no idea if our system allows for the confidential encounter option mentioned above; I'll have to check with someone who's already using it. If not, I'll have to come up with something. Perhaps the old-fashioned Rolodex would work for keeping notes - I'm still a big fan of those.

    And as I read this blog, I realized I'm not the only doc out there who likes to write about food. TBTAM is going on my blogroll.

    (via GruntDoc)