“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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To all who are reading this now, or in the future. The annual Christmas miracle kicked in about 24 hours ago. Traffic has slowed down, nay, has all but disappeared. Peace reigns over Los Angeles (more or less). Merry Christmas to you and yours. Be well and avoid the flu.

Labels: Random Thoughts

posted by Dr. Alice at #

 
Hi There, Captain Trips

Let's start things off with a picture, shall we? Notice the complete lack of any bioprotective gear on the guy cleaning up the Ebola-laden vomit ejected by Patient Zero on his way to the hospital?

Sigh. OK, I used to think the US had one of the best public health programs in the world. All that stuff about immunizations, handwashing, treating TB, clean water supplies - you know the drill. But after seeing the way the Ebola case has been mishandled I am beginning to wonder. Read the following (lifted from the Ace of Spades site, and MAJOR props to blogger tmi3rd for his info on the case):

The patient's quarantined girlfriend Louise told CNN on Thursday that she had not been told what to do with the soiled linens used by Mr Duncan when he was ill and had not been given food. The woman has been legally ordered to stay inside her Dallas apartment with her 13-year-old child and two nephews, who are both in their twenties, as they came in direct contact with Mr Duncan. ... The quarantined family members of Ebola sufferer Thomas Eric Duncan had tried to escape their Dallas apartment after being told they had to stay inside because they were at risk, having been around Mr Duncan while he was contagious... It also appears that Mr Duncan did not mention his close contact with a severe case of Ebola to his partner Louise, with whom he has one child.

So, yeah. That apartment is LOADED with infected bodily fluids and the local health department (and/or CDC) is telling them to stay in there. I don't see that working out real well. The family is understandably terrified and has already left the apartment once. Why doesn't the city move them to a clean, isolated area?

Go read Ace, who's all over this story. You won't get better info anywhere.

Labels: Critiques, Medicine, Science?

posted by Dr. Alice at #

 
Basic Chili


As an addendum to the previous post, I will tell you what I brought to the office today for lunch though I would never think of cooking it in the office (impossible, really). It's no gourmet surprise but works well enough on a busy week.


1 lb mince (aka ground beef, ground turkey, etc)
some chopped onion, maybe 1/2 cup or more
1 15 oz can diced tomatoes, preferably "Mexican style" (plain is fine)
1 15 oz can beans (pink, kidney, even black beans)
generous amt chili powder, between 1-3 tablespoons
shakes of cumin and garlic powder
salt, pepper


This is what I call good old housewife 1960's chili. And I mean that in a good way. Brown your meat, throwing in onion. Drain (if meat is not low fat). Add undrained beans, tomatoes and spices. I sometimes add some cayenne or Tabasco. Keep tasting to see if it is as you like it, simmer from 30-60 minutes. Serve with your choice of shredded cheese, chopped onion, sour cream.


You can turn leftovers into "chili casserole" as my mother used to call it. Layer the chili in a greased casserole with tortilla chips, chopped onion and shredded cheese. (This is also known as "Mexican Lasagna"). Bake at 350 degrees till done, maybe 45 minutes. It isn't great but it isn't bad either.

Labels: Ingestion

posted by Dr. Alice at #

 
Hands Off My Kettle!


The food writers of the Guardian have done it again. One of their recent "Word of Mouth" blog posts deals with fixing lunch in the office. Not bringing your lunch, but cooking it in the office. The writer gives the example of using the office kettle to boil eggs in. Need I mention the primary use of said kettle is to boil water for tea? I can only imagine the sulfury, eggy taste of the first cup of tea made out of that kettle after lunch. And I'd get tired of boiled eggs for lunch awfully fast.

As always, the comments are gold - better than the article really. I append a few.

As I worked in a foundry, I fear my eggs would have been very hard indeed.

According to my mother (a fount of misleading information) boiling eggs in the kettle gives you warts.

I've been crisping bacon in the laminator and making my own pesto in the shredder for years. It makes the office smell wonderful.

Rather than turning my pasta into tagliatelli in the shredder, we could use my pasta and your bolognese sauce to make ravioli in the laminator. Is there no end to the glory of the office lunch?

I've converted our office water-cooler into a fermentation vat and am currently conditioning a young but surprisingly fruity Rioja.

My jerky is nearly ready, I've had little strips of beef hanging in front of the aircon for two weeks now.

Several comments from vegans, folks with egg allergies and those fearful of salmonella livened up the debate. I also would not be doing my blogging duty if I did not point out that the comments include a very clever ode to the George Foreman Grill. You're welcome.

Labels: Ingestion

posted by Dr. Alice at #

 
A New Life In Total Disbelief


Apparently, the zombie apocalypse may be upon us after all:

Two Ebola patients, who died of the virus in separate communities in Nimba County have reportedly resurrected in the county. The victims, both females, believed to be in their 60s and 40s respectively, died of the Ebola virus recently in Hope Village Community and the Catholic Community in Ganta, Nimba. But to the amazement of residents and onlookers on Monday, the deceased reportedly regained life in total disbelief...

The above quote came from a Liberian news site called The New Dawn. I'd like to have a chat with the author about dangling participles and such. In all seriousness, it speaks to the level of panic and lack of medical support in this epidemic that patients could be mistakenly pronounced dead - and to the amazing powers of the human body that these two women could revive after (I would assume) at least 24 hours without fluids or medical care.

That said, if any news breaks about brain eating zombie rampages, I'm heading out to find a nice safe bunker.

Labels: Medicine

posted by Dr. Alice at #

 
How to Skate Around Obamacare (Maybe)


This article appeared in the New York Times this weekend. It relates mostly to surgical fees and billing, but I found it interesting. The gist of it is that even when savvy patients go in for surgery with a surgeon they know is approved by their insurance plan, and make sure the procedure is scheduled at the hospital contracted with said plan, they can still get hit with unexpected fees if the surgeon calls in a noncontracted assistant. In many cases the assistant is in the same office as the surgeon in charge of the case. It's easy to infer that the assisting surgeon's higher fee is likely split with Surgeon #1.

In other cases, patients reported that a hospitalist or internist who appeared on their hospital bill as rounding on them daily never in fact showed up. Or they got an echocardiogram that they didn't actually need for surgical clearance. Or other things.

The surgeons, in many cases, blamed the hospital for the extra procedures and charges; they state that due to the drop in reimbursements this is the hospital's way of getting additional cash. As for the assistant issue, it actually is common for surgeons to have an assistant on their cases. It makes things much easier and faster in the OR to have someone retracting the edges of the wound, assisting with suturing, and so forth. My father, in fact, did this for many years on his patients. This was well before the era of managed care. His specialty was family practice, but he was deft and smart, and the surgeons loved working with him. However, he did not bill for the astronomical sums mentioned in this article; he was just an assistant, and "out of network" was not a concept that applied at that time.

If the surgeon knows he or she is going to need an assistant on the case it is his responsibility to explain this to the patient (including exactly why one is needed) and to make sure the assistant is contracted with the patient's insurance plan. As someone who works for a large group which employs lots of staff who deal with this exact issue, I'm kind of surprised this ploy is as frequent (and successful) as it apparently is.

Labels: Medicine, Money

posted by Dr. Alice at #

 
Oh, this. THIS.


Please go and read this wonderful post right now. It's a collection of stupid comments made on food blogs and I hope it makes you as happy as it made me.

(h/t Ace of Spades)
posted by Dr. Alice at #

 
You may have noticed there has been a slight delay in posting. My apologies.  (Full disclosure: I started this post in May 2013.)

Quite a lot has been happening. I'll try to condense it for you.

- I once again went through the agony of recertifying in Internal Medicine. This happens every ten years and it seems to get worse every single time. The good news is that now all internists are equally discommoded by this process, instead of only those who were certified after 1990. The older doctors who were originally told that they would not have to go through this process are now stuck with it just like the rest of us. An online revolt began almost immediately; a torrent of protesting emails have been fired off to the Board and to the ACP (our academic organization for Internal Medicine). So perhaps we will finally get some relief from this torment.

In case you are wondering about ongoing medical education, there has been a longstanding requirement for licensure that all doctors must earn a certain number of CME credits every year. The certification process has been added on top of that requirement and, in my opinion, is the board's way of grabbing control of the lucrative medical-education pie. Many doctors are threatening to let their certification expire. You can still practice without being board certified, but most medical groups and hospitals will be reluctant to hire a doctor who is not certified in some specialty. The question is, would an established physician be dismissed for letting his or her specialty certification expire? No one seems to know.

- I turned fifty last year and celebrated it in a way I did not expect. On my birthday my mother passed out cold while walking to the refrigerator, crashed to the floor, was taken to the hospital and found to have a cardiac arrhythmia which resulted in her getting a pacemaker a week later. Fortunately she is now doing fine. But the month before my father had had a serious stroke. Add in an aunt who needed hip surgery and two cataract surgeries on my mother, and you can see it's been a very busy year.


So what shall we talk about then? The heat wave, perhaps. It has been really warm and humid for over a week, what with two rogue hurricanes tracking up from Mexico through the Gulf of California. In Los Angeles we got little or no rain, but Nevada to the east got enough to wash out part of Interstate 15. Like many older houses on the west side, mine has no air conditioning; and because the windows are French-style that open on hinges, rather than the slide up-and-down kind, I cannot use a window unit. I dug out the giant box fan my father gave me years ago and it has been a lifesaver. It must be 40 to 50 years old and still works like a champ.

Southern California residents are also now having to cope with the constant announcements that we are in a Drought. The Worst Drought Ever. We must save water. Well, of course we must; any fool knows that we live in a semiarid climate and the population count here is far too dense for the amount of rainfall we get. We were bound to run out of water at some point. Some years we get heavy rain and flooding, some years we get very little rain. This past winter we only had one significant storm and that was in February. California is working on desalination plants, but I think that water storage tanks in everyone's backyard to be filled during the rainy season would also be a good tactic to try. Strangely this idea has not been discussed in the local press (as far as I can tell).

And lastly, our medical director has decided that the medical group ought to have a blog. It won't be for the public, but available on company Intranet only. I wound up being one of the doctors picked to write for it and was happy to participate, but he came up with this idea over a year ago and we still don't have the website up and running. Enduring the various delays has been somewhat frustrating, but we are told that "any day now" the blog will be functional. Uh-huh.

The other problem regarding the work blog is that our Fearless Leader wants posts of 150 words or less. I told him that at 150 words I was just getting started. He says the idea is more to present ideas that will "foster debate" about the best methods of practice. Okay, I can see that would be educational and it will force me to stay current on topics such as vaccination recommendations, when to start treating high cholesterol levels, and so forth. But it won't be very entertaining. My idea is that after a month or so I will start mixing in a little entertainment as well. We'll see how it works.

He doesn't know about this blog. I aim to keep it that way. I'll post more soon.

Labels: Los Angeles, Medicine, The Doctor's Life

posted by Dr. Alice at #