“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






Email Dr. Alice

 
A Long Time Ago, In a Movie Theater About an Hour Away

When I was in eighth grade my history teacher wanted to teach us the importance of current events. One of the requirements of the class was that we would each get a subscription to Time magazine, choose a subject, and make a weekly presentation about it. The subject I chose was health and science (no surprise there). What is surprising is to look back and realize that back then news magazines were what people read once a week to keep up to date. They're on their last legs now.

Near the end of that school year (it was May 1977) I picked up my latest issue and looked at the cover. There was a small banner across the upper right corner of the magazine that said "The Year's Best Movie." Curious, I turned to the article.

It was a science fiction movie, which interested me not at all, but I kept reading anyway. I had never heard of the director, although he had directed a movie I had heard of - American Graffiti. The article talked about filming in Tunisia, as the movie was set on a desert planet called Tattooine. One of the actors had been in American Graffiti.

I showed the article to one of my friends.

"Have you ever heard of this movie?"

She looked at the article and shrugged. "Nope."

Yes. We're talking about Star Wars. That was 38 years ago. It seems impossible to believe now, but the film which left a massive impression on popular culture and led to (now) six sequels was completely under the radar until it hit the theaters. I don't recall any advance word of mouth regarding this movie at all.

I don't think I saw Star Wars until July. By that time it was well established as a blockbuster; it stayed in theaters for six months at least. I still recall that day, sitting in the darkened theater, wondering what to expect. Then electric blue letters appeared on the screen.

Labels: Pop Culture

posted by Dr. Alice at #

 
There Was No Gilligan, But There Was a Mysterious Dude.

I was converted to the concept of the e-reader (eBook, whatever) by my roommate on my Guatemala trip several years ago. Another busy physician, her specialty was family practice and we bonded over finally having the time to read without guilt, since there was nothing else to do in the evenings after the clinic closed for the day. She was glued to her Kindle every night. I was jealous that she never seemed to run out of reading material, whereas I zipped through my book and two magazines in nothing flat.

So when I got home I knuckled under and bought one. At first I wondered if I would ever download enough to justify the purchase, but that really has not been a problem. Have I bought more books? Yes, I have. But did you know that there are a lot of free books available for the Kindle? Yes, free. FREE. If you subscribe to Amazon Prime it gives you access to the Amazon Library system; there are a ton of books that you can obtain on loan. The limit is one per month, but if you are an avid mystery reader it's great to have access to all the paperback cozies you want without having to spend $7.95 on a book you'll never read again.

(Incidentally, what is it with mysteries these days? When did cozies start to incorporate recipes, scrapbooking, witchcraft, knitting and God knows what? I still read them, all right, but I'm starting to hate myself. The heroine/detective usually spends more time enthusing over her cats or her latest yarn purchase than she does solving the crime. I mean, Philip Marlowe would NEVER.)

But back to Free. I had heard that there was a big self-publishing market on Kindle, but I didn't realize how big until I started reading a prepper/homesteading blog in which the author used to publish a daily list of free books available on Kindle. I'd link to it, but the author then made the list available by subscription only. The books focus on topics of interest to preppers and homesteaders, such as homeschooling, working from home, religion, food storage, agriculture, etc. I have downloaded some of them, all of which were self-published, and the quality varies widely. Some are better than others.

But then I thought: What if I just type in 'free' on my Kindle? I tried it, and realized that on any given day there are thousands of free books available. Many of them are classics which some deserving soul has laboriously transcribed into a Kindle compatible format. Jane Eyre, Pride and Prejudice, Tom Sawyer - I felt as though someone had set me loose in a candy store and told me to grab everything I wanted.

And that is how I came to be reading Jules Verne's The Mysterious Island.

I love Jules Verne. Around the World in Eighty Days is still one of my favorite books, and one of my daydreams is to someday take three months off to go around the world. I also loved Captain Nemo, the self-exiled main character of 20,000 Leagues Under the Sea. Mysterious Island (published 1874) is commonly called the sequel to 20,000 Leagues, but that's not all it is by a long shot. I would rather call it a stand-alone novel which incorporates a character from his previous novel. Verne started with this premise: if a group of people are marooned on an island with nothing but fortitude, knowledge and the clothes on their backs, can they survive?

 The book is set in 1865 and focuses on a group of Americans, prisoners of war in Richmond, Virginia (they are Yankees). They escape from Richmond via a hot-air balloon which I guess someone carelessly left sitting around, are caught up in a storm over the open ocean and are forced to throw everything they own out of the balloon to reduce its weight before eventually crashing on an island. Captain Cyrus, the leader of the group, is an engineer; the other characters include his servant, a free black named Neb; Pencroft (a sailor); Herbert (the teenage ward of Pencroft whose hobby is natural history); and a journalist named Gideon.

It's interesting to read the book from a twenty-first century perspective. Our heroes have no qualms about exploiting every resource they can lay their hands on. They even wind up dynamiting part of the island to form an indoor shelter (it's a large undersea cavern, and the explosion allows them to drain part of the water out). The island just happens to contain clay, iron ore, nitrites, etc. etc. and the engineer figures out how to smelt the ore, build a kiln to make pottery and so forth. One running joke is that Pencroft is constantly hungry. Every time they find a new species, his question is: "Can you eat it?" Environmentalists everywhere would scream reading this book.

When the group initially lands on the island, of course, they have absolutely nothing. One of their group gets into trouble and then is mysteriously rescued; then they discover a chest of clothing and supplies sitting on the beach. Pretty soon they figure out that they aren't alone on the island...

The Mysterious Island is a good read, though somewhat stiff by today's standards. The adventure parts are interspersed with pages of straight-up chemistry whereby the engineer explains how the group is going to make gunpowder, why he knows the island contains iron ore and so on, which absolutely kills the suspense. But you can skim these parts. It's kind of like reading Tom Clancy where you blip over the parts describing tanks and aircraft in loving detail.

To get back to my initial point, I've been completely converted to the concept of e-readers. I continue to buy and read print books, and I don't think print will ever go away - nor should it. But the equipment is inexpensive and lasts a long time. I've had my Kindle for four years and it's still going strong. It's an older model to be sure, but I have not felt the need to purchase a new one. If you have been considering the purchase, or have bought one but aren't sure what to do with it, the free options alone are worth it in my opinion. Give it a shot.

Labels: Books, Random Thoughts, Science

posted by Dr. Alice at #

 
Nine Days Later

Well. Dad got through the aortic valve procedure okay, I am glad to say. The one-week follow up did not go so well. I don't want to throw in too much detail but he had a lot of swelling and pain which developed after he was discharged from the hospital. He of course did not share this with anyone, including my mother, until the night before the appointment. He insisted on wearing an old pair of scrubs to this appointment, as he could not put on a pair of pants - but he could not tie the scrubs and his pants kept falling down. (I sent an urgent memo to my mother to get him some sweat pants ASAP.)

He had to have a lot of neurologic testing done that day which further delayed us, and the cardiologist who had presided over the AV replacement wanted him to have an ultrasound. Long story short, we did not get home until after 9 pm, at which point my mother realized that she had lost the key to her car.

So I drove the 30 miles or so to their home and picked up the spare key, then drove back, then realized I had lost my cell phone.

That was the worst day by far. The rest of the summer was still pretty hairy, but nothing like as bad. While all this was going on, one of my co-workers was out of the office due to a severe illness of a family member; add all this up and you can probably see why I have not posted in a while.

But it's fall now, things seem much better and I'm going to leave it at that. It's time to get back to my usual ramblings.

Labels: Family, Medicine

posted by Dr. Alice at #

 
Horse Manure! (It's Therapeutic!)

I invite you to read this eye-opening article run by the New Yorker some time back about therapy animals. It's truly ridiculous what people can get away with these days. I found the article entertaining, as I have run into similar requests at work.

About a year ago in my office my partner was confronted by a therapy rat. Yes, a rat. The rat was in a bag around the patient's neck and it perched on her shoulder while she was having her blood pressure taken. I give the medical assistant credit for not shrieking during this process. After a hasty discussion with risk management the rat was placed into the patient's mother's custody and evicted to the hallway. Legally speaking, the only formally recognized service animals are dogs and miniature horses. ("You mean ponies?" I asked. "No, miniature horses" was the reply.)

I have gotten my fair share of requests to write letters allowing patients to take their pets - they are not service animals - just about anywhere. I usually decline, unless the patient has a known psychiatric or medical issue which really requires taking the animal with them. If it's psychiatric, they need to be seeing, or to have seen, a psychiatrist. It bugs the heck out of me when I see people playing the system like this.

Labels: Medicine, Twenty-First Century Crap

posted by Dr. Alice at #

 
Plunged Into Caregiving

About four months ago my mother asked me to call my father's cardiologist to get clarification on something - "He wants us to do some testing. Is this really necessary?" So I did.

"Your father has aortic stenosis," the cardiologist said without preamble (he knows I'm an MD), "and it's pretty significant."

My attitude when we opened the conversation had been doctor-to-doctor. Now suddenly all that vanished and I was repeating, in a very small voice, "Dad has aortic stenosis?"

The gist of the conversation: yes he did, and furthermore it was getting worse, and the cardiologist wanted to do an angiogram. One angiogram later, Dad had a stent in his right coronary artery but still no clear word on the valve. Cardiologist #1 suggested that we see his pal, Cardiologist #2, an expert in aortic valve problems. By a stroke of luck #2 works at my hospital, Tertiary Care Medical Center.

This guy is hardcore. He has a large office in the very newest building on the hospital campus. Each room has a chair that looks a bit like a recliner, which doubles as a scale. Yes, they press a button and the chair raises a few inches off the ground and they weigh the patient sitting in the chair. He also has a fleet of nurse practitioners and technicians, high grade office equipment and the ability to perform echocardiograms in the exam rooms. The tech clearly knew what he was doing but still could not get a clear picture of Dad's valve. He pressed a button on the room's intercom, ordered a bag of contrast and this was infused through a vein, right in the exam room, by a nurse who appeared out of nowhere.

It's wonderful what money can buy. I guarantee you that no internist or primary care doctor has facilities like this.

After this, we found that the AS was really quite bad indeed. Dad needed a valve replacement as soon as possible. We all agreed that the traditional method (aka "cracking the chest") was not a good idea as Dad is not in the best medical condition. He has a history of several strokes and some dementia. Cardiologist #2 specializes in valve replacement via the femoral artery. How he does this I have no idea, but overall it is less stressful and risky than open chest valve replacement.

Today we go for the final round of preoperative assessments and tests. He is having more of a workup than average because he's been entered into a study wherein the surgeon places a filter in the aortic arch before doing the valve replacement, which should lessen the risk of additional strokes. Tomorrow, if all goes well, he has the procedure.

I have been in charge since the workup started: transport to the hospital, spending the night in the hospital with Dad postprocedure and translating developments to the rest of the family. I now really empathize with patients who get confused and lost, and who complain about having to go to the doctor all the time; I am learning exactly how that feels. As you can imagine, I've had to do some canceling and reworking of my office schedule, but I really don't care. All I want is for this to work.

Wish us luck.

Labels: Family, Medicine, Science

posted by Dr. Alice at #

 
Not My Best Week

Another wildly insane day is under my belt. It's hard to say exactly why I left the office feeling so jittery and tense. It may have been the phone call that turned into a 30 minute conversation with a worried son of a new patient. It may have been my current patient who has lost her insurance and now is on Medicaid, which means that for some mysterious reason several of her medications are no longer being covered; suddenly the pharmacy is demanding authorization requests for even the most basic of medications.

It may have been the new patient I saw today who turned out to have multiple unforeseen issues. This particular patient discontinued their diabetes medication three years before and then proceeded not to seek medical care for three years. Today this person turned out to have a random blood sugar of 311. Surprise!

It doesn't help that I am still jetlagged. This past weekend I attended the ACP annual conference. This year it was held in Boston. I did not have the luxury of extra time to adjust to the three-hour time difference between Los Angeles and Boston either going or coming. The conference was good and I think I learned quite a bit, but it is very hard to get spoonfed lectures for 10 hours a day for three days running without losing your mind. No exaggeration; the lectures start at seven in the morning and run until 5:30 PM (with breaks, of course).

And there is more. Two weeks ago my father's cardiologist decided that he needed a catheterization to evaluate his aortic valve. The valve turned out to be functioning reasonably okay but he had a stenosis in his right coronary artery which required a stent placement. This meant that he had to spend the night in the hospital. Guess who spent the night with him? Yes, it was I. I was somewhat philosophical about this turn of events until I was told by the nursing staff that they have no arrangements made for family to spend the night with patients. This meant that I slept in two chairs, continually getting up to remind my father that no, he could not get out of bed to go to the bathroom.

This week I learned that two of our physicians will be taking medical leave somewhat urgently. I don't know the cause and I don't need to know. What I do know is that their patients have to go somewhere, and they will be distributed among the rest of us. Is it any wonder that I am giving serious thought to running away screaming?

I don't have a good way to end this jumble of thoughts. Consider it a therapeutic brain dump. I will be back soon, hopefully in a better mood.

Labels: Medicine, The Doctor's Life

posted by Dr. Alice at #

 
So Bad It's... Bad. 

Ladies and gentlemen, I am proud to announce the return of Workout Movie Theater. In this ongoing series I review fragments of film I have caught on the elliptical or treadmill while at the gym. (Yes, I belong to one of those chichi gyms that have television screens attached to the workout equipment.)

Today's film is Con Air, an action-adventure film from 1997. I like to think of the nineties as the golden era of crap action movies, possibly because that was the last decade when I actually had time to go to the movies. This film is outstandingly, memorably bad, not least because the cast is really very good. If only Arnold Schwarzenegger had been in it it would have been perfect. It's based on an actual federal air transport system used to move convicts and illegal aliens across the country. You don't have to be psychic to predict the plot: the criminals take over the plane and wreak havoc. Needless to say we've got a good guy on board who tries to take down the criminals.

So far so good. Things start to unravel when you realize that the hero is played by Nicholas Cage, who has clad himself in a wifebeater T-shirt and Southern accent for this film. He's supposed to be a former Army Ranger from Alabama who went to jail for manslaughter committed when he was trying to protect his pregnant wife from assault. He's been in jail for seven years and has never seen his kid. Why he wound up on a plane with a bunch of mad serial killers I have no idea (I missed the start of the movie). The cast includes John Malkovich (chewing the scenery as the head bad guy), Steve Buscemi as a serial killer who really doesn't seem so bad compared to Malkovich's character, Colm Meaney (aka "the Irish guy from Star Trek") as a DEA agent, and John Cusack, who looks about twelve, as a U.S. Marshal. (I understand Cusack hates this film so much that he refuses to talk about it in interviews. I can't say I blame him.)

So. With a cast like this, why is it so bad? Let's list the reasons.

• Language. Not only do we have F-bonbs galore, we have more gratuitous racist insults than you would believe. In the setting of a plane full of convicts, half black and half white, I would have expected to hear some of this stuff, but it was almost nonstop. This film is 18 years old and in this respect, it shows. I don't believe any movie, R rating or no, would get away with this today.
• Predictable plot twists. The climax of the film involves the plane landing in Las Vegas. They've cleared the runways for the plane to land at the airport, but of course it's out of fuel. The pilot then announces that he's going to land on - wait for it - the Las Vegas Strip. Cue the crashing neon, screaming crowds, flying propellers... on what seems like an endless loop for at least three minutes. 
• An unbelievably corny script. Nicholas Cage's cellmate was apparently also assigned to this flight. When Malkovich announces that there's a traitor on the plane and threatens to kill one of the guards, the cellmate does an "I am Spartacus," takes the blame before Cage can confess and gets shot for his trouble. The cellmate, lying on the floor of the plane and looking like he's about to check out, announces that he doesn't believe in God, whereupon Cage responds "I'm going to show you that there IS a God!" as he jumps up and heads forward to take over the plane. (Did I mention that he has shoulder-length Jesus hair?)
• The ending. Ugh. Our hero has been toting a stuffed bunny rabbit as a gift for his daughter throughout the movie. The blasted thing somehow survives the crash, landing in the gutter in a puddle of mud. Cage picks it up and presents it to his daughter, who promptly hides behind her mother. (I think this is supposed to play on the audience's heartstrings; I admired the daughter's good taste.) Prompted by her mother, who is dressed in a two-piece sweater set and has her hair in a headband and generally looks like she stepped out of Good Housekeeping magazine circa 1962, she takes the rabbit and hugs her daddy. The only thing that cuts the glucose here is the final scene in which we see good old serial killer Steve Buscemi, who survived the crash, shooting craps in a casino and announcing that he feels "lucky."

I laughed my way through this thing and managed 40 minutes on the elliptical while watching it, so I suppose it did its job. But afterwards I realized something that depressed me for the rest of the day: since 1997, movies have gotten even worse. At least Con Air had an original script. It was not a remake, had nothing to do with Marvel Comics or transformer robots, and had very little CGI. It had a cast of experienced professional actors who did the best they could with the material they had. There were no fart jokes, at least not in the part of the film I saw.

These thoughts left me asking myself "Whither Hollywood?" I could only answer with a shrug and "Nowhither, I guess."

Labels: Critiques, Pop Culture

posted by Dr. Alice at #

 
A View to a Crash

Driving home from work tonight I turned on the radio and found myself in the middle of a freeway car chase. If you aren't from Los Angeles, you may not realize how frequent a happening this is: L.A. has 527 miles of freeway and a whole lot of cars, not to mention any number of lawbreakers whose first instinct, when the police turn on their flashing lights, is to put the pedal to the metal. The first really heavily televised car chase was back in 1994 and I blame O.J. Simpson and his white Bronco for this whole phenomenon. Tonight's chase was out in the Lancaster-Palmdale area north of the city and was eagerly being narrated by the clowns John and Ken on KFI, a talk radio station with a conservative bent.

"They say he's going a hundred and twenty miles an hour!"
"He's slowing down. Why is he hitting the brakes?"
"He just went into a GATED COMMUNITY!" (The driver apparently rammed the gate, drove in, a passenger [who has since been arrested] jumped out of the car, and then the driver headed back out and onto another freeway. As one of the radio hosts pointed out, this has never happened before in the televised history of Los Angeles car chases.)

One well-meaning network journalist on television recommended that people in the area keep their children indoors. John and Ken greeted this rather obvious piece of advice with glee and every five minutes would again remind their listeners to lock their doors and stay inside. As I listened I heard that the chase had started in Northridge, in the San Fernando Valley - a good 40 miles back - and that the driver had hit a pedestrian there. No word on how the pedestrian was doing. Who cares? There's a car chase to narrate!

 Eventually the chase petered out, as these things do. The fox - I mean, driver - was run to earth on a dirt road out in Palmdale. Driver then proceeded to sit in his car for about fifteen minutes, before eventually being persuaded to come out of the car, where he was promptly cuffed and will no doubt face any number of charges. I just hope manslaughter isn't one of them.

Labels: Los Angeles, Pop Culture

posted by Dr. Alice at #