Thursday, January 31, 2008

When sports can kill you...

Looking forward to the SuperBowl?

Researchers recently showed that German men had three times the number of heart problems on the days when there were big soccer World Cup matches and Germany played. The closer and more exciting the games, the more heart attacks they found.

My advice?

We all know a dear family member with a cardiac risk factor or two. If you have a loved one who is going to be watching the big game this weekend, slip him (or her) an aspirin before the game. Tell him it's to prevent a hangover. It may just prevent a heart cath.

Wednesday, January 30, 2008

Long Lashes

Henry has the longest, thickest eyelashes. At least, he did. They're falling out. It's slow, lash by lash, unlike his hair. They're over halfway gone now.

I suspect, since it took so long for them to fall out, that it will be a while till they're back in again.

I'll miss them.

Monday, January 28, 2008

Phone message of the day

8 am: Blood sugar 802. On call doctor told patient to call 911. Please call as soon as office opens.

Not so funny, huh? This was a diabetic patient, but there is no way that her sugar has ever been close to 802. She's quite well controlled.

By the time we got the husband on the phone, he was feeling terrible.

She just left in the ambulance, and I realized that I was holding the monitor upside down. Her sugar was 208.

Boy is he going to be in trouble.

Friday, January 25, 2008

Up To Date

I need to find out how to get paid for my product endorsements. Zappos, are you listening?

On a recent post I mentioned Uptodate as a great source for medical information. Most residents trained these days are raised on Uptodate. Currently a subscription costs $495 annually, tho you get to renew for $395. I would have trouble practicing medicine without it.

It started as a great source for primary care docs, but they are adding content constantly and is not endorsed by some specialty societies as well. The information is evidence-based where possible, and well sourced.

I turn to it often, for all those diagnoses or clinical questions that I only run across a few times a year. It's a great refresher. It has all but replaced my textbooks, which are outofdate by the time you get them. I continue to use my sports medicine book, and my derm books, but little else.

It's got some downsides. I don't like the patient handouts - they're written at too high a level for my liking. I don't always love the way that it separates information on conditions. It often has a separate article completely for diagnosis, treatment, etiology, etc. I don't find it useful for derm issues either - I still need to leaf through something and look at pictures often. There are more and more photos, but of course you need to know the condition you are looking up first, which is not always the position that I am in.

All in all, I am a better doctor for Uptodate. While I'm at it, Epocrates on my palm pilot is difficult to live without. For good measure, I also officially endorse Hershey's Nuggets Dark Chocolate with Almonds.

Thursday, January 24, 2008

Book Review: The Poisonwood Bible

Best. Book. Ever.

You've got to read it. Really.

Religion. Politics. Motherhood. Materialism. History. Poverty. Daddy issues. Racism. Love. Death.

All written in the most luscious prose.

I read it for the first time years ago, maybe in college? I loved it then. I recently reread it and loved it even more. In another 10 years I'll read it again. There are some advantages to having a lousy memory.

Wednesday, January 23, 2008


I'm glad to have humor back in my life. It took several weeks to return. You really miss it when it's gone.

Sadness is always there, very close to the surface. I can cry at the drop of a hat.

I'm finding that anger is much closer to the surface than it used to be as well. Evidenced by my day yesterday. I was insanely grouchy at my patients yesterday. I felt bad, they didn't deserve it, and I'm not great at hiding my emotions. I'm never rude (to people's faces, anyway), but I'm not sure they were feeling the love.

One of my first patients of the day set me off. They're an altie family. I really enjoy them, and their kids, but I have to do a lot of stroking and hand-holding whenever we're talking about antibiotics for infections or vaccinations. Overall, I think we do pretty well.

The father inquired about my family, as I've been out so much. I've been telling patients who ask about Henry. I feel that I ask them to trust me a lot, so I feel it's fair to open up a little myself.

He expressed concern, and sorrow. So far so good. Then he started in on juicing. How he gives his kids wheatgrass shakes every day and it keeps them so healthy (I refrained from pointing out the URIs and ear infections we were treating that day.) How he's "done a lot of reading" and he "treats" a lot of cancer patients, and even their oncologists think it's a great idea. How you can cure, yes cure, breast cancer with wheat grass.

If his kids hadn't been screaming and antsy to leave by then you could have heard the pitter-patter of drops of contempt hitting the floor all around me. I could barely contain myself.

You bought a f*cking juice bar a year ago and now you're telling my how to treat my kid's cancer?!? The arrogance was overwhelming.

I've spent 7 years learning my trade. I spend lots of time discussing the limitations of medicine with my patients. I'm agonizingly aware the hubris of medicine. I politely bite my lip when it come to complementary medicine - tho I think most (if not all) of it is a steaming pile of donkey poo.

How dare you.

So, my patients for the rest of the day paid for it. I feel bad about that. But things are just pretty close to the surface these days.

Sunday, January 20, 2008

A new epidemic

Vitamin D is the new darling of the news. Over the last 12-18 months there's been a lot of medical and lay press about vitamin D deficiency, especially in older people who don't get out much. Deficiency has been associated with falls (and therefore fractures), muscle weakness and pain, and maybe even poorer cancer outcomes.

Something motivated me to check a level on a patient several months ago. It was extremely low, and I've put on her replacement doses. She's not convinced she feels any differently, but we haven't rechecked her level yet.

So the next time I saw an elderly patient who looked like she didn't get much sun, I checked it again. Bingo! Deficient again.

Check level. Bingo!

Check level. Bingo!

I have to admit, it's been a bit fun. I'm so used to seeing patients for complaints, where either I or the patient is convinced he has insert-your-favorite-easy-to-test-for-condition, only to get a normal lab back. Catching all this deficiency makes me feel like a clever clinician.

I'm now checking on virtually every elder I encounter, and some not-so-elder shut-ins. I've not yet had a normal level.

The real question is whether all of my super-refined-disease-finding accumen will make a difference to anyone. Time will tell. They're all on very large doses of vitamin D, and will need a repeat level in three months.

So to all you bored clinicians, start checking levels. Ch-ching! And if you're an elder who gets little sun, ask your doctor for a level.

Wednesday, January 16, 2008

The upside to Cancer

Warning: the following post could be interpreted as quite macabre. It's really intended to be funny. When your kid has cancer, things that really didn't used to be funny are funny. So try not to groan to much. This is lighthearted.

Free diapers and wipes. Every time we get admitted to the hospital we come home with loads of diapers. The hospital is not allowed to keep any that have been opened, so we haven't bought any in three months.

Insurance co-pays suddenly look like a bargain. $40 for a course of Zithromax: have to admit I have grumbled before. $20 co-pay for a $11,000 hospital bill: fabulous!

Save money on son's haircuts!

Effortless weight loss program. Turns out that I can't eat when I'm emotionally distraught, dropped 10# in the first month.

Easy out for any social obligation that you really don't want to go to. "My son is going to be on chemotherapy that week" pretty much gets you out of anything.

But of course, the best silver lining is learning to appreciate everything you've got. Every day.

C'mon, people, laugh with me. It's laugh or cry. Let's laugh!

Tuesday, January 15, 2008

Those are some shoes...

Nobody over the age of 70 seems to know the medical term "hiatal hernia". It usually morphs into something like "hi-hernia" or "hile-hernia", and it's easy to figure out what is meant.

Today, my patient had a "high heel hernia".

I wonder if she got those from Zappos?

Sunday, January 13, 2008

Patient hatred

Ten out of Ten wrote a great post about the truth behind how physicians feel about patients.

The love, or lack thereof, flows both ways.

Last week I had the love rolling in.

Three years ago I met her for the first time. The pus was literally dripping off of her foot onto the floor. Her ankle and foot were extremely red and swollen, and her blood sugar was 450. She hadn't seen a doctor in years, and had no idea she was diabetic. (For some fun pictures, google 'diabetic foot' and hit image.)

Not much of a diagnostic dilemma. I sent her to a local hospital, where she had extensive debridement and was admitted for several days of antibiotics.

She kept her foot. I've followed her since. She's done wonderfully. Her HgbA1C (an indicator of diabetic control) went from 14% to under 6.5%, where it's remained. I think of her as a Federally Qualified Health Center success story.

Recently, she's run into some unrelated problems, and the last time I saw her I recommended some imaging. The problem? You guessed insurance.

She works full time, and tho I don't know how much she money she makes it's unlikely to be much more than minimum wage.

And so, just like the fifth drug seeker in a row suffers for the anger of a doctor at the previous four, I became the official representative of the broken US healthcare system.

She was shaking with anger, and shook her finger in my face. "YOU put me in the hospital three years ago and I'm still paying on $17,000 of hospital bills. I'm not going to have ANY testing done. I'm never coming back."

I think I got her to agree to see me again next month. She was still pretty ticked. I can't imagine what $17,000 looks like to someone who might barely make that in a year. Hopefully I'll keep her engaged enough to continue to keep her diabetes under control.

Sometimes we hate them. Sometimes they hate us. The goal is to continue working together toward health.

Thursday, January 3, 2008

Your mom

Your mom should have a good primary care doctor.

Especially if your mom is a super-grumpy, help-refusing, know-it-all who doesn't like to listen to anyone, least of all her good primary care doctor.

Especially if all your mom does is complain about how much it costs ($10) to come see her good primary care doctor 4 times a year, or how much of a pain it is to have to call to order her free medications from the clinic.

And especially if you and your mom don't get along great, probably because you're too much alike.

Because, if your mom's good primary care doctor has a good nurse who is used to getting yelled at by your mom, she'll notice when your mom is a little less cantankerous than usual. She'll point it out to your mom's good primary care doctor, who will take a little more time than usual questioning and examining your mom, and who will have the appropriate level of concern when your mom is 2 months off of the date and thinks the president is Carter. They'll also notice that she's slurring her speech, but just barely. Because they know your mom pretty well.

So make sure your mom has a good primary care doctor. And make sure that she has a good nurse.