Posted by: notdeaddinosaur | August 24, 2014

Breakfast

Puffy Pancake:

photo (2)

Hazardous mainly to the waistline.

Posted by: notdeaddinosaur | August 17, 2014

Muscle Memory

Piano

 Muscle memory is a marvelous mechanism. Now that I’ve gotten that alliteration out of my system, let me explain.

The piano pictured above is a family heirloom Bluthner grand piano built in 1909. We know this because we found the serial number inside, then looked it up on the Bluthner age table. It was brought over from Europe by my mother’s family in the late 1930s. My uncle had it for a number of years, then my parents took it when he died. I’ve had it since about 1985. When we recently downsized, we made sure there would be a dedicated space for it — and what a space it is! Suffice to say the picture barely does it justice. After several months in storage, we finally got it to its new home. Then last week we got it tuned.

Many have asked me if I play. My response is, “I used to.” I took lessons all the way through high school, and apparently became good enough that my piano teacher sat me down and said, “I want you to think seriously about Julliard.” It was a mark of how much I loved her that I didn’t let the first words that sprung to my mind pop out of my mouth: “But Libba, their pre-med sucks.”

I kept my hand in pretty well for the next few decades. Through my 20s and 30s I would sit down and teach myself pieces from this old Schirmer Handel album that contained a Passacaglia from high school. I got to the point where I could play more than a few of them entirely from memory. Then kids came along and started demanding more of my time and attention, as did the medical practice with its hundreds of patients. Gradually I stopped going into the living room and futzing around with the Handel. Finally, I got to the point where I could only play the first few notes of a few pieces before my fingers fell apart.

But now…

The freshly tuned piano sits out in the open. The guy has left the lid open, allowing all of the sound to escape the confines of its old black hardwood case. I sit.

And can barely play more than a few notes.

But I fish out my old music book and leaf through the pages.

Here; let me try this one. Slowly, I begin to play. Studying the music after those first few notes, I continue, gratified as the familiar tunes emerge. Plenty of sour notes, of course. My fingers have to re-learn what an octave feels like, the shape of different chords in my hands. It may be called “muscle memory” but there’s a good bit of proprioception as well. Gradually, I make my way through the pieces. Even though the notes aren’t all there, I find the intonations still are. Legato here, I remember; these notes accented; forte the first time this figure appears, then piano for its echo.

I have to admit I’m surprised at how quickly it starts to come back.

I’m reminded of a Beethoven quote my sister told me about:

To play a wrong note is insignificant.

To play without passion is inexcusable.

Plenty of passion left in these old fingers, even as I fumble for the notes.

Maybe someday soon I’ll be able to say “Yes” when asked, “Do you play?”

 

Note to this crotchety old guy in his 80s whom I’ve known for years: It’s ready for you whenever you come to visit.

Posted by: notdeaddinosaur | August 3, 2014

Marble Dinosaur Egg: “What’s Your Concern?”

Another in a continuing series of the Dinosaur version of “clinical pearls”. Okay, so the series consists of three other posts, all in 2007:

  1. Medication adherence
  2. Biliary symptoms
  3. Extending your scale

But hey. Here’s another.

One of the most important things we teach medical students is to elicit any specific concerns patients may have about their conditions. Many of them get pretty good at it, though by the time they get through the rest of their training, perilously few of them — now that they’re called “attendings” — are still doing it. Yet I maintain it’s still one of, if not THE most important thing you need to elicit from the patient. Here’s why: if you don’t address whatever the patient is really worried about, that patient is not going to be completely satisfied with the encounter.

The major reason doctors stop trying to elicit this critical information is their perception that it takes too much time. They believe broaching the topic will open up a can of worms, as the patient drones on and on about all kinds of intangibles.

Wrong.

Actually, it’s as quick and easy as it is important. And here’s the kicker: it’s your chance to look outrageously smart, since the vast majority of the time, the patient is worried about something so far-fetched and different from everything in your differential that addressing it — and easing the patient’s real concern — is quick and straightforward.

Here’s how to do it: last question of the interview (phrasing options, depending on the presenting complaint, the seriousness of the differential, and the sophistication of the patient):

  • What’s your concern?
  • Is there anything specific you’re worried about?
  • What did you find when you googled this?

Some examples:

A patient rattling off symptoms of MS as if he’d read the textbook:

  • “What did you find when you googled this?”
  • “I didn’t.”
  • “Well, is there something specific you’re worried about?”
  • “Yes, a brain tumor.”

Piece of cake to reassure him that’s not what it was. Interestingly, once he’d heard that, he took the possibility of an MS diagnosis totally in stride.

Next: an older woman presenting with a complaint of her arm shaking, with a story very worrisome for partial seizures.

  • “What is it you’re worried about?”
  • “Parkinson’s disease.”

Last thing anyone would think of, given the specifics of the history. But very easy to explain why. Of note, the (young) neurologist she saw never asked if she had any specific concern, and was floored when I told him she was worried about Parkinsons. Never occurred to him.

Easy ones:

Sore throat, stuffy nose, cough in an adult. No fever.

  • “What’s your concern?”
  • “I want to make sure it’s not strep.”

Thirty second explanation and everyone’s happy. You could go on for half an hour about upper respiratory infections and viral pharyngitis, but if you never said, “Strep” (preceded by “not”) that patient would leave unsatisfied.

Tough ones: (mainly when there’s the potential for something serious, and the patient knows it)

Bloating, weight gain, early satiety, urinary symptoms for two to three months in a 50-something woman:

  • “What are you afraid it is?”
  • “Some kind of cancer.”

My answer: “That’s definitely a possibility. Let’s do everything we can to find out as soon as possible.”

By and large, though, when you take the time to ask something simple along the lines of “What’s your concern?” patients will come up with things that are so ridiculous from a medical standpoint that it would never occur to you to specify that that’s NOT what they have. The only way you’ll find out is to ask.

Do so.

It takes hardly any time at all, and the benefits in terms of both patient satisfaction and looking really smart are significant.

 

Posted by: notdeaddinosaur | July 30, 2014

Good Guys and Guns

Just in case there’s anyone left who hasn’t heard, there was a shooting in a hospital last Friday. A mentally ill patient brought his legally-owned gun into his psychiatrist’s office, where he proceeded to shoot and kill his case worker. He then pointed the gun at the doctor, who ducked behind a chair, drew his own legally-owned, concealed-carry pistol, and proceeded to shoot the patient in the arm and torso, disabling him and preventing him from utilizing the rest of his ammo (approximately 40 bullets total).

Official comment was swift and relatively unanimous:

Yeadon Police Chief Donald Molineux said that “without a doubt, I believe the doctor saved lives.”

“Without that firearm, this guy [the patient] could have went [sic] out in the hallway and just walked down the offices until he ran out of ammunition,” the chief said.

Wow. There it is. Can’t argue that at that specific time, in that specific place, in those specific circumstances, a guy with a gun he wasn’t supposed to have (per hospital policy) shot an armed individual who had already killed, preventing him from killing more people.

No, the first guy should never have had the gun. No argument there. And as it turns out, at this particular time and place, the doctor’s actions were appropriate. (The word “heroic” has been used; I do not disagree.) I can hear it now; all the 2A fundamentalists gleefully preparing to jump me:

“See! How can you possibly doubt the wisdom of our position now? A good guy with a gun stopped a bad guy with a gun.”

Yes. Yes he did.

How does this change my stance on responsible gun control? Not much. Why not? From the Harvard Injury Control Research center:

  1. Guns are not used millions of times each year in self-defense.
  2. Most purported self-defense gun uses are gun uses in escalating arguments and are both socially undesirable and illegal.
  3. Firearms are used far more often to intimidate than in self-defense.

References and more here. Rare events are rare. The fact that people win the lottery every day doesn’t make the purchase of a ticket a sound financial investment.

So in what way, if at all, has my thinking changed? This: Successful, legitimate use of concealed firearms is so rare that, to be honest, I doubted that it ever really happened at all. I now admit that, clearly, it does. At least it did. This once.

Do I intend to seek training in order to procure and carry a weapon of my own? No.

Do I continue to believe there are too many guns in this country without enough adequately enforced regulation, producing orders of magnitude more suffering and death from firearm violence than in any other developed country in the world? Yes.

Extending deepest condolences to the family and friends of the slain caseworker, Theresa Hunt, and wishes for a speedy recovery to Dr. Lee Silverman.

Posted by: notdeaddinosaur | July 21, 2014

Personae Public and Private

The house is done; we’re all moved in, mostly unpacked, and just starting to get organized. The guest room is my temporary writing room. No more excuses. Back to blogging.

My post analogizing car seats to vaccines has taken on second life thanks to a cool Australian site (Thanks, Mamamia of Oz.) This in turn has generated more comments (thanks, all!) including a long, thoughtful one from Patrick, who begins thusly:

I honestly believe there is fault on both sides of this debate. Vilifying and ridiculing each other doesn’t bring about good health results.

I feel the need to clarify something here:

I am not the same in person as I am on my blog.

In person, dealing with patients one by one, I neither vilify nor ridicule. I take my time, explaining in however much detail a given patient or parent wants to know, about anything and everything. How does this blood pressure medicine work? Where to kidney stones come from? Why won’t you give me an antibiotic for my cold? Is there any substance to these scary things I’ve heard about vaccines?

Even when people clearly do not believe what I am telling them (not “do not understand”, but “do not believe”) I remain polite, as I try to persuade by explaining. Analogies; stories; diagrams; articles; whatever it takes. I strive at all costs to educate.

So what happens when, after explaining AND ascertaining that the patient understands, she says in essence, “I don’t believe you.”

Nothing.

I don’t tie the kids down and vaccinate the m against the parents’ will. I don’t yell, I don’t wag my finger, I don’t shake my head sadly as I leave the room. Nothing.

Above all, I remain professional.

After a while, though, all those encounters begin to take their toll. Being called a liar tends to get me down. News flash: I’m human. So what do I do?

I take to the blog and hammer away at the idiocy of the antivaccine leaders and the sheeple who follow them. I flay the alt-med charlatans with words (though not nearly as eloquently as these guys.) Yes, I ridicule. Yes, I vilify. Yes, I shout from the hilltops, spreading far and wide the truth of science: vaccination works. But only online.

I find it amusing to intentionally adopt a far more curmudgeonly attitude here than I would ever dream of displaying in meatspace. It’s part of the fun of blogging, which is why I’ve been doing it now for almost eight years.

All I ask is recognition that my public blog persona is different from my personal, real self.

 

Posted by: notdeaddinosaur | July 12, 2014

Built a House (27): Final

House final

It’s done. We’re all moved in. So is our stuff; well, most of it. The piano arrives in a few more days. Then all we have to do is unpack, hang art, paint; you know, make it ours.

Once that’s all accomplished — or at least once I’ve cleared away a spot to sit down with a computer — real blogging will return. For all of you who followed along (three or four, I think) thanks so much for hanging in there with me.

 

Posted by: notdeaddinosaur | June 29, 2014

Not Just Tacky…

Wandering around Lowes picking up stuff for the new house, I came across this:

Tiki tacky

How tacky is this? Not just tacky. It’s….

 

 

 

…Wait for it…

 

 

 

Tiki tacky.

Posted by: notdeaddinosaur | June 25, 2014

Building a House (26)

House 26 (2)

Landscaping is in. Sod will be placed either the day before or the day of settlement, still on target for next week.

We had our walk through yesterday and everything looks great. Well, except for the dozens of sticky dots indicating painting and spackling imperfections to be addressed by yet another once-over by the painters and trim guys.

Moving day tentatively set for week after next. The journey is coming to an end…with a brand new one about to begin.

 

Posted by: notdeaddinosaur | June 16, 2014

Yahrzeit

Carousel 6-0057 (2)

28 years. Gone from our lives, never from our hearts.

candle

Posted by: notdeaddinosaur | June 15, 2014

“Energy” Does Not Mean What You Think it Does

Every time I think I’ve seen it all, something new blows me away:

Energy wataah

For those with trouble reading the fine print, this is “Energy Wataah”, on the shelves along with regular “Wataah”. As soon as I saw that word “Energy”, I thought “caffeine”. But no. Here’s what that green fine print on the label says:

Forget about caffeine and sugar. Ultra pure water with just enough oxygen is all the clean fuel your body craves.

WTF?

Water and oxygen are both critical for proper bodily functioning, but “energy”? “Energy” or “fuel” for the body comes from calories, found in carbohydrates (like sugar), fat, protein, and alcohol. Nothing else contains calories. Water and oxygen are necessary for burning them properly, but no matter how you twist the semantics, they’re not “energy”.

Here’s the thing, though: anyone know what you get when you add oxygen to water? Anyone?

Hydrogen peroxide. ( 2 H2O + 02 –> 2 H2O2)

Not really. That equation is thermodynamically backward. Bubbling oxygen through water will just give you water with bubbles of oxygen, which will probably come out of solution, collect at the top of the bottle, and escape into the atmosphere the moment you open it.

Besides, drinking oxygen isn’t going to do a thing. Oxygen is transported through the body attached to hemoglobin, a protein found in red blood cells. Red blood cells pick up oxygen when blood flows through the lungs, not through the stomach or the intestines.

This product makes no sense physiologically, chemically, or thermodynamically. Yet somehow this company figures it can get unsuspecting scientific illiterates to fork over six bucks for twelve little bottles of this stuff.

Unbelievable.

Edit: Clearly this is a New England based company. If it were in Philadelphia, they’d call it “Wooder”.

Posted by: notdeaddinosaur | June 14, 2014

Building a House (25)

photo (3)

The front door has been painted black, and the final trim/flashing/whatever-it’s-called has been added across the bottom parts of the roof line over the garage. Now the outside just needs some sealing and painting (mainly the half columns on the front porch), landscaping, and sodding.

Inside is practically done. They’re working hard on the final painting and trim; then it needs a really thorough cleaning. Everything still on schedule though.

 

Posted by: notdeaddinosaur | June 11, 2014

Driving While Hypertensive

The Second Law of the Dinosaur states:

It is impossible to make an asymptomatic patient feel better.

So true.

Chapter 2 of my book, Declarations of a Dinosaur, discusses how I handle a patient who may be asymptomatic at present but who will not remain so for long without taking my advice. Essentially, I explain in as much detail as necessary to create just enough anxiety, which can be relieved by doing what I say, be it taking pills, quitting smoking; whatever.

Another way of looking at it is that although the patient may not feel there’s anything wrong with him, my anxiety spikes when I see things like a hemoglobin A1c of 14 %*. All I have to do is find a way to get my patient to feel the same level of alarm as I feel.

This is what I did a few months back when I saw an African American gentleman with a blood pressure of 210/130. He hadn’t been to see me in quite a while (I think his BP had been a little elevated then and he was afraid of what it was going to be now). It also turned out that his LDL was 180, and his A1c was 12%. I felt like I was on the verge of a cardiovascular event just sitting there in the room with him! With that collection of risk factors, he was literally a heart attack waiting to happen. And that’s what I told him.

He felt fine. No chest pain; no headache; no retinal changes. No symptoms at all (which was why he didn’t meet the criteria for a diagnosis of Hypertensive Urgency with its attendant trip to the ER). Still, as I explained to him, if I were to get a phone call the next day that he had dropped dead of a stroke, I wouldn’t be surprised.

He hated pills. That was another reason he hadn’t returned earlier. Carefully prioritizing the situations, I prescribed two antihypertensives (in a single combination pill) and a statin. Hardly optimal therapy, but I wanted to start him as slow as I felt was safe, explaining at length exactly how scared I was, and how important the pills were.

He said he understood, taught it all back to me to show he got it, and thanked me, setting up an appointment the following month to see how he was doing.

Job well done! Or so I thought.

Next month he comes back.

“How are you doing with the new medicines?” I ask.

“Well, I didn’t start them.”

Aack!

“Why?”

“I don’t know.”

Double aack!!

Blood pressure was still over 200. Another month closer to that stroke. How could I have failed so utterly to get through to him? No idea. I had to try something else; some other way to communicate to him the emotions these encounters had produced in me.

I had an idea:

“Listen,” I began, “Have you had the conversation with your sons about ‘driving while black’?”

“Oh yes,” he replied. “Of course I have.”

“Okay,” I continued. “Do me a favor. Think for a minute about how you would feel if, after you had this conversation with your son, knowing what you know about the world we live in, he came home one night and told you that a police car tried to pull him over, but he managed to ‘get away’? Or that he was stopped, and boy did he give that cop a piece of his mind. Somehow, he lucked out, and got off without serious consequences. But wouldn’t your heart be in your throat, aware of the risk he had taken? Even worse, that he didn’t even seem to recognize it?”

My patient was nodding.

“Well, that’s how I felt hearing that you’re not taking any of the meds I asked you to. Seeing how high your blood pressure still is gives me palpitations. Please, please, please…please start taking the pills.”

This time I got through to him, and I’m pleased to report that three months down the road, we’re on the right track at last.

 

 

*(corresponding to an average blood sugar of 355; poorly controlled diabetes, with increased risk for heart attack, stroke, blindness, kidney failure, impotence, etcetcetc.)

Posted by: notdeaddinosaur | June 9, 2014

Building a House (24)

House 24
We now have trim over the garage and windows, a lamppost, and downspouts. The deck — really just a landing and a few stairs — out back is also done:

20140609-213137-77497056.jpg
Just a few more weeks to go.

Posted by: notdeaddinosaur | June 4, 2014

Building a House (23)

House w-shutters

Brick is completed and cleared from the front yard. Shutters are up. The deck is going on the back (really just an oversized landing with a small flight of stairs.)

Inside: tile is complete. Finishing is in progress.

Closing 4 weeks from today; on schedule.

 

Posted by: notdeaddinosaur | May 31, 2014

Building a House (22)

House (22)

Finally the brick is done. Actually, there’s still one small row of it to go under the front door, but clearly the vast majority is completed. The “holes” over the garage doors and window are where the trim will go. The front door will be painted and shutters will be added to the single first floor window.

Indoors; well, indoors is magnificent! Hardwood flooring is down (and protected with cardboard and duct tape), the kitchen cabinets are in, as are the counters (covered with protective plastic that makes them look weirdly blue.)

Still a lot to do: bedroom carpets, installing appliances, finishing up the tile, trim, painting, and fixtures. Outside there’s a lamp post that still has to go in (whenever the brick is finally moved out of the way), a light between the garage doors, and a tiny deck out back. Plus grading, landscaping, and sodding.

However we cut it, though, it’s definitely closer to the end than the beginning.

 

 

Posted by: notdeaddinosaur | May 31, 2014

American Rights

Americans have rights. Most of these rights have limits, though. For example, even though the First Amendment to the Constitution guarantees the right to free speech, Americans do not have the right to yell “Fire!” in a crowded theater.

There is one right, however, that would appear limitless. I’m referring of course to the right to be stupid. I suppose this means that someone can walk into a gun show and yell, “Bad guy!”

Posted by: notdeaddinosaur | May 24, 2014

Urgent Hypocrisy

I received a solicitation in the mail to apply for a position at a new company moving into my area, forthwith to be known as the “Facility for Urgent Care, Killer-Docs, that’s going to be opening a new office nearby:

FUC, K-Docs is looking for physicians who enjoy the practice of medicine, and the chance to focus exclusively on patient care. If you are looking for freedom and autonomy without the heavy financial and administrative burden associated with establishing and maintaining a practice, FUC, K-Docs may be right for you.

Cool. Unlike too many other primary care docs these days, I still very much enjoy the practice of medicine. It just so happens that I have found the greatest freedom and autonomy comes from having my own practice instead of being an employee. But hey; maybe this is something I should think about.

I read on:

Responsibilities include, but are not limited to:

  • Providing the highest quality* patient care while on shift.
  • Managing all patient care at the center while on shift.
  • Supervising all medical staff while on shift.
  • Ordering and reading all diagnostic x-rays and labs.
  • Ensuring medical staff follows proper protocols and conducts patient callbacks.
  • Ensuring pharmacy and CLIA approved laboratory compliance with regulations.
  • Ensuring center has all the necessary urgent care equipment, supplies, and medications.
  • Ensuring accuracy of ICD-10 coding.
  • Participating in the hiring and training of medical staff on shift.
  • Compiling quality data and addressing with medical staff as needed.
  • Participating in monthly conference calls with Chief Medical Officer
  • Ensuring all charts and medical records are accurately completed in a timely manner.
  • Ensuring patients are discharged with detailed instructions.
  • Collecting biological specimens and process them in the lab when needed.
  • Adhering to all center policies and procedures.

Excuse me? Only four out of the fifteen items on that list address actual patient care (bolded by me). Sounds to me like all of the hassles of running a practice — a pretty good-sized one at that — without any of the actual authority of ownership.

How could that introduction, followed by that list, be written without the author’s head exploding from sheer irony? It’s downright Orwellian.

It even turns out the guy opening the place isn’t even a physician. Figures. More money to be made getting doctors to manage, supervise, compile, ensure, participate, and adhere than by actually practicing medicine.

Sorry, dude. Not buying it.

* Defined as…?

Posted by: notdeaddinosaur | May 23, 2014

Building a House (21)

20140524-222326-80606026.jpg

Approximately one half of the brick done. It took three days, which means that the unofficial estimate of another three days sounds about right. Unfortunately, nothing is going to happen until after the holiday weekend, though we’ll probably still go out there and keep poking around.

Posted by: notdeaddinosaur | May 22, 2014

What if Car Seats Were Like Vaccines

What if a big TV station, say WTOP in Washington DC, came out with a blockbuster story claiming that infant car seats were implicated in cerebral palsy? After all, something like 99.7% of babies diagnosed with cerebral palsy had been brought home from the hospital in a car seat. In fact, every single time they went anywhere in a car, they were strapped into them. That’s an impressive number. There has to be some connection!

Imagine video of kids crying piteously as they’re buckled into the wretched contraptions. After all, car seats are restraining and uncomfortable. Kids hate them! But parents have been duped into using the damn things claiming it makes their children safer. Pshaw! How could a baby be safer anywhere other than in its mother’s arms?

Suppose this idea gained traction. Cerebral palsy is a dreadful thing! Why take the risk? Don’t use those nasty old car seats. Besides, don’t you know that the doctors who recommend them are all getting kickbacks from the manufacturers? [Less preposterous than kickbacks from vaccine manufacturers. Far more money in car seats.] Some Playboy celebrity reality centerfold comes out as the spokesperson against car seats. Suddenly there’s pushback from new parents who want to decide for themselves what the safest way is to transport their precious bundle. Never mind decades of car seat research. They may not be automotive engineers, but their parental gut feelings are good enough. Besides, no automotive engineer ever had to listen to their baby cry whenever she gets strapped in.

Facebook communities emerge where car seat refusal is supported and celebrated as the newest way to keep babies safe. Parents are carefully steered to “research” that hypes the dangers of CP. “Why take unnecessary risks?” becomes their mantra. Because the hype is scary. Parents of kids with CP conspire to sue the car seat manufacturers, because “Someone’s got to pay!” Why did this happen to their child? No one has any good answers [hint: It's not birth trauma] and vague discussions about prenatal injury to the brain like “Sometimes these things happen” is just not good enough.

Of course there’s no plausible connection between car seats and cerebral palsy. But that doesn’t matter. Studies are done to try and prove car seats don’t cause CP, which is technically impossible, since you can’t prove a negative. The anti-carseaters deny that they’re against car seats. They just want “safe” ones — defined as ones that don’t cause cerebral palsy. Do a large double-blind trial: randomly assign some babies to car seats and some to be held in mom’s arms and see how many in each group develop CP, they cry. It will take nothing less to convince them.

What happens? By and large, nothing much. Most kids don’t develop CP, however they travel in cars. And the vast majority of babies who ride in mom’s arms arrive safely at their destinations. There is a small uptick in infant fatalities that steadily grows as more and more people refuse to use car seats, but not many people take notice. The occasional family is devastated by the loss of a baby in a crash, and vow to tell their story high and wide. They do, but the only minds it changes are the ones that weren’t already made up.

Far-fetched? Sadly, not so much.

 

Edit: NOT plagiarized from this, which in turn is probably not plagiarized from this or this.

h/t TBTAM for the second 2 links.

 

 

Posted by: notdeaddinosaur | May 20, 2014

Building a House (20)

House 20

New mailbox.

Inside: Painting has occurred. Final electrical has begun. Most light fixtures are in, though not all. On track to close in about 6 weeks.

Posted by: notdeaddinosaur | May 20, 2014

To Refill, or Not to Refill?

I have an ethical dilemma, and would appreciate the opinion of the Collective.

Patient with controlled hypertension who hasn’t been in for a visit for over 2 years keeps requesting refills on her medications, despite multiple requests and decreasing quantities first of refills, then of medication quantities. We are finally down to my Note to Self in the Refill field, “No more refills without visit.”

Pharmacy request comes in for refill. No call from patient; no appointment on the schedule. Ideally, I like to see my hypertensive patients twice a year, but I’ll settle for annually. This patient hasn’t been in for over three years.

What to do?

First round of analysis: What are the harms of going off BP meds? Answer: potentially significant, in that patient is on several meds which are controlling BP well, and has other cardiovascular risk factors. 

Next, anticipating the patient’s objections to a visit: Why exactly to I need to see her? We call it “monitoring”; making sure her BP is still controlled, and that there are no side effects or other related (or unrelated) problems emerging. “But you never do anything,” I hear her responding, and it’s hard to argue. It certainly seems that the greater benefit comes from continuing to authorize the refills.

What’s the down side? This: What if something changes, and either the BP is no longer controlled, or something else happens as a result of the meds (kidney failure comes to mind)? I can just hear the lawyer bellowing, “Why were you continuing to prescribe these dangerous medications without monitoring them?” causing the jury to come back and strip me of all my worldly goods. 

So what to do? Refuse the refill and risk having her stroke out from uncontrolled blood pressure? Or keep on prescribing without seeing her? If so, how long? Four years? Five? Ten? 

Another option, of course, is discharging the patient from my care. But that’s not going to help her in the long run, nor me in the short run. (Discharging a patient is at least a 30-day process, and involves certified mail, which costs money and involves a post office run.) I would prefer not to go that route.

Thoughts?

 

Posted by: notdeaddinosaur | May 16, 2014

Building a House (19)

House 19

And garage doors.

Not sure why the brick hasn’t gone up yet.

We have reason to believe that painting will begin inside today.

Posted by: notdeaddinosaur | May 14, 2014

Building a House (18)

House 18

Now with a driveway.

Inside, the trim is virtually complete, and boy does it dress the place up! It’s still very white (which it will be for the first year or so; wait for the nail pops before painting is conventional wisdom) but oh so elegant. Seven weeks to closing, but with the final walk through a week before that.

Starting to get excited.

Posted by: notdeaddinosaur | May 13, 2014

Dinner

Veggie Meatloaf:

photo (8)

That’s meatloaf with veggies (almost more veggies than meat.) Not meat-free.

INGREDIENTS:

  • 1 lb ground turkey
  • 1 tbsp olive oil (for sauteing)
  • 1/2 cup chopped onions
  • 1/2 cup chopped celery
  • 1/2 cup chopped bella mushrooms
  • Leftover cooked corn from one cob
  • 1 egg
  • 1-2 tbsp barbecue sauce
  • 1 cup panko bread crumbs
  • Salt & pepper to taste

Saute chopped onions and celery in olive oil about 3 minutes until soft. Toss in mushrooms and saute another 2-3 minutes. In large bowl combine turkey, cooked veggies, corn, egg, BBQ sauce, salt and pepper to taste. Add panko, stirring just until mixture holds together. Turn into loaf pan and top with more BBQ sauce. Bake at 350 degrees 35-40 minutes.

Yum.

 

Posted by: notdeaddinosaur | May 12, 2014

Building a House (17)

House 17

The hardscape is taking shape; we have a front walkway, a sidewalk, and a driveway apron. Inside, the drywall is all done; taped, beaded, spackled, and sanded. Walking through it you can get a real sense of the space…and it is magnificent.

Posted by: notdeaddinosaur | May 7, 2014

All Physical Exams are Not Created Equal

Once again, I am in receipt of a letter from a specialist (a surgical subspecialty, of course) that has me alternately shaking my head in disbelief and trembling with fury.

The letter was clearly crafted with electronic medical record software to support billing as high a level office visit as possible. In addition to a complete specialty-specific organ system examination, a “Multi-System Physical Examination” was also documented:

  • Constitutional: well-nourished, no physical deformities, normally developed, good grooming
  • Neck: neck symmetrical, not swollen, normal tracheal position
  • Respiratory: no labored breathing, no use of accessory muscles
  • Cardiovascular: normal temperature, normal extremity pulses, no swelling, no varicosities
  • Lymphatic: no enlargement of neck, axillae, groin
  • Skin: no paleness, no jaundice, no cyanosis, no lesion, no ulcer, no rash
  • Neurologic/Psychiatric: oriented to time, oriented to place, oriented to person, no depression, no anxiety, no agitation
  • Gastrointestinal: no mass, no tenderness, no rigidity, non-obese abdomen
  • Eyes: Normal conjunctivae, normal eyelids
  • Ears, Nose, Mouth, and Throat: left ear no scars, no lesions, no masses, right ear no scars, no lesions, no masses, nose no scars, no lesions, no masses, normal hearing, normal lips
  • Musculoskeletal: normal gait and station of head and neck [whatever the hell that means]

This is verbatim, by the way.

If I saw this from a medical student, it would be a big fat fail. Oh, there are plenty of bullet points, and they’re arranged in enough lines to pass the billing clerk’s checklist. But it basically says next to nothing.

The really interesting thing about this writeup is that although the patient is being seen for an unrelated problem, it completely fails to convey that she is actually a heart-lung transplant candidate. This surgeon probably doesn’t even own a stethoscope anymore, because anywhere you’d care to put one on this patient’s chest reveals findings that are anything but normal. She’s missing a lobe of one lung, and her heart swishes and hums more than it lubs and dubs. Frankly, I doubt the specialist even realized there was anything wrong.

More proof, as if it were needed, that EMRs document for billing instead of medical care.

Posted by: notdeaddinosaur | May 6, 2014

Princess Dressing; or, You Can’t Fight City Palace

Princess

Daughter of a friend turns 7. Proud mama posts pic, with apologetic self-flagellation about having “given in to princess dressing.”

Question: What do you think mothers in the ’50s and ’60s would have done if they’d had things like Facebook, Twitter, and the Internet?

  • OMG! How is my poor little Agnes ever going to find a husband, going around in dungarees like that all the time?
  • All this pressure on young girls to “express themselves” by dressing however they feel like is preposterous!
  • This “women’s lib” is such a scourge. It’s not like when I was a girl!

I thought the whole idea behind raising girls (and boys, for that matter) was teaching them that it’s what’s inside that counts. Wasn’t there something about not judging a book by its cover? I understand that there’s still this pesky thing called “the outside world” populated by the ubiquitous “other people”, where external pressures and snap judgments are rampant. But isn’t the whole idea of parenting to instill that internal sense of Okay-ness that allows the child’s genuine self to shine through, however clothed?

I’m not talking about appropriateness. Certain venues call for certain modes of dress, which young children are not equipped to accurately judge. Party dresses aren’t worn to school, and jeans shouldn’t be worn to church. But if there are other times when kids are offered the choice of what to wear, the least we can do is respect those choices.

What’s the difference between telling a girl, “Oh no! Not a princess dress!” and “Oh no! That’s what boys wear!” Don’t both statements have the effect of devaluing the girl’s choice?

I have another friend whose daughter used to put together the funkiest outfits for school. The kid was a hippie whose mother had worn Catholic school uniforms. Teh horror! Bottom line: so what? Advice was given (and taken) to choose one’s battles, and the kid ended up a lawyer.

I understand that “society” (the collective version of “other people”) is doing terrible things to girls (and women): hypersexualizing them, objectifying their bodies, devaluing them as thinking, feeling, inherently worthwhile beings with a right to, well, themselves. I agree that it’s a fight that needs to be fought.

But it’s still okay for a seven-year-old to dress up like a princess from time to time.

Happy Birthday!

Posted by: notdeaddinosaur | May 5, 2014

What Gun Extremists and Anti-vaxers Have in Common

What kind of a masochist am I? Sticking my head back into the lion’s den snake pit and taking on the gun nuts again. Not the responsible gun owners, though. It turns out there really are such people, and apparently they actually outnumber their more vociferous crazy-heads compatriots. Nevertheless…

In medicine, we try to use scientific research whenever we can. Research is more than just someone saying something is so because they believe it to be so (see: Acupuncture). There are objective rules and standards by which people other than those doing the research can feel confident of the accuracy of the findings.

Every now and then, someone comes up with a research result significantly different from previous studies. (See: Galileo) Often this kind of result appears to make no sense at all, as it may be the complete opposite of the currently understood state of the issue. What to we do with this kind of confounding information?

First off, we try to replicate it. If the new findings are in fact true (that is to say, scientifically accurate) then properly done studies will have similar results. We call this “confirmation.”

What happens when studies fail to replicate the odd finding? The next step is to figure out (if possible) where the aberrant result came from. Were the researcher’s statistics flawed? Did he draw incorrect conclusions from his data? Might he just have made shit up? Did he have something to gain, financially or otherwise, from the unusual result?

Much of the opposition to vaccines, MMR in particular, stems from the work of Andrew Wakefield, whose Lancet article of 1998 purported to show that the MMR vaccine caused autism. It doesn’t. Many people tried very hard to replicate Wakefield’s results, without success, in the process pretty much proving the safety of vaccination, as much as a negative can be proven. Eventually the Lancet retracted the paper, Wakefield’s license to practice medicine was suspended, and the entire MMR-autism hypothesis was definitively refuted.

Except to an increasing number of hard-core antivaxers, who contend to this day that Wakefield was railroaded and that his findings were legitimate. Somehow they cling to the discredited results from a single researcher, denying the findings from numerous other sources that say they are wrong.

What does this have to do with guns?

Guns are dangerous. They have their uses, but only in the proper hands, with proper training, and with proper safeguards. Legitimate research has borne this out over and over again. (See Harvard Injury Control Research Center) And yet in any discussion when true gun extremists are called upon to cite evidence for their position that more people with more guns is a good thing, they always quote the same source: a book called More Guns, Less Crime (not linked; easily found) by a man named John Lott.

Turns out that the findings of this book (and this researcher) have been debunked over and over and over again. Furthermore, when confronted with inconsistencies in his research, Lott changes his story. This has gone on long enough that serious researchers in this field no longer consider his contributions credible.

Just like the anti-vaxers, this doesn’t stop gun extremists from clinging to the findings of a discredited academic as they go on insisting that the dangerous notion of “more guns means less crime” be used to guide policy. As dangerous as vaccine-refusal is, I daresay more people have died in this country from gun violence than from vaccine-preventable diseases.

There is something called Scopie’s law, which states:

In any discussion involving science or medicine, citing Whale.to [a known source of anti-scientific nonsense] as a credible source loses you the argument immediately …and gets you laughed out of the room.

I hereby propose Dino’s Gun Corollary to Skopie’s law:

In any discussion involving guns or firearms policy, citing More Guns, Less Crime or any other writings by John Lott as a credible source loses you the argument immediately.

I wouldn’t laugh at them, though. There’s nothing funny about guns.

 

Posted by: notdeaddinosaur | May 3, 2014

Building a House (16)

House 16

All the siding is now finished. Everything left wrapped in green will soon be brick, which has already been delivered to the front yard. Inside, the drywall is just about done. They still have a lot of work left on it, beading, taping, spackling, etc. But it’s coming along very nicely indeed.

We also have a new neighbor to our right (left in the picture). There’s another one on the other side that’s due to be framed any day now. Within a few months of moving, we’ll have neighbors.

Posted by: notdeaddinosaur | May 2, 2014

Home

Home

 

For almost thirty years, this was home. I secured the mortgage the same week I matched for residency. I moved right before medical school graduation.

Throughout my training, this was home. This was where I came post-call to lay my bone-weary head. Middle-of-the-night hospital calls rang here; this was where I came back to afterward.

I raised my family here. Babies brought home, watched as they learned to walk and talk, headed out to school (walking to elementary school around the corner), quickly becoming taller than me, and finally heading out into the world on their own.

This was their home.

This place saw its share of anger and fear along with love, joy, and triumph. My heart was broken here, though it mended with time as most things do. Love and joy returned.

It looked a little different at the beginning. Over the years it got new siding, an extra bedroom, a wider driveway, a new deck, a storage shed. It had more trees when I first moved in. Inside, every single room was eventually re-done. Twenty-nine years is a long time.

But no more. With kids gone, there’s no reason to bounce around in such a big place. Time to move on to smaller digs; someplace with an “open concept” and a first floor master. Near enough to get to work conveniently, but definitely a different neighborhood.

It feels strange. Even over these last four months of apartment living, I could still go over there whenever I wanted. But as of today, I no longer own the place. Make no mistake: it’s a huge relief to have the sale finally a done deal. But still; twenty-nine years is a long time. It will be a while yet, but I’ll get there. Watching the new house come together is exciting.

But today I pause to remember: Home.

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