Of Remembering Names

Any of your out there have the same problem as I do?

I shared this story with Kristin the other day. I was filling the Lexus up with gas in a nearby gas station. It was 6.45 am, and I was on the way to work. It was also pretty damn cold, for October. I was hungry (always too lazy to have breakfast, and I always curse myself 30 mins later) and sleepy.

"Dr. Magus!" I heard a yell (he had mispronounced my name).

A patient happened to be driving by, and recognized me. He excitedly looped around and drove into the gas station. He asked how I was, and proceeded to tell me how things have been for him since I last saw Mr. H. After a minute, he eyed me suspiciously, probably realizing that I haven't yet called him by name. He probably realized that I hadn't the foggiest idea what his name was.

I'm ashamed to say that was certainly the case. And though I do think of my patients as people not as diseases, when you see so many and you're as demented as I am, it's impossible to remember the name. The thing is, you do tend to associate faced with diseases. And while it took me days to figure out his name, I knew who he was right then. Mr. H with the hypopituitarism from neurosarcoid. I had not seen him in 6 months, but I had a clear picture in my head of his medical history, and what dose of steroids I had him on.

And so I asked him how he was doing, and when he last saw his neurologist, and how things were doing from that standpoint. I asked him when they next wanted to do his MRI. I asked him how his visit with his dermatologist went. He beamed, and excitedly gave me his updates while I waited for the tank to fill. I guess I had redeemed myself and he realized I do remember him. He shook my hand before we parted ways, and promised to keep me updated. And somehow, I wasn't hungry or cold or sleepy anymore the rest of that morning.

But it does remind me of the other time I ran into another patient in the store. Hadn't the foggiest idea what her name was. But I remembered her case, her diabetes. And I joked with her about not telling my nurses I had 2 frozen pizzas in my cart.

I think many of us are guilty of that though. We do think of patients as individuals, but perhaps to ease our recollection, we always begin our presentations with "This is a 50 year old man with Addison's" or "This is a 28 year old woman with hyperthyroidism...". Naturally we tend to remember medical details better than names. Nonetheless, I really should try to do a better job with remembering my patients my name though.

Anyone has any good remedies for poor memory?

Another Interesting Case

I saw this interesting case that has me salivating all over it. No it's not because she's hot; but rather like many academics out there, I'm pretty much a nerd and a sucker for interesting cases. I'm in the midst of working her up but I have a pretty strong hunch.

This was a 54 year old woman referred to me for 'hypothyroidism'. Was found to have an elevated TSH of 6.2 (normal 0.5-4.5). Her GP started her on Levothyroxine and was puzzled when her follow up labs yielded a TSH of 7.2 and a free T4 of 2.3 (normal 0.5-1.5). The labs remained about the same after the medications were subsequently stopped.

Her history is otherwise significant only for hyperlipidemia, mild hypertension and a history of hysterectomy for fibroids. Family history is negative for any thyroid issues though diabetes is somewhat prevalent in her family. Aside from some rare palpitations, she feels well.

How would you proceed working this patient up? What is your preliminary diagnosis?

Someone explain this to me:
Why do dogs like to stick their heads out of moving cars?

Consults I Dread Seeing

I'll be honest. I think I had pretty good medical training, and I consider myself to be pretty damn good treating certain conditions like thyroid nodules/cancer and pituitary problems. Having said that, there are some consults I really dislike seeing, often because of misinformation to the patient from the referring physician, or misguided expectations. In random order:

1. Weight gain- "It must be the thyroid because you can't lose weight. Never mind that your TSH/fT4 were normal"
2. Fatigue
3. Night sweats- I saw one of these patients yesterday- she was a nurse and was befuddled when her referring MD punted her to me. She actually asked him, "My thyroid labs are normal- why are you sending me to an endo?"
4. Hair loss- unless this was thyroid or hyperandrogenism in nature, please do not promise the patient I can help them grow their hair back. A dermatologist would be smarter then I am in that regard. Believe me if I could treat this I wouldn't be putting up with thinning hair myself
5. Adrenal fatigue- despite a robust AM cortisol, and/or a normal ACTH stimulation test. I don't want to start a debate since I know what the believers say, but the science says otherwise. And I consider myself a scientist.
6. Low libido
7. Mood swings- (are you kidding me? My WIFE gets these. Heck, I get these myself)
8. Decreased muscle strength- I see a few of these regularly, usually bodybuilder types who are already benchpressing >150 lbs and have biceps the size of sequioa tree, but still aren't happy they aren't getting stronger. Some of these eventually make it known that they are hoping for anabolic streroids
9. Wanting a bigger penis- no, I kid you not. Seen a couple. Nothing I could do, unfortunately
10. Syncope- this one probably wins the prize, and I've gotten a handful of these from, of all people, a cardiologist!

Not that I'm downplaying any symptoms, just that there are some things the science and medicine and research has shown to be hormonal in nature. Many others, however, are not, and when the GP promises a cure from me (I suspect it's usually a case of them not having the foggiest idea and so making a blanket statement of "it MUST be your hormones" without actually having found any abnormality), is often counter-productive to the patient and a waste of their time. I can't say it's a waste of my time because the patient ends up paying to see me, but I do wish I saw fewer of these, and more of the stuff I can actually help people with.

The Weekend That Was

We had a swell time. Never mind that the weekend was short.

Good friends, good food, lots of alcohol, and a firepit.

We rental a lodge in the Dells. It was a good 5-hour drive for Kristin and I, but armed with buckets of snacks and a 10-hour audio novel, the drive turned out to be pretty pleasant and not too tiring.

We met up with the gang in Wisconsin, dear friends from our alma mater, for a Malaysian-Singaporean reunion. It had been a while (since we moved to IA) since we had the company of our friends, with no regards for any curfew or needing to hold back on alcohol because we had to drive- basically we stuffed ourselves with food and wine/beer/mojitos (whenever we get together, we inevitably overeat. I came back 1.8 kgs heavier. Seriously).

Also spent the better part of a day hanging out at one of the indoor themeparks. I think the adults had as much fun as the kids with the laser tag, rock climbing and go-carts. I realized how much I missed my pals, and how precious these little gatherings are for us to catch up, be ourselves amongst our 'family' or just to see how much their kids have grown. Yes, we had fun, indeed.

And what better way to top this up than with a nice, toasty campfire to warm you on the outside, and lots of alcohol to warm you on the inside?
Thanks, guys, for a fun weekend!

Popquiz

Question:

What do you get when you stuff:

1) 10 adults

2) 9 kids

3) Lotsa food

4) Highly flammable stuff

... under one roof for the weekend?

Answer:

A weekend full of chaos and fun! Will be meeting up with good friends for a weekend getaway and some much needed R&R.

PS: If I'm not back by Monday, someone please come and bail us out from jail.

End of life

I was asked to to manage this patient's diabetes while he was in the ICU. As my medstudent presented the case to me, things began to sound grim.

This patient, a longtime diabetic on insulin, had a cardiac arrest shortly after a surgical procedure. Despite valiant efforts on the part of the code team, they had difficulties intubating him (congenital malformation of the airway) and then bringing a pulse back. Once they did, he was brought to the ICU. They coded him for over 10 mins, apparently. He was only 58.

Because things happened so fast, when he was apparently doing well, the family was left unprepared for all this. When I went in to examine the patient myself, they were optimistic, talking about how they were expecting him to wake up any day. The nurse, however, had told me that the neurologists had already given them the bad news and that the damage was done, but perhaps because of the shock, they had trouble comprehending the implications.

After I had requested for some private time to examine him with my medstudents, it became very clear to us. I opened his eyelids; his pupils were fully dilated, with no response to light.

When I was a medical resident, one of the things I hated most to do was to 'call' a patient. You check for signs of brainstem reflexes. Verify the absence of spontaneous breathing or a pulse. And then you say, as if to an audience, "Time of death ...".

Being a subspecialist, I tend to stay focused on the matter I've been consulted on, and steer clear of other issues. In this case, it was neither my duty nor my place to try to convince the family of how he was never coming back, and how he was being kept alive only by the ventilator. I don't miss those life-changing and devastating (for the family) discussions about the futility of keeping a patient on the vent. Nonetheless, it was a bit difficult to watch what that family was going through, and knowing what they would eventually go through when it sunk it.

And so, we came up with a reasonable insulin plan for him. And I quietly said a prayer for peace, for him and his family.

You know it's bad when...

... the radiologist gets the right side confused with the left.

It's a good thing I did an ultrasound of the neck before I stuck that needle in.

ALREADY???

A (medical) horror story

My wife shared this story with me the other day, of how a surgeon scrammed shortly after he was done with surgery just so he could start with another surgery on another patient, in another hospital.

Except he didn't wait till this patient was in recovery. And so, she started deconpensating; she started bleeding vaginally. Heavily. And the anesthesiologist tries calling the surgeon. Except he doesn't answer his pager.

Finally, after what seems to be an eternity, he calls back. And gruffly says that he is late, and doesn't want to bump the other case. Tells them to 'hold pressure'. He's not going to come back to this hospital. In other words, he doesn't want to cancel that other case to come back to deal with this. Read: It's going to cost him too much money in terms of OR time to cancel a case to come back to deal with this if this turns out to be a 'minor' problem.

And so the OR nurses and anesthesiologist are left with trying to stabilize a bleeding and potentially unstable patient for the next half hour. In the end, thing turned out OK. But the story gets us mad. Not that this is an exceptional case; I'm sure this happens in so many hospitals, because the truth is many doctors have privileges in multiple hospitals, something many may consider to be a mild conflict of interest. In this, my wife and I miss working at our alma mater. Yes, we're biased, but hell, I think for good reason. There's a good reason the WFMC is ranked the number 2 hospital in the country. The physicians and surgeons there simply are not out to make money- they're salaried and it doesn't matter if they rush to see more patients. And they see patients only in one medical center- they don't work in multiple systems.

And so, when people ask if I miss working in an academic institution, at the WFMC, deep in my heart, my answer seems clear. But I am here, and this is now, so it's pointless missing the past. All I can say is that I hope my loved ones are never under the care of a doctor like that.

Finally, they're getting it out. I'm glad the Star published this yesterday, which prompted a statement from the DG.

PETALING JAYA: There’s a scam going around and what they are after is your blood. With just a drop, unscrupulous doctors, sinsehs and alternative medicine practitioners claim they are able to diagnose a host of illnesses, ranging from vitamin deficiencies to cancer. They are able to convince their unsuspecting patients by using an impressive but discredited test method called Live Blood Analysis (LBA).
It is believed that thousands have fallen victim to this scam over the past 10 years. Alarmed by the growing number of centres offering such services, medical associations are now urging the authorities to take action against those offering LBA.

Medical doctors also criticise the test as a fraudulent practice to mislead unsuspecting people into buying unnecessary and expensive supplements or alternative therapies for non-existent medical conditions.
Malaysian Society of Haematology president Dr Ng Soo Chin said: “The society’s stand is very clear - LBA is junk science. It is a mixture of a little bit of science that is unsubstantiated and interpretations that are erroneous.

Perhaps with more public awareness maybe fewer people will fall victim to these scams. Not only are these scams costing patients a lot of money, but they may also taking them away from the care that these patients may need.

Almost done

I'm exhausted, and counting down the final 16 hours before I hand off the pager. I'm nearing the end of my 7-day call.

Admittedly, I'm still sometimes unprepared for this. True, I worked a lot harder as an intern. But, then I knew there was a light at the end of the tunnel, that at the end of the wretched year, things get better. Now I'm still sometimes unnerved that as a non-surgical attending, like today, I started rounds at 6.30 am, and got home at 6.00 pm. This, on top of the 12.15 am, then 2.00 am, then 3.03 am pages. And somehow, they always know how to catch you at the worst of times: pager is quiet for a coupe of hours. You decide to take a shit, or take a bath. Wham, beeper goes crazy.

I do catch myself wondering, if this kind of lifestyle sustainable for the next 20-30 years of a professional career?

Perhaps too heavy of a question, after all in these times one should be lucky to even have a job, especially one with excellent colleagues, support system and reasonable salary, even if the hours are heavier.

I just can't wait to break out my bottle of rum and take a few swigs of hard liquor when I'm done with call.

While leading my entourage of medstudents on rounds today (had an unusually bigger group this week) we came upon man and his son in the hospital lobby.

Their interactions made me pause, and really does show one father's simple act of love for his son.

The son was a 40+ years old, also fairly obese (medically, it's a BMI of >50). He had obvious issues walking, and was fairly out of breath. His shoelaces were also undone, but as he was, his tummy was too protuberant to allow him to even bend down. His father, probably in 70's, was a dearly old bespectacled man, who walked with a bit of a shoulder stoop.

"Son, let me do up your shoelaces for you."

And so, he did. There, in the busy lobby of the hospital, the father nonchalantly bends down to tie the shoelaces of his adult son (who was probably somewhat embarassed).

It wasn't something we were expecting to see, waiting for the elevators to start rounds. And true, one could have been judgmental about how the son had let himself get into that shape. But no, I'd much rather see that moment for what it really was, a moment when a father was simply being a father to his son, and the rest of the world didn't matter.

I'm glad they shared that heartwarming moment with the rest of us, though.

It's Over

It's in the air. The coldness. The relative darkness of the morning that greets my wife and I as we drive to work. The yellowing leaves on the trees. In fact some are already beginning to fall.

^%$%$!!!

Today is the official first day of autumm. What on earth happened to summer? Did it already end? While I do like what fall brings (apple cider, the sound of crackling leaves under your feet, campfires, the fiery red color of fall leaves) it's what follows I dread: the white stuff that comes next, winter. It was a topic of half-hearted humor at clinic today when I saw my patients, for we knew when we next met for their 3-monthly hemoglobin A1c checks we'd see the dreaded white stuff on the ground.

And childishly, fearfully, this will be the first winter in, oh, 4 year, where I won't get to spend with my family (well, aside from my wife)- mom and dad usually like to spend a month here during winter but I talked them into coming during spring 2010. So much for my big fat mouth. Oh well.

Home!

Ok, after a week-long trip, we're back. I have to admit, we were beginning to miss the dogs, and work was starting to creep up on the back of our minds and we were getting ansy. In a weird way, it's great to be back to our smaller city, and away from the relative craziness of California. One day to recuperate before we start work.

San Francisco

We biked the Golden Gate Bridge!

In San Francisco now, will be here till Saturday. Napa Valley was interesting though we visited only four wineries for the lack of time (and liver tolerance!). One additional treat was a stopover at one of Guy Fiore's (of the Food Network) restaurant, Johnny Garlic's. The food was good, but the treat was that he was there, filming a shoot for one of his shows! So we actually got to watch all that.
Will be making a trip to Alcatraz tomorrow, and probably Chinatown. Will need to stuff up on our dim sum!

So we made it to Napa Valley! Yosemite was swell, and we even got to see a bear in the flesh, not more than 200 feet away (though there were some jokers who actually ran after the mother bear and cub to snap more pictures- definitely not smart people). Will spend a night in wine country, then we'll be headed to San Francisco. That is, IF we're sober enough.

KNNCCB!

It costs more to fill half the tank of our rental Yaris with regular, than to fill up the tank of the Porsche with premium gasoline. Another sore reminder of the cost of living in California.

Yosemite

Giving this mobile blogging thing a try. Yosemite was simply magnificent; the giant sequiaos against the granite mountain backdrop- just breathtaking. However... If you have a thing with heights, try driving a wobbly rental Yaris on a narrow road along the cliffs and you will discover that your cremasteric muscles possess strengths you never knew they had.

Staying in this decent hotel, but we found this mom & pop bed and breakfast by accident, and we really wished we knew about this sooner as we would have stayed here in a heartbeat. The locale was excellent, the rates were better than our hotel, buffet breakfast was included. And, we were kinda miffed to find out that our hotel was trying to buy out this mom and pop property (but they wouldn't sell) so they decided to literally build around it. Anyway, this was a very charming property with new rooms, magnificent views of the Merced river. So, if anyone's ever thinking about looking for a place to stay at Yosemite, this is just a mile away from the west entrance of the park: The Yosemite Blue Butterly Inn

Tel: (209) 379-2100, email yosbbinn@att.net

Anyway, we're off to the wine country for some indiscretions before heading to San Francisco. Updates soon.

Vacation!

We're off for a vacation to California. A much needed break.

Back in a week (if the bears or the sea lions don't get us first) (if those aren't clues to the two destinations we're going to).

Have a good week, folks!