STD

Gosh. Apparently I gave my wife an STD. The doctor hasn't said much, except that this condition is expected to persist till July 2010. Looking at the test results, I don't quite recognize the microorganism; doesn't look like Chlamydia, doesn't look like a spirochete either... though there is something vaguely familiar. Maybe someone out there can help me. Any ID specialists? Jimbo?
Clinical features are unfamiliar to me too, but then again I'm just a humble endocrinologist and don't remember my microbiology, but they include secondary amenorrhea, food cravings, nausea, fatigue and extreme mood lability and high risk for bodily harm (to me).
What is the most appropriate treatment for this condition? I've been told that generous amounts of chocolates, back rubs may help control things?

Dear Santa

You know that song, 'My Grown Up Christmas List'? Yea, yea, I know, I make all kinds of greedy requests to Santa every Christmas. That's just the childish, selfish and imaginary yearnings. But listening to that song the other night got me thinking. Reading the news, both on CNN, and even the Malaysian media, looking at the global occurences, just gets a person down. If there were truly things I could ask for, no matter how miraculous it may seem, it would be:

• Peace and kindness amongst mankind. No more of that petty, racist nonsense in Malaysia. None of that political rubbish, there or here in the US. No more that that suicide bombing in mosques in Pakistan. No more wars. Just for people of all walks of life, to live together.
• For people to be able to afford what they need. For my patients to not have to pay so much for their medications, or health insurance. For the homeless to be able to afford shelter. For the hungry to buy food.
• No more global warming. Deforestation. Pollution. Just come up with some renewable, non-polluting, cheap and freely available energy.
• To be here, and yet only a few minutes away from my family and dear friends. From my parents. To be able to say at a moment's notice, "Hey mom, dad, let us take you out for dinner!". To be able to be there when they're sick. To share in their lives, and to be able to share ours with them. To bea able to reap their wisdom on life, now that I'm older but none the wiser.
• To have no more sickness in the world. To be able to tell ALL my patients, yup we can cure that 100%, and it won't even require a shot. To have my buddy get well again soon.
• For everyone to be loved. Loved. A word we sometimes take for granted. But I'm reminded of the elderly patients I've admitted on Christmases and Thanksgivings of years past, because their families dumped them in the ERs before they left for their trips. Or patient who plain didn't have families left. Or that patient I saw just last week who said this would be his first Christmas without his mother (who died recently) and wife (who left him).

Dear God, or Santa, if that's who you have entrusted to give out Christmas gifts, this is my grown-up Christmas list.

What's yours?

How to Tell if your Med Student Isn't the Brightest Bulb in Box

• He tells your 65 year old osteoporotic patient she cannot absolutely be pregnant while taking Fosamax
• She thinks Malaysia is a Canadian city
• She thinks urine microalbumin is a bacterium
• When asked what is the function of the adrenals, he says "to make urine."
• She tries to auscultate for heartsounds with the earpieces of the stethoscope on her neck, not in her ears
• He suggests a pregnancy test prior to radioactive ablation of a 35 year old patient with Graves' disease. Except the patient's a man
  

Yup. These are true stories from the last 1.5 years.

It's always nice to have grateful patients. Even if in some cases it's undeserved.

I saw Mr. S previously for consultation of an adrenal mass. He was a jolly old man, though he did look a bit more frail than his 72 years. This was picked up as he went through staging for his cancer. The CT showed a 3.8 cm left adrenal mass that lit up pretty intensely with some good ole' contrast. When I ran him through the usual tests, I was somewhat surprised that his urine metanephrines were elevated, though honestly I didn't think much of it, thinking it was probably just some false positive. After all, he was pretty asymptomatic (teaching point for the medstudents out there: pheos are often asymptomatic and you should never defer screening in an adrenal mass because of the absence of symptoms) , and you sometimes see borderline screening tests for pheo especially if the patient was hypertensive. Nonetheless, I told him he needed surgery; I was much more concerned that this represented a metastasis of his cancer, rather than a pheochromocytoma. Either way, this needed to come out, and given the equivocal labs, you had to block him pre-op, just in case. And boy, was I glad I did: the path did confirm a pheo.
He did well post-op, and saw me in follow up 2 months later this week. His repeat 24-hour urine tests were normal this time. Biochemically he seems cured. And really, the surgeon did most of the work; I just pointed him in the right direction. Apparently that's not how they saw it.

His very peppy wife announced, loudly, and repetitively from the moment they checked in at the reception to the time they brought him to my exam room,

"Dr. V saved my dear husband's life! He did, he did!!".

I had to remind them that I wasn't the one who did the laparoscopic adrenalectomy, and while I was concerned about the mass, I was betting against this being a pheo but a focus of cancer. But they would have none of that. Apparently to them I might as well have been the one who operated on him. And so, on and on they went. And it probably didn't help my ego that we had a bunch of medstudents in the hallway that day, who seemed to be in awe for the next few hours and didn't nod off when I taught them as usual.

Ahh. Gratitude, even if undeserved, is nice.

The First Cut...

As the song goes, the first cut is the deepest. Except unlike Sheryl Crow, I'm not talking about love.

Anyways, we dinged our new car a couple of days ago. A minor ding, with the paint still intact, and overall smaller than the size of a dime (well, for us Malaysians, less than a 5 sen). For the sake of simplicity, let's call it a pebble (it was a garage door incident, but too unbelievable to be told). Dime or eye of the needle, for that matter, it's never too small for a new item. It felt like someone had yanked out the family jewels and run them through the grinder. I moped around home and work for the next 3 days. I teared up everytime I got in and out of the car. It felt like Santa himself ran over my dogs.

Yup, the first cut hurts the most. And I'm not even talking about expensive things, but rather just things that one holds dear. I remember that Tommy Page button badge I had when I was in Form 1 (13 years old). He was like a God, with longish wavy hair and a voice that made all the girls crazy (God, I wished I could sing like him. I imagined me singing his ballads to the girls I fancied in school). Somehow, having that badge on my school backpack seemed to make me think that I was half as cool as him. After I got it scratched on that school bus, I felt like I had personally dug my nails into my idol's cheek and gave him a laceration on that sacred site that girls wanted to kiss. I spent a few hours painstakingly touching up and retouching the finish with some spray on clear paint (interestingly enough, no one I know this side of the world has heard of a famous-American singer named Tommy Page).

Oh, and I remember back in those days when cellphones were 'in' (now I consider them a pain-in-the-ass way for work to get in touch with me). I remember my first self-paid cellphone, that Nokia 2142 (the cheaper version of my brother's 2110) on the now-defunct A.D.A.M carrier, that I had saved up with months of allowances to buy. Never mind that it was the size of a brick, and had a talktime of an hour; it was cool. I remember how it felt when my (then) girlfriend dropped it onto the gravel road. Still worked fine, but it left a 1 mm nick in the corner of the phone and a gaping hole in my heart. It took a lot of effort to hold back the tears, and to convincingly tell her "It's ok".

Something else that I held close to my heart back in college was a yellow (yup, banana-yellow) Casio G-shock watch. Supposedly the craze all over America (never seen someone wear that here yet, but then again I've only lived here for 7 years). That watch was supposed to be indestructible (it probably is- it still works). But the first time it got a scratch darn near gave me a stroke. Now, it just sits in my dresser- my wife tells me that unless I'm planning to go deep-sea diving, it's not something people wear (and I'm not really sure why it is built to withstand depths of 250 m; would you need to know the time when you're dead?).

Anyways. Back to Lexi (the car)- it was heartbreaking. As I was relating the story to friends, I mentioned it was less painful to have my wife scrape her knee than to ding the car- at least that scrape heals. My wife didn't think that was funny though (I swear I was joking)(well, at least partially). Well, now that we've gotten the first ding out of the way, I'm thinking it'll be easier from now on.

(Dear readers, I swear I'm not that big of a materialistic bastard and certain emotions were exaggerated, but you guys out there- come one, admit it, you know what I'm talking about when you nick/ding/scratch a new prized possession!)

Update, Part 3

So the snowing's slowing down, but the winds aren't. With windchill, it's a freezing -27 C. One fatality so far from hypothermia in the city, we heard from the news.

Just spent 2 hours of backbreaking labor to clear our driveway. The snow's too deep even for our gasoline snowblower. Damn snow came right up to the level of my hand.

Still waiting for the snowplows to clear our street, otherwise we're still going to be stuck here.

Brrr...

Blizzard Update, Part 2

So we're stuck home. Kristin's Honda CRV, even with the all-wheel drive, was stuck just 3 meters out in our driveway. We couldn't even get her out onto the street. And we can't get in back into our garage, either.

From the news, sounds like things are pretty much a mess- all the schools are closed, most offices (including mine). The conditions are so bad that even the snowplow (trucks!!) have been pulled off some highways. This is the pile of snow just outside on our deck (which is actually a couple of inches lower, still). 15 inches so far.
Though the dogs are sinking into the snow, they seem to enjoy it though. And Calvin seems to like sticking his face into the snow. Which explains the icicles hanging off his face.

Oh well. Stuck at home. Only one thing left to do...

An Update!

Got off work early today. 50% of my patients cancelled their appointments. Counted at least 6 cars in the ditches on the way home. Car was tricky, eventhough I was driving a 4WD. Oh, the joys of winter!

Blizzard

And so they're forecasting blizzard-like conditions tomorrow night/Wednesday. Right now they're tracking the system over California, and it'll hit us in 24 hours. It got me thinking though, if we were to be snowed in, what would I consider my vital items in my survival kit? Well, I consider myself a simple man, with simple needs:

• Indomie Mee Goreng. I can live on these for months
• Internet
• TV
• Beer

With these, I'm more than prepared! Bring on the snow!

See You Later, Claudia!

With a heavy heart, we put Claudia in storage for the season. With the first snow having fallen, this was probably time. I used the car through winter last year, and I have to say even with Blizzaks and 100 lbs of added trunk weight for more traction on the rear tires, there were a few days I couldn't drive the car. And so this year we decided to leave the car in the garage for the winter (which is what most Porsche drivers do I believe- to spare the car from the road gravel and salt). To avoid the battery draining, I got a battery maintainer which you leave plugged in to the car's outlet (you gotta love Ebay. Got original Porsche parts at a bargain).
Anyway, some tips I found online on how to store the car for the winter:

1. Replace all fluids
2. Top up the gas tank; prevents condensation and corrosion of the tank
3. Overfill the tires. They say go up to 40 psi, to prevent flat spots on the tires. That, or you can jack up the car for storage
4. Remove the battery and connect to a maintainer (or use one of those you plug directly into the cigarette lighter)
5. Plug up the exhaust; apparently mice like to hole up in nice, dark places in the garage!
6. When you're all set, give the car a good wash. Sounds counterintuitive to wash the car for storage, but this cleans off whatever dirt, sap and salt and avoids corrosion of the car's finish
7. Call your car insurance; you can suspend your coverage and save a bundle, since you won't be driving the car for a few months (but still retain basic coverage for fire. theft etc)

Hopefully this works, and the car isn't dead by Spring! Will probably still be starting the engine every week or so, just to let the fluids flow a bit. See you in Spring, Claudia!

The Good and the Bad

Today was one of those days when even my office manager told me to take it in stride and not let a few bad apples bother me. But it's true, as much it is a science, medicine in many ways is an art too, and a very human one at that. Even for me, as a physician.

The first was a patient who said he wasn't coming back because my nurse pissed him off. Also claimed he didn't see eye to eye with me, and accused me of making him wait while I played tic-tac-toe on the PC. He requested a meeting with my supervisors but within a few moments it was clear something didn't add up. He was tangential, and went on and on about his animals at home, and his orchard, and kept talking about what his mother wanted him to do (he was 55). Also, the day he accused me of making him wait, he didn't have an appointment to see me, but rather he just showed up and wanted to see me. And not being very IT saavy, must not have realized I was on the computer typing up patient notes on people I saw and thought I was playing games (actually I hate tic-tac-toe). And he was pissed because I kept him waiting 10 mins, when he showed up unscheduled on a full clinic day and I still did him a favor by seeing him.

The 2nd was a patient who was seen by 4 of my colleagues previously, who refused to take their advice about a treatment, and instead left our practice to find someone (who wasn't even a physician) to start her on some non-FDA approved treatment she was wanting. She knew she wasn't going to get it from us. And so, after she was able to get on this treatment, she decides to return to our practice for us to manage this unapproved treatment regimen that some witch-doctor started her on but apparently can't manage anymore because of licensure issues. And so she sees me for the first time. I said what I thought, very professionally and courteously, but I made it clear I did not sanction that treatment and will not continue it though offered to at least supervise things until she got back to her previous provider. To which she took great offense, and wrote a nasty letter to the clinic accusing me of being a liar and threatening to sue me for 'stupidity'.

Neither one of these have merits, and my supervisors, after having reviewed both cases and my notes have unanimously supported my recommendations. On the logical side, if I wasn't on the receiving end I would have laughed my head off reading these stories simply because these were ridiculous. However, as professional as one can be, being a doctor, there is always an emotional side, one I do not share with most patients except my closest (I have on occasion shared hugs, and sometimes tears, with patients). And I have to say that eventhough your patients may be totally irrational or have their own ulterior motives, these things do sometimes get to you. You want to feel like you're really there to help the patients and that you're making a difference, but sometimes these things really do take the wind out of you for a few days.

Thankfully, near the end of the day, one of my patients clasped my hand with both of hers, and tells me, "Thank you, Dr. V. I've never had any doctor listen to me the way you did, and be as honest as you did. I know you have my best interests in mind, and I know I am in good hands. God Bless You."

I just muttered an embarrassed "You're welcome" before I left the room, only because it left me almost speechless, God knows how she knew I needed a pick-me-up then.

Yea, like any other job you have to deal with the good and the bad, and thankfully, hopefully, you get a lot more goods than the bads. And all one can do is to use the warmth and smiles and handshakes from the grateful patients to help us get through the bad days.

Christmas Tree

We had a swell weekend. We had a visit from friends from MN. To top it up, the weather turned out to be pretty nice this weekend, unlike the last several days. We took advantage of the warmer day and went out to the nearby lake/dog park.

As always, whenever we get together there's always a bit too much food. And yes, that's a SECOND turkey you see (the first one being Thanksgiving Day). Except this time, it was a 22-pounder. The dang thing took me 5 1/2 hours to roast, and by that time my guests were gnawing on my legs out of hunger.

Yup, it was a busy but extremely fun weekend. Thanks for visiting, guys!

Happy Thanksgiving

As usual, our maniacal chef (mua) got to play with his trusty flavor injector again.A lot of basting, herbs, and 4 hours later, waa-laa:
One juicy 16 lb turkey.
Really though, the secret to a juicy turkey is brining. Roasting the turkey for so long tends to dry the breastmeat out. So, my secret is to dip the bird in brine overnight. What I use are:

• 1 cup salt
• Half cup brown sugar
• Minced cloves, aniseeds, allspice
• Also what I do is to inject the bird with flavoring (I use a concoction of soysauce and orange juice), and then make about a dozen slits in the meat and stuff in cloves of garlic.
• Lastly, cover the top part of the bird with foil- prevents burning.

Works every time.
Also tried out this new recipe for pumpkin pie, with a twist. Besides pumpkin filling, I also added a cup of apple butter. Pretty damn good, even if I may so so myself.
The dogs seemed to agree.

Hope you all had a good Thanksgiving, folks!

Idle Christmas Thoughts

I can't believe it- they've been playing Christmas songs on the radio for the last 2 weeks. The holiday lights and deco are up. Admittedly, if you've followed my blogging trends over the years you know I get nostalgic and perhaps a bit homesick this time of year. Not that I regret the path I took; I think I'm very fortunate and I am blissfully happy. But one is allowed to ponder, no?

• I think about my highschool buddies with whom I'm still very close emotionally, though I wished we got to see each other more. I wish going out would be as simple as a call and a drive to the mamak stalls. Then again, with kids and work and all, even those who remain in Malaysia don't get to hang out the way we used to.
• I miss my family. Though we never really celebrated Christmas, we do put the tree up. And the last couple of Christmases they were around. Not this year though.
• I miss the snowless, hot and humid Christmases back home. With the fake (cotton wool) snow and the very fake Santa. I suppose it's inevitable in Asia; you're not going to find a white man with a big belly and a facefull of white beard to play the role. It's always going to be some Indian or Chinese guy. Not sure which is funnier. But yes, I do miss Malaysia's attempt at trying to be Chrismassy.
• I miss my buddies from our years in Rochester; I miss simpler times when all we cared about were 1) What crazy cases we saw oncall and 2) Which buffet to hit now that we were postcall, pissed and hungry.
• I am happily married, but I have to say Christmas makes me ponder about lost loves too. Girls who came and went, and a lot of what ifs. Most of all I wonder about my first love, Elaine, for whom I developed a huge crush when she performed in that Christmas dance when I was 11. Whose family migrated to New Zealand that following Christmas. Wham's 'Last Christmas' and 'Hark, the Herald Angels Sing' tend to remind me of that.
• I miss hearing my dad sing along to the Christmas songs over the radio. Sinatra, Como, Elvis and a host of others. For some reason though, 'The Little Drummer Boy' seems to stick in my head the most.

Thinking about it all, I realize that what I'm missing most isn't just family and friends, but also memories we've shared, those special moments in the past that have forever left their mark in one's psyche. Moments that will never return, and for that reason, is probably even more special. Bygone times that seemed so much simpler; no jobs, no worries about mortgage or life insurance or bills, no wives or kids; just hanging out and fostering friendships, having simple, thoughtless fun. Having said all that, it's part of growing up (or old, however you look at it). I now have my own family, and it's exciting too thinking about how we begin to pave our own paths, and make our own family's (yes, MY family) traditions and memories (like what we've done for the 2nd year, heading out to the local Tree Lighting ceremony and how we discovered puppies don't like fireworks, but that'll have to be another blog entry).

34 more days to Christmas, folks. What's on your mind?

A Tale of Two Losses

I lost two 'patients' in the last 3 days. What a difference it was between them, and no less tragic was either.
I'll call the first Karen, a patient with poorly controlled diabetes, a1c 12.2%, a 20 year old who also found out last month she was pregnant. This was unplanned, and though I hate to judge, I could not help myself. She still chain smoked, and still refused to check her glucoses nor was she compliant with her insulin despite my advise, despite glucoses running clear into the 400's. When she found out this week that she miscarried, she expressed relief. Now, perhaps she was putting up a façade or trying to act cool, but she actually told me, "That's good news than, I can stop my insulin and go back to pills". Now, I've seen patients more upset about losing a football game, than the level of emotion this woman showed. Perhaps it was true, the baby meant nothing to her.

On the other hand, Lisa was a patient who came a long way. I saw her during her admission for ketoacidosis and new diagnosis of type 1 diabetes. After the initial shock, they took control and learnt all they possibly could about diabetes and insulin. They were also about my age, and in many ways they reminded me of Kristin and I. I have gotten to know her and her husband well; their dreams and their fears. A couple of visits ago, she had dropped her a1c to 6.2% and was doing well, and seeked my blessings for them to try to conceive, which I gave. When Lisa called me 4 weeks ago to share the good news, I was excited and supremely happy for them. She called me today crying, sharing that they had just miscarried. I have to say I felt genuine sorrow for them; my eyes actually welled up. I made it clear to her; there was nothing she could have done differently, she tried, and I knew she did. This was one of those things. After all, miscarriage occurs in at least 25% of clinically apparent pregnancies.

I was mad, mad that this happened. And while I can't say that anyone deserves this, I was mad because I knew very well that Karen could have changed the outcomes had she been more responsible. And I was mad that on the other hand, though someone tries their darndest, these things can still happen. And no two patients were ever more different.

Nonetheless, I still lost two patients. And for one would-be mother, she lost a child. For another, she had a burden lifted off her shoulders.

For that, we shall mourn together.

Dear Santa...

Holy cow. Not that I'm unhappy with our Lexus IS or anything; conversely, it does what the Boxster can't- a quiet, comfortable ride for the family, and handles much better in the snow. But geez, watching this video just makes one lust for this like nothing else.

Question is, would anyone spend US$350,000 on not a Ferrari, but a Lexus???

The Lexus LFA is the Japanese answer to the Italian and German supercar makers. 6 years in the making, so much so that many thought the car would never ever be developed, this car costs more than a Ferrari 599, makes 560, hits 60 mph in 3.7 seconds and tops out just over 200 mph! Just listen to the engine; it sounds more like a Formula 1 race car than a luxury supercar.

Oh Santa, what would I have to do to get one of these this Christmas?

There's really nothing quite like:

Having your patient spray you with his pee on a Friday morning.

Actually it wasn't that bad. Poor Mr. A had to potty during his visit with me. He was a disabled man on a motorized scooter, and usually needed help to go. Because I was the only man in the clinic, he sheepishly asked if I could help him, instead of getting the nurse.

I agreed, before he cautioned me that he has a tendency to spray (Uh oh...).

Well, he did. All over my hands as I held the urinal (he couldn't get up close enough to the toilet). He pretty embarassed by it, though we both had a good laugh when I reassured him that urine is sterile.

I had this interesting experience yesterday. I saw a patient in consultation for thyroid cancer. He had received initial care at my alma mater, and then heard there was a WFMC-trained endocrinologist here (closer to his home). He was excited to find out I was Malaysian Chinese (so he said in his emails to the clinic making the appointment).

And so I saw him yesterday, a dearly older gentleman who reminded me of Albert Einstein. Even had the same crazed hairstyle. This Caucasian man in his 60s. But I didn't expect what came next.

He stood up to shake my hand. And started jabbering in some foreign language excitedly. And then it hit me that he was speaking in Mandarin (and it sounded fluent too).

Sheepishly, I had to tell him I didn't speak Mandarin, which prompted him to switch to saying 'Hello' in pretty damn good Cantonese.

Apparently, Mr. K was well-travelled, and spent considerable time in Asia, including Malaysia. At the end of our visit, after I had outlined the treatment plan for his thyroid cancer, and discussed the prep for radioactive remnant ablation, he proceeded to write 'Thank You' in Chinese on the whiteboard (well, so he says. Could have been F*ck you for all I know).
It was amusing, and admittedly a bit embarassing; my ancestors from China were probably turning in their graves, disavowing any relations to me.

Paintball

Question: When is it legal to shoot your wife?

Answer: At paintball!! We spent the weekend visiting Kristin's best friend 5 hours away. And joined them for a paintball session. Something her friend has been hosting in conjunction with her birthday for the last 3 years, as a fundraiser for toys for kids.

It was our first time playing paintball. It was quite an adrenaline rush, actually. And great fun; we now have several welts and bruises to show for it.

(and no, I did not shoot my wife)(not that I wasn't tempted, but I was too fearful for the safety of my gonads had I shot her)

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?