Thanksgiving 2008!

Happy Thanksgiving!

Not that a Malaysian boy like me really understands the historical significance of this day. To me, it's a holiday! A day of good food. Followed by crazy 4 am shopping deals (yes, the day after Thanksgiving, also called Black Friday, is the best time of the year for deals. Malls open at 4 am)(Interesting factoid: This is only in the USA, in Canada it was Boxing Day, the day after Christmas).

Anyways, Kristin gave me my very own flavor injector this year! At least I no longer have to swip a syringe and needle from work like I did the previous years. Remember that surgical procedure I did a couple of years ago?

Anyway, it's gonna be a special Thanksgiving this year because my mom, sister are enroute from Malaysia as we speak. We'll be having dinner this weekend, along with my visiting in-laws. So, our house will see family for company!

One interesting work-related Thanksgiving issue that came up. I saw this guy with flushing and diaphoretic episodes yesterday. Probably nothing I can do from the endocrine standpoint, but I should at least try to rule out carcinoid. Sent him home with a urine container for 24-hour urinary 5-HIAA. And then I did a double take, and told him to do the collection only next weekend. Any other week I would not have made this an issue. Though not listed as one of those things that can interfere with the test, I figured with Thanksgiving and all, I didn't want the tryptophan-laden turkey to give a false positive. Perhaps that would be interesting research study?

Tips for saving money

In these bad economic times, I thought I might share some tips on how to save money when seeing your doctors.

1. When seeing a subspecialist for a specific problem, refrain from bringing every single scrap of x-rays and test results if they are irrelevant. I know you're trying to be helpful, and perhaps just want me to 'go over everything' just in case, but really, making me review a lab test just adds a point to the 'complexity' of data I have to go over, while the x-ray adds another. Very soon a simple 'level 3' consult becomes a 'level 4' (about $400) and 'level 5' (almost $500).
2. Be succinct, get to the point. We also bill on time. So, when you come for that 15 min hyperthyroid follow up visit and decide instead to yap about your recent cruise or just beat around the bush when I ask you yes/no questions, it ends up costing you.
3. With perhaps a handful of exceptions, it is perfectly okay to use a generic version of a drug. Just because a medication has gone generic does not mean it is inferior.
4. Unless it is directly relevant to your current illness, please also avoid telling me to 'call your family doctor' to get information on that colonoscopy you had 3 years ago. It has nothing to do with the thyroid problem you came to see me for, and my calling another physician up to discuss your case probably adds at least another hundred bucks to your charge.
5. Don't ask me to order a bunch of tests that has no connection to your presenting complaint. If your HMO does not see it as relevant to why your doctor referred you to me, then you may end up paying for the test out of pocket.
6. Unless you really need your doctor to go over your test results with you in person, it's okay to discuss things over the phone. I can't bill for time I spend on the phone (usually) and so you save yourself gas, parking and a doctor's bill.
7. While I appreciate the business you bring me, I'd rather not be seeing you in the first place if this could have been avoided. So, take good care of yourself, and for Heaven's sake, quit smoking!
8. Ask me if the older drugs work as well. Frequently I have patients asking me for the 'newest' diabetic pill on the market. While sometimes these may be necessary, often the older ones work just as well, and are a lot cheaper.

I'm exhausted. True, nothing like internship, but everything considering, I feel just so dang tired. I haven't had a day off in 2 weeks now. And today I woke up at 5 am, started rounds at 6 am, and got back past 630 pm.

Between that patient with DKA, and another in shock with Addisonian crisis, and that post-op pituitary patient and the dozen or so diabetes patients, and that meeting I had to attend today, I feel like I'm running around like a chicken with its head cut off.

I just can't wait to sign the pager out tomorrow noon. I'm looking forward to a relaxing weekend, hopefully some friends visiting, and maybe catching that new Bond movie.

DKA

I'm oncall again this week. And just had to deal with a difficult patient.

A 28 year old man who should have known better.

Type 1 diabetes who was admitted for the 3rd time in the last 4 months for diabetic ketoacidosis.

Now, diabetes is a challenging disease, and requires a lot of lifestyle changes and discipline. So I really admire and empathize with my patients who have learnt to check themselves numerous times daily and give themselves insulin. Sometimes, things happen despite their attempts, and so I don't hold anything against them.

But then again, you sometimes have different patients. Case in mind, this guy who ran out of syringes, not even the insulin, 3 days ago. Apparently he still had a couple of vials of his Lantus.

And so he's just stopped his insulin. Just like that. 3 days ago. After his last admission 5 weeks ago he was supposed to follow up with my colleague 2 weeks back, but he never showed up for his appointment.

It's no wonder that he came in almost comatose. When the ICU called me just now, his glucose was 1197 mg/dL. His anion gap was 32.

When he came to, he was apparently pretty mean to the nurses too who were trying to save his life. He wasn't that warm to me too, when I saw him.

Now, sometimes things happen. Maybe patients fall ill. Maybe they have financial difficulties. Maybe they forgot. But in this case, come on. He's a grown man. Before Banting and Best discovered insulin, type 1 diabetes inevitably results in death. He should have known better.

I told him bluntly; if he keeps this up, he's going to end up killing himself. That pissed him off, but it pisses me off too, the resources and manpower we expend trying to help patients who don't want to help themselves, when there are so many others out there we'd rather be helping instead.
I suggested to the admitting team to get psychiatry involved to see if he is able to comprehend the situation or if he needs to be committed. We'll see what they think.

This guy will probably make it out of the hospital alive this time. But one of these days, he's not going to be so lucky...

Rosuvastatin in Low Risk Patients- The JUPITER study

This NEJM article may change the way we treat 'traditionally' low-risk patients.
In this prospective randomized, double-blinded, placebo-controlled study involving over 17000 patients, subjects were considered to be low risk using traditional criteria:
Men over 50 or women over 60 years, with no known coronary artery disease, with a screening LDL of <130>2 mg/L. Patients were randomized to placebo or Rosuvastatin 20 mg daily and the protocol had planned to follow patients for up to 60 months.
Primary endpoint was first major cardiovascular event, while secondary endpoints included death from any cause. The study was terminated after a median of 1.9 years after the safety monitoring commitee found significantly different rates of primary endpoints; 0.77 in the treatment group per 100 person-years, compared to 1.36 in the placebo group (hazard ratio 0.56, 95% CI 0.46-0.69; P<0.00001).

Which begs the question, what exactly should we be aiming for? Should CRP be something we be checking more frequently?I remember in residency, CRP is always talked about and yet because at that time no intervention has been showed to decrease the risk even in high-CRP patients it kinda fell out of favor, kinda like checking for homocysteine levels. This study, may however change some thinking.

On thing to bear in mind; although the relative risk reduction seems impressive, this was already a lower risk group. The authors do add that the number needed to treat to prevent 1 occurrence of the primary endpoint in 2 years is 95 patients. Therefore you treat 95 patients with an expensive statin to reduce the event in 1 patient; what is the cost vs benefits?

While I'd like to see this reproduced in other studies, this was a pretty well-designed study (albeit financially supported by Pharma) with a good number of subjects and fairly compelling results. I'm sure I'll be getting some requests from patients in the coming weeks to check their CRP levels.

First Snowfall

It snowed yesterday. The first snowfall of the year. Just some light powder.
I was looking through my photo albums the other day and was just looking at some pictures from my medical school days in Canada. I came across pictures of my first winter. We were up on the rooftop of the student dormitory, pathetically trying to make snow angels (it was only a 1 cm snowfall), laughing, playing, singing. At 12.15 am!
1998. Yup, this would be my 10th winter.
The first snowfall always seems as a shock to the system. Not so much because of the cold. But more so because you go to bed one day, only to wake up to a magical white winter wonderland. It's almost as though someone put you in a different, alien world while you were asleep. It's silent; no birds chirping, no sound of crickets. The snow buffers noise. Instead, on a heavy snow day, you almost hear the soft ruffling sound of the snow crystals falling.
It's God's gentle reminder to slow down. Enjoy the show. And it's a reminder that Christmas is round the corner.
This year, I suppose snow has another implication; sadly I had to put Claudia's hardtop up. It'll stay up for the rest of the year; no more driving to work with the top down. And today, I'll be taking her to the garage to have her Blizzak winter tires put in. Because she's light, and is rear-wheel drive, she'll need all the traction she can get and so I decided to get a 2nd set of wheels to mount the winter tires on. I'm just waiting for the day I get stuck in the snow, and have to trade in the Porsche for an SUV!

With the hardtop up

With the Blizzak LM25 255/45 R18 winter tires on

The summer tires in storage for the next 4 months

An Interesting Bone Case

I saw an interesting case the other day. One that's left me thinking still about the possibilities.

This was a pleasant lady in her 30's with a history of recurrent fractures. After one too many, her doctors decided to send her to a specialist some years ago who did some skin fibroblast studies and diagnosed her with Ehlers-Danlos.

In addition she has a history of chronic colitis that is managed by her gastroenterologist; this apparently has been refractory to everything but Prednisone 7.5 mg daily.

To top it up, she had total abdominal hysterectomy with bilateral salpingo-oopherectomy.

Yup. Wham, wham and wham. Three whacks to the skeletal system. Premature osteoporosis, a collagen disorder, and supraphysiologic steroid therapy.

It's no wonder she is deathly afraid of breaking more bones.

We talked about some options aside from the calcium and Vitamin D shpiel. But really, I told her we don't know what works with the Ehlers Danlos.

Do we:

1) Put her on estrogen therapy, since she is young, and is surgically post-menopause? She is a nonsmoker, has no risk factors for HRT.

2) Put her on a bisphosphonate because of her steroid therapy? However, the efficacy data is from physiologically post-menopausal women, and no study has been done on Ehlers-Danlos patients. Basically we don't know if it works.

3) Do both?

4) Do nothing?

In the end, for the lack of anything else, we both agreed on starting Alendronate. I'll probably start her on estrogen too, the next time I see her, to optimize her bone health. Despite her bad luck, she remains amazingly resolute and active, wanting to live life to the fullest.

What would you do?

A Historic Day

A truly historic day. The American people have spoken, and they demand change. And for the first time ever, an African American is elected president.

Not that I have any right to comment much seeing that I'm Malaysian, but I've been pretty sick and tired of how things are headed over here. The economy is collapsing (or some may say, has collapsed), young American men and women are dying in the Middle East, fighting a war they don't necessarily agree with, and in the process of hunting down 'insurgents' kill hundreds of innocents.

Collateral damage, they call it. Maybe it's acceptable for Bush and co. to have a few innocent women and children die in the war against terror, but imagine if you were on the other side of the fence. If you, an innocent farmer, comes home someday to find things left in a crater from a smart-bomb attack that some American had ordered from half a world away, your wife and 8 year old child's bodies buried somewhere in the rubble. Who are we to decide what is 'acceptable collateral damage'? Would the President allow for this if this was a mission on US soil? What if we were talking about his own family?

That's probably one thing I find it difficult to understand. What exactly is acceptable in war? Especially one that was started on the grounds of lies. True, Saddam was a tyrant, but to invade a country claiming to have evidence of weapons of mass destruction, only to reveal that this was all not real. What real benefit have the Iraqi people seen, I wonder? Especially if you were that poor farmer, totaly oblivious and uninvolved in all of this until someone bombed your home?

I can see why some people accuse Bush of having committed war crimes.

In the process, billions of dollars have been spent, billions more are being spent fueling the US war machine and the paranoia that attack is imminent. 'Kill them now or be killed".

While over here the working, middle class American struggles with paying for his mortgage and having foreclosures, not being able to afford his medications, paying exorbitant taxes. It irks me, as a physician, seeing every single day how my patients make a conscious decision to skip a few months' worth of their meds just because they cannot afford it because they are in the 'donut hole'. Every single day I have patients asking me if I have free samples I can give them. I had never seen anything like this before, such a medical tragedy, in my 6 years of practice, until now. And it's not like we're not paying taxes too.

Every year, my taxes cost more than a new Porsche Boxster. Where is all this money going?

Though I am not American, I must say I join the millions who are celebrating over this historic day. You kinda knew this was going to happen; you just pity McCain who had to be the Republican candidate after George W. Bush's catastrophic presidency. As they said on CNN just now, Bush is probably the worse ever US President.

I do catch myself wondering if the Malaysia will someday be matured enough to see past skin color and race and one day allow a person from a minority group to be Prime Minister? Then again, with idiots still considering us 3rd generation Malaysian Chinese as immigrants, I already know the answer to my question, sadly enough.

Only time will tell if Barack Obama will live up to his promises.

Sorry for the lack of updates, dear readers.

I've really slacked off the last couple of months. I've pondered over this for some time to figure out why.

Partially because work has been busy, and I'm just so dang tired and braindead when I get back.

Partially because now that I'm settling in to practice in a non-academic institution, perhaps the acuity and complexity of the problems I see is different compared to those during residency. I noticed this when I went way back to my 2004 posts, and realized things were a lot more exciting then.

Partially because (sad to say) between my work and Kristin's studies (she's putting work on standby as she pursues her Masters) our life really is pretty boring and not half as exciting as some of you may think.

Partially because I'm getting old(er) and my brain is getting mushy and less creative.

But, interesting happenings over the week:

My dad, sister, and sister-in-law were admitted for dengue fever. Had me worried for a while, but thankfully they've all been discharged from the hospital. I so hate the feeling of being so far away and helpless when family falls ill.

My family's getting ready to invade our home here! My sis and mom arrives in 27 days, while dad, older brother +his wife +2 kids get here sometime in January. It'll be swell to see them again, and more so to host them in our new home. Our home kinda lacks family right now (Kristin's folks don't get to come often), so having them here will warm the place up.

And oh ya, Lewis Hamilton won the championship!! Did anyone else watch the race today?? The way he took 5th place on the very last lap of the last race to win the championship. Brilliant! Though I wasn't sure if Glock intentionally let him overtake. Nonetheless, it was a good race.

I'll get my butt in gear and post more interesting updates, I promise.