An email

I got an email from a patient. He got his driver's license back!
This was a 52 year old family man, with a long history of type 1 diabetes. Somehow, work and family got in the way of his health and he stopped monitoring his glucose levels. With a busy work and family life, neglecting our health probably happens to most of us; unfortunately with type 1 diabetes there isn't any other alternatives I tell my patients: Until we have better technology they will need to self monitor their glucose with their glucometer.

And so last year, got into a motor vehicle accident during a hypoglycemic episode. His driver's license was taken away from him. For most of us, for him, the breadwinner in the family, this would be a devastating event. When I saw him, he was a wreck, and felt that he had failed as a husband and father. He had to get his wife to drive him to work. He could not drive his daughter to school. Of course, he could have driven illegally without his driver's license, but Mr. K, bless his heart, was too responsible for that.

He broke down the first time I saw him, and my heart went out to him.
In the last 8 months, we were able to get things turned around. We put him on an insulin pump, reeducated him on insulin management and glucose monitoring. His hemoglobin a1c dropped from 12.1% to 7.1%. More importantly, his hypoglycemic episodes decreased significantly; he has not experienced another severe episode since his accident.
When I saw him a month ago, I felt that he was ready to try to reapply for his license again. I filled out the necessary paperwork. And a month later, he's succeeded.
I wish him all the best and I'm confident he'll continue to do well. Is there the chance this may happen again? There's always the chance. Always the risk. But will he let this happen again? I strongly doubt it.
Well done, Mr. K!

Case of the week

This was a 56 year old woman referred to me for hypercalcemia. This was found 2 years ago incidentally; she remained asymptomatic now (and was amused by the attention she got). Her internist had done an excellent job working her up thus far:

Calcium was 12.8 mg/dL with a suppressed PTH, normal TSH, Phos, Vit A, 1,25-OH Vitamin D, 24-hour urine calcium, SPEP, UPEP and even ACE. Her PTHrp was undetectable, while her 25-OH Vitamin D was a bit low.

History was significant only for arthritis, hypertension and psoriasis. She took only antihypertensives (thiazides were stopped a year ago) and some cream for her skin issues.

Exam was remarkable for some fairly classical psoriatic plaques on the extensor surfaces. In addition, she had some reddish nonpruritic patches all over her trunk and on the legs.

What is your provisional diagnosis?

Answer: Beats me

Okay, okay, potong steam I know but I have a biopsy set up (biopsy? biopsy of what??) and so I won't have answers for another few weeks. Some of you left pretty good answers. I had the patient bring in her cream to verify that she wasn't overdosing on topical Vit D for her psoriasis (she wasn't but that was on my radar too, good thoughts!). But I think the clue lies in her labs:

If her PTH is suppressed (telling us clearly this isn't mediated by parathyroid hormone), then the question I was asking myself is, what the heck is hydroxylating her 25-OH Vitamin D to 1,25-OH Vitamin D (which is usually mediated by PTH). And why the discordance between the low 25-OH D and the midnormal 1,25-OH D?

So, something is causing her to activate the Vit D leading to abnormal gut calcium absorption. Typically you think of granulomatous disease but you sometimes see this in hematological malignancies. I think that clue lies within the skin- while her extensor lesions look classical for psoriasis the trunk lesions do not. Indeed, cutaneous lymphoma has been reported to do precisely that. And when I google images for cutaneous lymphoma I got the picture above; almost a carbon copy of what my patient has.

So, I'm sending her for a skin biopsy to prove this (doesn't show up in blood studies, I was told when I shared my concerns with a hematologist). If it is, she should respond nicely to Prednisone.

A mix up

One of the joys of being married- your wife reminds you to write 'thank you' notes, birthday cards and other thoughtful notes (do your wives make you do this?). Usually she writes on the card, stamps and addresses it, and just lets me write a short line or two.

And so, last week, I dutifully wrote:

Dear B, Wishing you all the best on your special day. Happy Birthday!

We received the call from her best friend B today, who was laughing her head off. To my wife's horror (mine too) she finds out that I had inadvertently thought that card was a birthday card. It was actually a note of sympathy: B's grandmother passed away recently.

I'm not sure if I'll ever hear the end of it. Still, at least B thought it was funny, and it did cheer her up.

An Appointment

One of my many nicknames in high school was 'The Professor'.
Heh, this was because a doctor cousin of mine gave me a medical book, The Human Body by renowned South African cardiothoracic surgeon Christiaan Barnard. And so, being the (horny) nerd I am, I devoured the pages in the book. Especially the parts about human sexuality and reproduction. And so, at 14, I knew much more of the theory than many of my peers (though being an all-boys' missionary school I had minimal interaction with the gentler sex until I was 18). Many of my friends, all of us in that weird curious phase, asked me questions from the anatomy of the female reproductive organs to how people had sex (this was after all Malaysia, and our sex-ed consisted of just 30 mins, during which our flustered female teacher told us to read pages X to Y and left the room).
Anyway, in a weird way maybe that was prophetic.

I just received word from the U that they are appointing me the rank of Assistant Professor.

Who would have thought??? On one hand it does make me kembang a bit, but on the other hand I'm fighting the overwhelming need to roll on the floor laughing my ass of.

As my sister pointed out, images of an old bespectacled balding man comes to mind. Not too far from the truth, I suppose. Even my wife admits she dated me because she had a thing for nerds.

Professor Vagus. Who would have thought???

One of those days

Just handed off the endo pager. I have to say this was a horrid, tiresome call week. I feel burnt out. And to top it off I came back to my office to read a nasty message from a patient accusing me of misdiagnosing her.

I went back and reviewed my note. I saw her over a month ago, and told her there was probably nothing to worry (was seeing her for some slightly abnormal labs). I identified a couple of medications she was taking that is known to interfere with this test, and so suggested she stops those meds, return to see us in 2 weeks to repeat the tests to see if they normalize now, for if not, I told her a CT scan of the abdomen may be indicated (you can probably guess what I was seeing her for). Even set her up for a lab appointment and gave her a urine container to begin collecting so that she could drop that off on her return date.

She no-shows. Despite us sending reminder slips. And on the day she didn't show up, my office called and reminded her to reschedule. No word from her.

And now, over a month later, she's pissed because some other doctor apparently found something. And sent us a nasty note.

I went through my notes, my orders, and even the lab appointments. Spoke to the front desk and lab techs to identify if we missed something. And it's now clear- the patient herself did not show up despite having picked the return date herself. And she never returned our calls. And so the workup was never completed. And now she's mad at me?

It's clear what I did was appropriate and that this was a fault of the patient's. But speaking as a person, really, even if it was the patient's fault, sometimes having mad or angry patients get to you at a personal level. You want to think of yourself as a people person, and that you are there to help the patients (even if they don't want that sometimes). And so, sometimes things like this hits you deep.

I've been a physician only 8 years. And out in practice on my own only 7 months. I don't know how the veteran doctors out there take it. I know I shouldn't let these get to me; I wonder though if I'll ever get to a stage where I'm immune to negative comments, even if they were unjustified.

However, I found this inspiring picker-upper which cheered up me some. You should check it out on YouTube. A breath of fresh air.

Things you shouldn't say to your consultant

Ok, so this is a few weeks late. But since I'm again oncall and have to work with medical students I thought I'd share this experience from last month.

It's hard to stay motivated at this time of the academic year. The final year medstudents have their residencies lined up and will be out the door in a few weeks. Ditto for the final year residents. After all, I've been there. After 6 years of post-grad training.

We call it 'senioritis'.

The opposite of 'seniocephalus'.

The latter being early in your final year, when your head swells up to immense proportions from being a senior and having the knowledge and authority to push your interns around. In the former, you're just so sick of residency/fellowship/medschool that you just want to get on to greener pastures (except you don't yet know 'greener' refers to the skin color you assume when you actually do start work in the next step). You don't give a damn anymore.

And so, being the teacher to such students, at this time of the year, can be a major pain in the ass. I like teaching, I really do. After rounds everyday, I do set aside at least 15-30 mins running a discussion/didactic on a topic of our choosing. But really, there is nothing more irritating than wasting your time with uninterested, indifferent medical students. The ignorant but keen ones I don't mind, after all, we're there to teach. But the uninterested ones, I'd rather be sliding down a razor blade on my scrotum.

And so, at this time of the year, it's not unusual to be working with people whose minds are in la-la-land. Case in mind, this young lady I had last month. She knew nothing of the questions I asked her. Never even tried. So, to try to give her a chance, I gave her several reading assignments, on pretty basic stuff like osteoporosis (relevant to her since she was going into family medicine).

When I asked her to tell us what she had read the next day, she said she hadn't done so yet. Her excuse?

"But it was Mardi Gras yesterday!"

>_<

The things you want to say (but can't) (since it's not acceptable to yell at students here- I did write her a bad review though).

I'm just glad she's not going to be the physician caring for any of MY loved ones.

Screen all maids for Herpes?

Letter recently published in the Star's Letter to the Editor:

Recently I employed a maid and was shocked that Fomema, the health screening agency for domestic Indonesian maids, does not screen for herpes.
Since it is a highly contagious disease, which can be transmitted through saliva and vaginal fluids, all maids should be screened and deemed unfit for employment if they are found to have the virus.
Doctors and professionals have confirmed that there is no antidote for this virus, and once infected, the person becomes a lifetime carrier.
Perhaps the Health Ministry can play an active role to include this as part of Fomema’s standard health screening for foreign workers to ensure that they don’t spread the disease.

SWAN,
Petaling
Jaya.

Maybe it's just me; maybe I'm reading too much into this. But the truth is genital herpes (presumably that's what he's referring to) is an STD; not something you pick up in casual contact. Yes, as a physician I'd certainly advocate steps to prevent STD transmission, but doesn't this kinda take it overboard? Makes you wonder what job 'Swan' is hiring an Indonesian maid for?

ER Last Episode

And so, after 15 year, FIFTEEN, ER comes to an end. NBC aired the finale Thursday night. Admittedly, I was a big fan in the early years, and then it got a bit too draggy. And it started to remind me too much of work, and so I stopped watching years ago.
But wow, 15. I was in pre-med when the series started airing. And I remember the excitement as a medical student, when I actually saw the stuff I learnt that week in class come out in the show. It was pretty neat, to be able to tell my family what preeclampsia was, or point out that they had their stethoscope on backwards.
Anyway. Because this was the final finale, I had it recorded and watched it last night. It was a bit of an emotional experience for me for many reasons.
For one, I thought of my early medschool days in IMU (then IMC) when my buddies and I would follow. Boy, that was 1996. We had good times, there in PJ Old Town. And it felt like a reunion too (which was intentional I believe), to have some of the old cast show up. Carver. Carter. And that asshole Benton (well, he's now nice to Carter).
Seeing the episode last night, especially the part where the woman had an everted uterus post-partum, reminded me of some of those harrowing nights I had oncall in the MICU. Nights when patients were coding left and right. That night when that lady with the GI bleeding was exsanguinating to death right before my eyes. The ICU room floor was splattered with her blood. I remember coming home that day with blood on my shoes.
(A bit of digression, but you know, I do believe that many of us who have gone through internship suffer from mild post-traumatic stress disorder. I really do. On bad nights I still get nightmares of that woman, or that man who died from a tension pneumothorax right in front me despite my senior's efforts. Or the numerous resuscitations I have been involved in. ICU alarms still give me palpitations. I guess it comes with the job, and one has to be strong through internship, and so I tell my sister as she begins her journey into this world)
Anyways. Back to topic. ER finally comes to an end. I enjoyed watching the final 2-hour episode. And yes, one of the docs still got his stethoscope on backwards (really, just go watch it!).