Question:

Of the following statements about Vagus, which is least accurate?
a) He is showing male pattern baldness
b) He names his cars
c) His armpits smell like cumin
d) He is a closet chick-flick fan
e) He used to sport a fu-manchu moustache and a Tommy Page hairstyle

I've been busy writing up questions like these. Yup, I'm writing up diabolical exam questions for the endocrine course for the 2nd year medstudents here. Question is, should I be kind, or should I be cruel and make some really tricky questions to mess them up?

I feel all powerful, suddenly.

Then, again, with the some of the students I've seen, they like to challenge every question especially if they're getting just a borderline fail. The one who wins the prize last year was the gal who asked that I remove a question from the exam because I apparently said during a lecture that this subject "isn't very important" and hence it was unfair that I asked it in an exam. Never mind that my lecture contained a slide on that topic.

P.S- Re: the question above, any takers? Here's a clue...

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.