Baby Names

And so we're trying to come up with baby names. I won't even go near the middle name yet, since we're already having a tough time with the first name (BTW Chinese middle name, or not?).

I mean, this is big deal, isn't it? It will be for life. It will write her life, her future, her destiny. It matters, whether you name your kid Hillary Rodham or Smellikoochie-kaka.

I do think some people try a bit too hard to give their kids special names. To each his own I suppose. But come on. Apple? Phycilin? Escherichia??? (I swear, the latter is true, I read it in The Star when I was in college- some Malaysian microbiologist loved his work so much he gave that name to his son. Poor kid (well, he's probably in his early 20s now), being named after a fecal bacteria.

"Oh yes, my dad named me after Princess Diana.."

"My name means morning sun in Japanese. What did your parents name you after?"

"..... >_< "

Now, if this wasn't a big deal, and would not psychologically scar someone for the rest of their lives, I'd like to have fun with this. Oh, the names I'd give. Offhand, Mercedes comes to mind. After all, it IS a girl's name. Except I see her make a career out of pole dancing. Or worse.

I could do as the nobles do. Kristin the 2nd (obviously I'm not gonna name my daughter after me). Or, in this technological age, Kristin 2.0. Or iKristin?? Yea, I think I like that one.

Or, perhaps to guarantee free college tuition, you could do some commercial endorsement. Name her KotexLightdaysExtracoverageOdorAbsorbing, or Kot-tee for short (Gawd, that's a nickname I certainly had to put up with). Or since we love our dogs, PurinaBeneful, that sounds kinda feminine. I'm having too much fun with this; my wife is going to kill me. I'd better stop.

Anyhoo, we keep throwing the same few names out so I guess we have it kinda narrowed down. Kinda. Except she keeps finding new ones, and tires of the old ones. We'll eventually come up with something (in the meantime, anyone out there looking to advertise their product? Call me)

Where do we go from here?

I was in the shower when I heard this song dedication on Delilah. It went out from one friend to another, from this world to the next after she lost her battle to some cardiac ailment. And perhaps I was in a soppy, sentimental world, but I caught myself thinking, where do we go from here? I mean, it's all a leap of faith, isn't it? It's not like we have tangible proof that we step in one world into another, another plane of existence.
I think about the patients I've lost, even just recently on my last call. I think about that patient with diffusely metastatic cancer who probably has only months to live. I think about lost friends, YS who was killed in a motorcycle accident on the way to school. Or AK, who had a fatal pulmonary embolism. I think about family; aunt Lian, about Grandpa. God, I miss him- it's been 12 years and I wasn't a man yet, but I'd like to have known him when I was grown up.
I'd like to think that after we close this chapter, after we exhale the very last molecules of CO², we don't simply cease to exist. That we do move into a different existence but yet are aware of the happenings in the world. That Ah Kong is still around, looking down at us.

I'd like to think that at the end of the road, I get to see my old friends, my family.

Deep down, I do believe in it.

I really do.

I do hope I'm right.

Guess who's afraid of thunder?

-- Sent from my Palm Pre

Baby Shower

So our buddies organized a Baby Shower for us over the weekend. It was a treat to get to see some good friends again. But then again, the torture games they put us through, with friends like these who needs enemies??
Anyone wants to guess what's on the diaper? And yes, I had to eat it.

Sometimes I Hate Being Right

Really.

I saw L for consultation just yesterday. He has a history of prostate cancer who for the last 6 months has been having back pains. Conveniently treated by his chiropractor, who said he didn't need to see his doctor (mistake #1). After 6 months of manipulation he didn't feel better, and so finally sees his GP. In the meantime he has gotten weaker, and has been feeling pretty nauseated. GP orders labs, serum Calcium comes back 15.5 mg/dL and he is in acute renal failure. "It must be your parathyroids. I'll just refer you to an endocrinologist." (mistake #2).

Thankfully there was a last minute cancellation on my schedule and he was able to see me within a day (my usual waiting list tends to go out weeks). When I walk into the exam room, he's laying on the exam table, too weak to sit up. Mr. L asks for an emesis basin, and a blanket. Not having too many patients ask for blankets, my room didn't have any fresh ones. I was embarrassed to have use my white doctor's coat to cover him to keep him warm (he didn't mind). He's essentially failed the eyeball test, labs notwithstanding. I literally wheel him to the ER 2 floors down myself for hospital admission; this should not have been an outpatient evaluation to begin with, and his GP should have had more common sense than that. Calcium levels like that can kill.

His Calcium there was 16.3 mg/dL. Expectedly, his PTH was suppressed. Expectedly, ominously, the Phosphorus, Alkaline Phosphatase were up.

I looked at Mr. L's PET-CT results today, and it was the worst report I had ever seen. Diffuse skeletal metastasis, with intense FDG uptake in every vertebral body, as well as other sites.

As a doctor, we all like to be right. We don't like to make mistakes. But times like this, I wish I was dead wrong when my gut told me what the source of his hypercalcemia was.

More Hollywood Drama

I read this in disbelief on CNN.

Woody Allen raised eyebrows at Cannes over the weekend when he offered words of support for another internationally known filmmaker, Roman Polanski.

“It’s something that happened many years ago," Allen said of Polanski’s sex scandal during an interview with French radio station RTL, according to the L.A. Times. "He has suffered, he has not been allowed to go to the United States. He was embarrassed by the whole thing."

Polanski pleaded guilty to unlawful sex with a 13-year-old girl in 1977, but fled to Europe before he was sentenced. He’s now fighting extradition from Switzerland to the United States.

For cryin' out loud. I wouldn't exactly say that Woody Allen carries much credibility in my eyes when it comes to morality and relationships with 'young' women. Maybe it's the 2 glasses of wine speaking (yea, I know, I got distracted working on a hypoparathyroidism presentation...) but methinks no matter how long ago it is, Polanski committed a crime. Never mind the lapse of time, never mind the fame, the money. He should be jailed.

Pattern recognition, for you internal medicine people out there. This was my patient's blood in a tube.

Diagnosis?

-- Sent from my Palm Pre

End of the Road

After a busy week, today I handed off the call pager. I also thanked the 4 medical students who worked with me, and wished them well. After all, this is their final week of medical school. In a couple of weeks, their names will be forever changed (corny as this might sound, and though I'm not a fan of having people call me Dr. Vagus outside of work, this is the truth. Even some of my neighbours call me 'Doc'). I took it as a compliment when Ben asked me what advice I could give them to enable them to be a good teacher like me. I had 2 things to say:

"Time", I told him. Because the truth is teaching always takes more time. As a resident I always thought that I was making my attending's life easy and I was doing all the scut. Now I realize that I round in literally 1/3 the time if I had no resident or medical students. It's tempting to do speedrounds and not discuss cases, to correct mistakes or misconceptions, explain rationales for treatment. But these are bright young minds full of potential; the passing of knowledge from one (academic) generation to the next is vital for bilateral growth. And so I try to make time to teach.

The second thing I told him was, if you have a teacher you found effective, try to emulate him/her. Ask yourself what about her that made her a good educator, and what it would take for you to adopt that trait. I think my style probably emulates a good dozen teachers I've had in medschool/residency/fellowship. I think I picked up Dr. Lemaire and Dr. Bahn's respect for students and how they were always keen to hear our explanations even if we were wrong, and how she patiently corrected us. My sense of humor with students/patients probably reflect that of that Scottish surgeon Dr. Preshaw. My habit of coffee-breaks midrounds (yes, I end up buying the coffee) for some impromptu round-table teaching probably came from Dr. Lee.

I really don't know how well I teach (after all I've been a student before- you always tried to kiss ass in a rotation ).

But I hope I did a good job. For a month from now, these guys will be out on their own.

Steve asked me for some final advice. I shared with them my pearls of wisdom from residency:

1. When oncall, eat when you can, sleep when you can. Never think it's too early for bed, just because it's 8 pm. You never know when that pager will go off, and if you'll get to see the callroom again for the rest of the night
2. You're human. You'll screw up (I still do). Learn from it. Forgive yourself for it
3. If you have to, use the Hide-In-The-Bathroom-To-Cry trick. I've had to employ that several times in my internship. Remember, even the worst day ever will eventually end
4. You're going to be (almost) perpetually tired for the entire year. Life goes on outside the hospital, so have a balance. Have a social life, even if you don't feel like it
5. Never piss off the nurses. If you do you'll never get a good night's sleep. There is never an excuse to be rude or obnoxious
6. Nurses may not have had the training you have, but they've had the experience. If they ask you to come to the floor because a patient doesn't look well, come stat!
7. The learning never stops. Having said that you'll have way too many journals to read, and soon they'll stack up and will only make you guilty. If you have a 3-month old medical journal you haven't already read, you probably never will. Get rid of it. Pick and choose the type of journal and article you'll read, get rid of the rest
8. Lastly, never say no when a consultant offers free food or coffee (no, seriously)

To those of you who complete this stage of your career this week, I wish you all the best.

Being Oncall

It's been a crazy call. In fact yesterday might have been one of the worst calls I've had since I came on staff. True, you're thinking, "he's a consultant in endocrinology, how bad can it be??" and while it's nothing like internship, it was crazy nonetheless. I had a total of 8 new consults and 14 old patients to see, in 5 different hospitals (19 km apart). So I'm going to vent:

Some of those consults really pissed me off. And this is where I think I'm not as smart and as business savvy as my colleagues. Some of them feel that a consult is business, we shouldn't turn things away. Unfortunately I'm dumb; my thoughts are, if you really need my help I'd be happy to see your patient, but think before you order a consult if this is really necessary.

Case in mind, a surgeon who did a minor knee procedure on a patient with well-controlled diabetes on oral agents only, who just had to ask me to see him because he wasn't bothered enough to just write for this patient's pre-admission medications. In fact, I fumed when I drove 19 km to that hospital to find that he didn't even have any glucose checks ordered. When I asked for one, it came back 115 mg/dL- pretty damn good for a post-op. We've also had problems from a notorious surgeon who'd ask for consults for 'hypocalcemia' following thyroid surgery, only to find he hadn't as much as even ordered a calcium. Most of the time, we'd order it and it comes back normal. We sign off immediately. In the meantime, I've driven miles to see the patient. I skimmed through his medical records and usually review his thyroid ultrasound to find out why the patient had surgery in the first place. I'd examine the patient. And so, this brings the consult to a Level 5- the patient's hospitalization gets tacked with an additional sum from my consultation that was not necessary in the first place (no, that money doesn't come into my pocket, but goes to the clinic). Just because a doctor was too lazy to order the test before he ordered the consult.

Like I said, I'm pretty money-stupid and I don't think like some of my colleagues, but really, I could do less with these unnecessary consults.

(and I don't mean to generalize that all surgeons put in dumb consults as I'm sure many of you don't. Just that the same few here keep doing it)

I'm ready to hand off my pager tomorrow and break out that bottle of rum!

Happy Mother's Day!

Happy Mother's Day, to all the hardworking moms out there (including mine).

We had an interesting debate the other day. So Kristin is 31 weeks pregnant, and we have 2 pups. Does that qualify her as a Mother? My neighbours were telling me I had better get her something, or else....
Kristin herself dropped some hints too, that Mother's Day was coming... Uh-oh.

What do you think? Does she qualify?

(No, I did not end up getting her something. But miraculously the dogs and our unborn daughter were able to get a card and a gift for her! )

My New Palm Pre

Disclosure: No financial conflicts of interest to disclose.

Ok, that being said, I just wanted to tell you that I love my new Palm Pre Plus. Nope, I'm not getting paid to do this, either (speaking of which, I do envy those bloggers who get free stuff and trips to Tasmania doing reviews!).

For far too long, I had been using a Palm Treo running on Windows Mobile. It was a phone given by work (well, not really, it ends up coming out of my quarterly bonus) and it was my first smartphone. And so I thought it was cool. At first.

And then I realized it was painfully slow. Pulling up my medical applications took forever; my medstudents often beat my Windows/Epocrates (a drug reference) using their paper Pharmacopeia. The camera sucks too, the photos would come out dark and blurry. Half the time, my car's bluetooth would not sync with the phone (never a problem with my OLD Nokia). And, gawd, like a typical Windows platform, the phone freezes. Frequently. When I'm surfing the net. When I'm pulling up emails. But most worrisome, when I wasn't doing anything. I found this out the hard way when the office was trying to contact me for a semi-urgent issue and my phone didn't go off. We tried again when I was in the office- it would go directly into voicemail and the phone wouldn't even ring. This was happening at least once every other week; I'd find out only when I tried to call and it would not connect, or when others tried to call me. And I'd be resetting my 'hang-kei' phone once a week or so. And so it was time for a new phone.

While I was initially tempted to go with another Windows Mobile phone to allow me to log into the hospital system (I'd be able to pull up my patient list and look at labs) my painful experience and the reviews I read kept me away. And so we settled on the Palm Pre Plus. Now, I've always been a fan on Palm (I consider the Treo issue more of a Windows problem). In the last 12 years I had used the Palm Pilot, and then the Palm IIIc, Palm m500 (which my sister inherited) and more recently the Palm TX before I got the Treo. I loved how fast the Palm OS was (aside from the Blazer web surfer on the TX). So when it came time to look for a new phone, it was down to the Motorola Droid running on Google's Android OS, or the Palm Pre Plus running on WebOS. Because we liked the smaller Palm and thanks to rave reviews from many including our esteemed Palmdoc, we settled on the Pre.

Lemme just say that using this phone is just a relevation. I'd been so used to my old phone being slow and unreliable, with no fun apps (aside from Bubblet) that 7 days since we got the Pre I'm still discovering new things about it!

I love how this syncs with my corporate email and calendar seamlessly. And how it syncs so well with Gmail and Hotmail, even the calendars! And with my wife and I sharing each other's calendars we can easily update each other of family events.

The apps are great too. So many possibilities, though being the stingy guy I am, have only downloaded the free apps. Pandora's one of my favourites- being able to get essentially music-on-demand is great. When I went to the gym just now, I no longer had to carry my phone and iPod- the music player worked well enough that I was just streaming music with the phone.

The camera works so much better than the Treo, too. I don't have to put up with dark, blurry pictures anymore. And while I thought the LED flash was just a gimmick, it does a decent job lighting up nearby subjects in a dark room. And I was thoroughly impressed by this picture I took at the baseball game last weekend. Most importantly, it works well as a phone. The sound is good, the mic pretty sensitive. When calls come in and I hit the connect button, it connects instantly. Unlike the 3-8 second lag I was getting with my old phone.

One neat feature I like which I'll probably never use, is the mobile hotspot option. This phone can be used to provide wifi using the 3G line, and with the data plan this is pretty much included for free (well, up to 3 gb which I've been told is plenty). This will be great for Kristin since she doesn't get internet on some rotations, so using the phone to connect her laptop would be a big plus.

My only gripe with the phone is the same issue with pretty much all smartphones. The battery life. Having said that it doesn't seem as bad as what some reviewers had complained. Some were claiming it wasn't lasting even a day. For me, the shortest was on day 1 (not an engineer but I've heard this is normal for a new battery?). But after that, with some calls and some browsing (including frequent Facebooking) and occasional use of the Bluetooth (I don't leave BT on all the time, only when I need it) my battery is still at 60+% at the end of the day. So, while my 3-year old Nokia still beats that, it's pretty decent for a smartphone, methinks.

Yea, we did contemplate other phones. But I'm one who needs a real keyboard, not just a virtual one. So, the iPhone and upcoming HTC Incredible were never considerations. People have complained about the keyboard being small, but I got used to it pretty fast, and it probably kept the size of the phone down (unlike the Motorola Droid). So far, we've been pretty happy with the phone. And that we got a buy-1-get-1-free phone with our 2-year plan was another bonus.

So there you have it. I hope this phone lasts, though it does feel pretty solid.

Number 3

So I saw my third patient from my alma mater. Not a referral from them, rather the 3rd patient whom I saw when I was a fellow who found out I'm in practice here now and wanted to see me here instead because this was closer to his home.

When I saw my patient list for the day and the comment "Dr V's old patient from XY" I wasn't too sure- I didn't recognize the name and the presenting complaint of 'hypogonadism' didn't look like it was a big enough deal for a patient to transfer care here.

Sure enough when I happened to walk past the waiting room to grab a quick coffee, I saw him checking in and instantly recognized him. I was blurry on the details, but I remembered enough that I saw him in my final months there for secondary hypogonadism from a pituitary macroadenoma and that we were prepping him up for transphenoidal surgery when I left. I also (strangely enough) remembered details about his history- he wasn't sexually active and did not believe in masturbating (something you ought to ask when evaluating a patient for low testosterone).

Anyway, it was in a way fun, catching up with him and having him update me on the happenings in his condition since I last saw him (which was 2 years ago).

Impending Fatherhood

Admittedly, this whole impending fatherhood thing is new to me. And believe it or not, it's causing some weird probably hormonally-induced emotional surges.

Take today. I saw PC back for post-partum follow up of her diabetes. She has type 1 diabetes, A1c was 13.1% when she got pregnant, which she brought down to 6.1% by the time she was at term. I made some changes to her pump after delivery, and she came back today to see if she needed more adjustments. She brought the baby along with her, and seeing that healthy baby boy and the proud parents just filled me with immense joy. I'm not exaggerating when I say my eyes teared up some.

Some patients, unfortunately, don't do as well. Another patient with uncontrolled type 2 whose A1c was >14% at first visit, called me the other day. She was trying her best, but the insulins and the frequent checks were a challenge. She tearfully told me that they had found a hypoplastic ventricle on ultrasound and were considering an abortion given the very high mortality associated with this. I tried not to choke on my words when I tried to offer her some words of comfort. I couldn't help but picture ourselves, Kristin and I, in a dire situation like that. I imagine as a father I would feel so helpless, knowing that there is nothing you can do.

And sometimes, I've had to bite my tongue, as I did when that 19 year old woman with diabetes and an unplanned pregnancy, callously told me "it was probably a good thing I had a miscarriage- I can eat whatever I want now...". Perhaps I'm just too judgmental, but I couldn't help but think, if you're not ready to be

I admit, this is catching me off-guard in many ways, how I seem to be assuming a more protective (paternalistic?) role?

Well, ladies and gentlemen- only 8 more weeks. Might as well get some practice.

Phew..

Thank heavens Mrs. C did well. Truth be told, I had been worried sick about her for the last 3 months but until the outcomes were known it was something I was not wanting to blog about.
This was a woman in her 30's I saw for Graves' disease; fairly typical presentation with also moderate ophthalmopathy. I reviewed the usual treatment options and the possible side effects, and as most patients she quickly ruled out thyroidectomy. Between the antithyroids and I131 radioactive ablation, she was more keen on the former, since most are nervous about doing something irreversible to the thyroid. From my standpoint, she was pretty thyrotoxic which meant even if I were to ablate her, I'd probably bridge her with a transient course of medications anyway. In addition, with her active eye disease, the I131 probably wasn't a good idea. In the meantime we had her on a good dose of beta-blockers.

2 weeks into Methimazole, she calls my office, complaining that she had developed a rash with this medication which is something we sometimes experience. She had the same sentiments about the ablation, so we opted to try PTU instead at an equivalent dose.

Over the months, I slowly adjusted to her improving-but-still-abnormal thyroid levels while monitoring her liver function and CBC. And then, 4 months into therapy, as instructed she called in complaining of a deepening in the color of her urine, and a yellowing of her eyes. Worried, we arranged for urgent labs to be done (she was from out of town so a lot was done over the phone) and my heart sank when the results came back. Her bilirubin was high as suspected, while her transaminases were over a thousand.

Both PTU and Methimazole are potentially hepatotoxic, with the first carrying a much greater risk. PTU-induced hepatotoxicity is a rare and idiosyncratic side effect that is neither dose- nor duration-dependent, that has been felt to occur in about 1:10,000 patients. Fulminant hepatic failure has been described with numerous patients requiring liver transplant and many having been fatal.

The emotions I had were somewhat indescripable. Though we had played by the rules (use PTU only if the other was not tolerated, monitor labs whose benefits in itself of which is so unclear even a recent ATA publication stated that routine monitoring probably wouldn't change anything) my patient had developed a potentially fatal side effect. Moreover, she was close to my age, and I couldn't help but think that in treating her illness, a medication I prescribed had destroyed her life. While this wasn't medical negligence, but rather a known possible complication, you still can't help but feel like you failed a patient, and question your own abilities. So, especially in the first week or two, I literally had panic attacks, waking up in a cold sweat and sometimes chest pains at 2 a.m., thinking about Mrs. C.

We stopped the meds immediately and set up an urgent GI consult and monitored her liver function over the next few weeks. I prayed that her liver would have the capability to heal itself, and sure enough, painfully slowly over 8 weeks her numbers came back down (but her thyroid labs again got worse).

Given the lack of options, I sent her to a surgeon. With her high T4 levels, ablating was probably not a good idea. Problem was, it's usually ideal to bridge a pre-thyroidectomy patient with antithyroids and iodine (a week before) to at least normalize the T4 and decrease the vasculature for the surgeon. Obviously the former wasn't an option anymore.

So, we did what we could; ramped up her beta-blocker, and gave her a 5-day course of SSKI (saturated solution of potassium iodine) knowing that without antithyroids first this may also sometimes cause T4 to paradoxically go up; rare for this to happen but Mrs. C hasn't exactly gotten a run of good luck. There was nothing else to do, but to keep our fingers crossed. I had discussed with her many times the dangers of what was going on, though I think she has always been amused by how I was so worried while she was pretty cool about it (she was a nurse, and a mother of 3 so she probably copes better than me).

I saw her post-op Friday. She looked great, with a small 2-inch barely visible incision, with good vitals. Postop calcium looked good too, and she felt pretty good. After just a night's stay she was dismissed that day.Never have I been so disturbed by a case, never have I feared as much for a patient. We played by the book, so I wasn't as concerned about lawsuits and having to face a judge, but as dumb as this might sound, I was more concerned about having to face God when my time comes, and having Him ask me: Why did you harm this daughter of mine? Why did you take her away from her family?

It was a basic human feeling, that as a person I had done harm to another.

Now that she has done well, I can breathe again.