Traditions

So it's the weekend before Chinese New Year. I just read about the usual traffic rush on The Star. Balik kampung time.
I have to say, this is where it gets me nostalgic, and perhaps a bit homesick. For my family, Chinese New Year was the biggest event of the year. An event that was filled with all sorts of traditions, admittedly many of which was quirky. And though we're very happy with life here, with a nice home, wonderful family and a baby girl, our health, and great jobs, one thing I idealistically yearn for sometimes for my daughter is to have some of the CNY experiences and traditions I grew up with. Because, in Midwest USA, there is zero New Year festivities. Well, unless you hang out in the Asian grocery stores. And so, if my daughter could understand, what traditions and memories would I share with her?

• The night before, the family gets together for a big round-table dinner. I miss my mom's ginger chicken, and roasted pork in dark sauce (the kind with at least 1 cm of fat)
• We have prayer sessions to welcome the God of Fortune, usually at midnight.
• How we wake up at unholy hours the morning of (well, it was before medical school, so it felt early. Now, early has a new meaning). Got dressed, rushed downstairs to greet mom and dad with our hands clasped and got our angpows, and then left for the temple for prayers. Oh, how I miss the sting of the incense smoke; it got so thick that it could probably trigger an asthma attack.

• The redness of the festival. In the cards, the clothes, the mall decorations, the food, the angpows. Heck (I kid you not), I even had a few pairs of special red underwear I'd wear, which brings me to the next tradition:
• Of gambling! This was the time of the year parents allowed for us to gamble. Nothing big time, just Black Jack, usually. Betting 20 cents felt like I was a whale at the Bellagio. Of course, the older crowds would bet much larger amounts of money, actually using PAPER notes (back then, RM 1 was a lot of money!). And yes, this is where my red undies came in, for luck. But as even my younger brother would attest to, I lost my money to everyone. The red undies never worked.
• Ah, the smell of black powder from the fireworks. Even when firecrackers were made 'illegal', well, there was no shortage of it. I remember the over-the-fence rocket wars we had with the neighbor kids. It was our own Gulf War. Until we set fire to the neighbor's yard and got a spanking.
• The irritating yet hypnotic CNY music. From the "gongxigongxigongxini,yagongxigongxi" (which incidentally, means I will Gong You to Death) to the music videos of little boys and girls in heavy makeup singing. Playing those songs in an insane asylum would trigger instant rioting. And yet, strangely enough, I miss hearing that.
• Mandarin oranges. I love the navel oranges from Florida here. But this doesn't even come close.

Ah yes. Those memories and more. Someday, when Alli is big enough, I will sit her down and share these with her (minus the undie part). At least last year, I was lucky enough to have been able to be in Malaysia for CNY (though Kris missed it).

Ok, so I'm going through a phase now. I blame it on the cold, cold Midwestern winter (it's -19C today, KNNCCB!) and that I'm losing hair on the top, and therefore feel the need to replenish hair elsewhere!
Anyways. I've been sporting this look for the past few weeks. My patients have been polite enough to say, "Oh, you look different".
My wife however is more honest, bless her heart: "You look like you have pubes growing out of your face!"
(But she also adds, "... but I love you anyway")

What do YOU think?

Being 'Oncall'

Ugh. So we had a rough night yesterday. The little monster angel was up at 1 am, then 3 am, and pretty much stayed up since then. We suspect she's teething.
No amount of rocking, feeding, singing would appease her, and so I had to resort to taking her into the bathtub at 6 a.m., while it was -17C out there! She likes baths, and so that seemed to do the trick.
It got me thinking about internship and being oncall though. And in many ways, this was tougher:

- At least when you were oncall, you had a maximum number of hours when the ER could hurt you with admissions. After 8 am the following day, you were home free (I read that now, interns can only work a max of 16 hours. That's cush!)
As a parent, you're oncall 24/7.
- At least you get paid as an intern for the work you did.
- At least your patients don't puke and poop on you (well, you'd hope they didn't- but if they did, the nurses cleaned them up!)
- At least your patients don't cry inconsolably.

Anyway, the babe's asleep now. And I'm feeling like a zombie- exhausted but too tired to fall asleep. Ah, just like the good old days of internship!

Fathers and Mothers

As much as I'd like to think that I'm being a great parent to Alli, I've realized that there is a reason there are mothers in this world: To keep the fathers out of trouble.

Situation: Baby drooling all over her face
Kristin: Goes upstairs to the baby room, gets a hanky, brings it down and gently wipes off the copious amounts of saliva.
Me: Picks up my dirty T-shirt from the couch, the same one I wore to the gym yesterday, and nimbly dries her face (while hoping my wife didn't catch me doing it).

Situation: Baby lets out a few loud farts
Kristin: Pulls the baby's pants and diaper aside to check if she did a number 2
Me: Picks baby up and sniffs her butt. If it doesn't smell, it's all good

Situation: Baby needs a diaper change

Kristin: Puts the baby on the changing pad, removes her PJs, takes off the dirty diaper, wipes her down, tosses the dirty diaper into the bin

Me: Puts the baby on the floor, does a quick switcheroo, and forgetfully leaves the dirty diaper on the floor, where the dogs proceed to shred it

Situation: Baby has a damp diaper

Kristin: Changes the diaper at regular intervals

Me: "Diapers are absorbent for a reason!"

Situation: Dressing Allison up for daycare

Kristin: "She needs to look pretty...". And so her pink top matches her pink bottoms, and she gets to wear a hat to stay warm

Me: Allison goes to daycare in a brown shirt and purple pants that is worn front to back, that she wore yesterday as well.

Situation: Allison needs soothing

Kristin: Rocks and sings her to sleep with her limitless lullabies

Me: Twinkle twinkle little star. Repeat 80x until baby is unconscious

Situation: Babe picking up her toy from the floor and puts it in her mouth

Kristin: Grabs it from her, rinses it in water before handing it back to her

Me: "Exposing her to contaminants is good for her immune system..."

As much as I'd like to think I'm this independent, metrosexual Dr. Dad, I'm glad my wife is here to keep an eye on me. Something tells me I'm not winning the Father of the Year Award!

An Urgent Message

I didn't quite know how to respond when I got this urgent message from the front desk. These things usually get me pretty ansy. A patient in trouble? DKA? Hypoglycemia? In this case, a patient had called in to the phone messaging system and left this message for Dr. Vagus:

"Please send in a prescription for the most powerful male enhancing medication out there as soon as possible..."

Verbatim.

I called him back, and gently explained that I saw him 3 months ago for a thyroid nodule, and had since dismissed him back to his GP after my biopsy found this to be benign. I suggested he talks to his GP about whatever problem he had.

Admittedly, part of me was dying to know why. But I didn't think it to be relevant nor professional to ask.

(male enhancing=penis enlarging? Or did he mean erectile dysfunction? Hot date coming up, perhaps?)

OMG

I could only shake my head and laugh in disbelief when this (see video below) landed on my desk.
I know I'll get some flak for this, but it's all business, nothing personal: I avoid drug reps like the plague (and I say this with some good friends who are reps who are very nice people).
It's a personal, ethical choice. I get what I need from medical publications, meetings. I don't need some hot-rep-in-a-miniskirt, or powersuit (I know it's a generalization, but it's apparently true. Didja read that CNN article a couple of years ago showing Pharma tends to preferentially hire good looking people? Which means I'll never have a future in a pharmaceutical firm!), to tell me how good their medications are. And so, I avoid drug lunches (when they peddle their products over a meal) whenever possible. For one, my lunchtime is my zen time, not to listen to someone talk. But mainly, as much as I love Chick-Fil-A, or Panera's, or whatever else they may buy, the fact is this:
It may be free, but really, way down the line, someone's paying for those meals. My patients.
A big chunk of the $300/month cost my patient is putting up with probably ends up in doctors' tummies.
And so, this is a personal choice of mine (realizing too that drug lunches has their benefits too). I avoid them. And the reps know it. And yet, in our clinic we have a strict policy: peddle your stuff only at lunch, do not interrupt the providers in their offices.
I imagine there must me others like me for big pharma to come up with something as (pathetically) ingenious as this to 'speak' to doctors who are avoiding their reps:

(as amused as I am with this, again, I catch myself thinking. Can't they have spent the $$$ they used on this, to make the drugs cheaper?? And no, I'm not promoting or discouraging the use of this product)(but then again, I'm Asian and hence cheap, and I try to use generics whenever possible )

Working up adrenal masses

I saw Mrs. R, a pleasant 62 year old woman who was found to have an adrenal mass incidentally when she had a CT abdomen/pelvis for diverticulitis. Her medical history was significant only for hyperlipidemia, hypertension, both well controlled, and knee surgery.
Her right adrenal had a 3.2 cm nodular mass on the medial limb of the gland; this was 15 Hounsfield units pre-contrast, 40 post-contrast, and 22 Hounsfield units on delayed washout images.
When I saw her, the diverticulitis has resolved and she was totally symptom-free.

This case I'm working up reminds me of the conversation I had with someone recently about something similar: someone had the brilliant wisdom to biopsy a pheo before ruling out a pheo. For Mrs. R, on the basis of the radiologic features alone, adrenalectomy is probably indicated; the strong enhancement with IV contrast is worrisome, if nothing else for malignancy. Now, some may say, "She is asymptomatic, and is normotensive and has no spells. No need to screen for pheochromocytoma".

Wrong.

Wrong wrong wrong.

Here's a caveat I picked up from one of my mentors who's one of the world experts on this subject. You ALWAYS have to screen for a pheo in cases of adrenal masses. Even if the patient was asymptomatic, as quite a number of pheochromocytoma patients have no symptoms. And those who do, one of the most common is essential hypertension. In other words, none of the classical spells of uncontrolled hypertension the textbooks talk about. And certainly none of the crap you saw on that episode of House MD.


In Mrs. R's case, I ordered 24-hour urine catecholamines and metanephrines (another teaching point- always look through the medlist and ensure all interfering medications are stopped)- her urine normetanephrines came back at 1100 mcg (3x normal). She's coming in to see me tomorrow to draw serum metanephrines as a confirmatory test and to discuss preparation for surgery. I'd be surprised if this did not turn out to be a pheochromocytoma.

(and even if this isn't, it still needs to be removed)

Sometimes, you just can't win.

I got a note from the front office today. One of my patients with Graves' disease was transferring care to a different endo. The reason was that "Dr. V insisted I had to take the medication (Methimazole) whereas this other endo suggested the radiation treatment..."

And so I looked back at my consult note. And saw that I had given her the options of I131, or antithyroids, or even surgery. And had reviewed each in detail with her, and suggested after she completes the confirmatory thyroid scan and uptake, to return so that we can pick a treatment option. I even printed out a patient handout for her outlining these options. Except she no-shows the appointment, and calls me wanting to discuss over the phone instead. And when I called her, she vehemently refused the radiation treatment, instead opting for a course of Methimazole. Except 2 months into it she stopped her meds because she 'felt better' but by her next follow up she was frankly thyrotoxic with a free T4 3 times above normal and I had to resume her meds. She then cancels the subsequent lab visit.

And so, here we are. Sometimes you just can't win. Whether it's because I didn't make myself clear, or she didn't understand, or just some other personality issues, I suppose I don't care to find out. Sometimes though, try as you might to explain things, and give patients the option of treatment choices, and things backfire, it does leave a bad taste in the mouth.

Good riddance, I say.