Signs Your Kids Are Growing Up

• Your girl is able to brush her own teeth and doesn't need any help
• Being able to get herself dressed on her own
• Telling me she doesn't need me to wave goodbye to her anymore as I drive away from daycare, as she'll have her friends to play with
• At one time, you stand in the restroom with your daughter as she goes potty to make sure she doesn't fall into the bowl. Now, she goes "Daddy, I need some privacy please"
• Going from singing lullabies at bedtime (I swear I've probably sung Twinkle Twinkle Little Star over two thousand times in the last 4 years) to reading bedtime stories, to now watching a video on the iPhone of One Direction and having the girls swoon and go "Oooo He's so Cute" at bedtime
• Being able to tell me the name of a song when she hears it on the radio (when I've never even heard of it before. I guess this is how our dads must have felt hearing New Kids on the Block for the first time)

I'm reminded of the song Butterfly Kisses. To perfume and make-up from ribbons and curls. Trying her wings out in a great big world.

 

Don't grow up too quick, kids. Because someday I'm going to be giving you away at your wedding. And THIS dad is definitely going to cry.

Another Phaeo

Phrase that sends shivers up an endocrinologist's spine:

"Biopsy-proven phaeochromocytoma..."

 

Saw my 2nd case of this recently, to my chagrin.

I've seen perhaps 20 cases in my career so far of catecholamine secreting neuroendocrine tumors. But theses should be diagnosed based on clinical suspicion, appropriate biochemistry and radiologic findings.

Never (usually- but will come back to it*) is it justified to diagnose this from a biopsy, as this usually means the physician/surgeon evaluating a patient with an adrenal mass was not considering a phaeo in the differential diagnosis. Or that he/she made the fatal assumption that asymptomatic rules out a phaeo and that lab testing isn't needed- just stick a needle into it.

My first referral was 7 years ago- that patient had a hypertensive crisis in the radiologic suite immediately following the adrenal biopsy. I think the radiologist shat in his scrubs when it happened and it must immediately have dawned on him what the mass actually was.

The second, this patient, had adrenal hemorrhage that required invasive intervention.

 

What I tell residents is this: The classic features of a phaeo isn't that classic after all. All adrenal masses need a biochemical workup, especially before you stick a needle into it.

 

Most phaeos are asymptomatic. And of the symptomatic ones, the most common is hypertension; what looks to be plain old simple essential hypertension. So never assume.

 

(*perhaps the one situation in which I would not blame this on shoddy work is a paraganglioma/extraadrenal phaeo in a weird location- which would be unfair to expect one to consider a phaeo in the differential diagnosis)

When you eat too much sugar...

I think I need to stop talking about work when I'm home.

Out of the blue, the little comes up to me and says this:

"When you eat too much sugar, you get diabetes"
(strictly speaking it's not true- DM has a lot more to do that eating sugar...)

Is it unprofessional to pay for a patient's meds?

So last week I did something unorthodox. Even for an eccentric guy like me. Mrs. G has had longstanding refractory Graves' disease. For some reason, resistant to antithyroids (which usually means some component of noncompliance).

And so, push came to shove and we opted instead to refer her to surgery.

As you know, the Graves' thyroid is enlarged and usually very vascular which makes surgery more complicated. And taking a thyrotoxic patient into surgery obviously carries its risks. So a short course of high dose iodine is usually warranted preoperatively, to take advantage of the Wolff-Chaikoff effect; to transiently shut down thyroid hormone production and decrease the vasculature.

I attempted to get her started on this, except she calls me a week before surgery, crying on the phone that she has only a few dollars left to last her for the week and cannot afford the medication. Nevermind that SSKI is relatively cheap.

And so I told her: "Never mind the cost. Just promise me you will take it."

After all, with her paroxysmal a-fib and recent stroke, she needs the thyroid out ASAP.

She did. And so I told her I would pay for it. I called up Walgreen's and called in the prescription, and gave the pharmacist my credit card information.

I saw Mrs. G 3 days ago post-op. She was sore- but otherwise looked great. And her thyroidectomy went smoothly, thank heavens.

In the 7 years of practice, this was the first time I actually paid for a patient's medication, and I'm still partially expecting this will come back to haunt me. I'm half expecting my supervisors to come back with a reprimand, that this is 'not professional', and may open us up to legal action citing discriminatory action, if other patients get wind of it.

After all, I've been cited for crap like this before, like the time I underbilled a patient because he couldn't afford it.

Often, I wish we lived in simpler times. Times when it comes back to two human beings, one a doctor and the other his patient, and that decisions are made just between them. Far away from the attorneys, the administrators, the insurors, the PR department.

To me, it's a simple matter. She needed it. I could help, and I made a judgment call. So what's the big deal?

A doctor and his patient. That's it.

Snow Day

We are in the midst of another snowstorm. About 12 inches so far and it's not going to end for another 7 hours. So we are all huddled in, under our blankets and sipping on hot chocolate.

That being said, sometimes there's nothing prettier than a nice snowfall.

Everything is white and pure again. Sounds are numbed by the snow, and all you hear is the soft rustling sounds of snowflakes falling, and perhaps distant sounds of snowblowers. Tree branches are frosted white, and there's a thick layer of icing on our patio furniture. The squeaky sounds of footsteps, of the rubber soles against the slippery snow.

It's was something I could not fathom, coming from Malaysia, of how instead of needint to mow the lawn, we use gasoline powered snowblowers to clear the snow. How driving in snow feels, or how you can sweat underneath all that gear, but yet to have your face freeze because of the direct contact with the cold.

This blizzard ends at 9PM tonight. Thankfully, we have nowhere to go this lazy Sunday afternoon. I hear over 2000 flights have been cancelled so far. So, we're just going to stay lazy and enjoy the day.

Stay safe, folks.