All Ears

Wasted Medical Visits

2010-02-04T18:24:00.003-05:00

A medical provider only has so many hours they can devote to appointments. I typically work 12-hour shifts (my choice) with a patient scheduled every 15 minutes, taking only one break (lunch) during my busy day. I reserve the hours of 5:30 PM to 8:30 PM for urgent care visits - about ten appointments. Our advice/triage nurses are supposed to screen the patients for these limited evening appointment, allowing only acutely ill patients; those who cannot wait until the next day, and those not so ill that they need the services of an emergency room. I never intended for these evening appointments to be "convenience care" - utilized by people who will not make an appointment during our normal office hours. People are so grateful that I have extended hours, three days per week. Some people do abuse this service, I have to say.

We do not have a lab or x-ray services after-hours, so any encounter that may need imaging or lab, like a suspected appendicitis or orthopedic cases, I send them to the ER. I get a great number of kids with otitis media, people with Strep throat, mysterious rashes, vomiting/diarrhea cases, and of course, fever of unknown causes.

I will see most lacerations that need suturing. Lacerations should be repaired within a few hours, no more than eight, so waiting until morning is not an option. I am one of the few providers in our group practice that will see kids with lacerations. I don't believe in sedating them, and I rarely restrain them on papoose board (probably not a politically-correct term). The vast majority of children (even two year olds), given an adequate explanation of what you are going to do to them (they are mostly concerned about pain, as you might imagine), will sit still and allow me to sew up their little faces without squirming. If I had to take a guess, I tend to have more issues with the parents, than the kids. At least once a month, a parent will faint or vomit while I am suturing their child. As I am suturing, I have to keep a close eye on the parents (mostly fathers) who are sweating and looking pale. On a few occasions, I had to suture both the child and a father that hit the floor.

Now that I have set the stage about what types of patients I like to see in the evening clinic, I would like to talk about "wasted visits". I guess I shouldn't complain too much, since even people who come in for unusually-minor problems; are still charged the same fee. What really tics me off are those who fabricate the reason for their visit in order to snare one of these precious appointments, those that have illnesses or conditions so minor that I can see them heal spontaneously in front of my eyes, and those that just need notes for work, school, or PE. If I could charge more for these wasted visits, I would.

Jonas was a two-year old who was bitten by some sort of crawly creature (flea, ant, mosquito, or spider) two days ago. He had an appointment last night for two, tiny mosquito bites on this right foot. He didn't seem to notice them, but mother was particularly worried because he had a history of getting an infection in the past. Mother wanted to have him started on antibiotics right away, so that those bites would not become infected. Needless to say, she left disappointed and a few dollars poorer. In the vast majority of cases, antibiotics should not be used to prevent infections. The only thing that Jonas needed was a bath, nail-clipping, and some hydrocortisone cream. If you have ever made a doctor's appointment for plain 'ol mosquito bites; shame on you.

Cory was 13 years old and was supposed to have a laceration of his scalp. My nurse put him in the treatment room and prepared him for sutures. After spending a few minutes looking for the spot that was supposedly-bleeding, I finally found a tiny, tiny, tiny scratch at the back of his scalp. He said that it suddenly bled during social studies class. He did not fall asleep and hit his head, nor was he shot by a random bullet or arrow. The hole was not big enough for brains to fall out, although I considered the possibility. After a period of denial, he finally admitted to scratching off a scab from previous injury sustained during wrestling. He left with a dab of antibacterial ointment on the wound - another wasted visit.

Madison was ten days old and was bleeding from her ear. This got an immediate appointment. The new mother was in such a panic, she scraped the entire side of their new car pulling out of the garage. Upon examination, a tiny scratch was noticed on the outer ear, mostly likely self-inflicted by sharp, little newborn fingernails. Her nails were like razors, but the mother was reluctant to trim them. There were no other sources of bleeding found. The baby was perfectly healthy, mother was embarrassed, and Dad seemed pissed about the car. This was wasted visit number three.

The last of the inappropriate visits involved a rash that had completely resolved. The parent was hoping that I would be able to determine what it was. Based on history alone, I determined that it was probably hives, but now that it is gone, there is really not much that I can do, other than suggest Benadryl next time. I had to inform the parent that there are no blood tests that can conclusively determine what caused the hives. They needed a note for missing school today.

The other six were appropriate visits, however, one even needed hospitalized for RSV (respiratory syncytial virus). This child, having considerable breathing difficulties, is one should have been triaged directly to the emergency room.

When I was a child, there is no way that my mother would have coughed up $3.00 for a medical visit for mosquito bites, a scratched ear, or a bleeding head. Granted, my mother was not the best triage person either. I once came home after completely impaling my right foot (I still have the scar) with a rusty pick; ruining a good pair of tennis shoes. The pick went all the way through my foot between the metatarsal bones. She filled the holes (both ends) with Vaseline and wrapped with a clean rag. I can't recall a tetanus shot or even a subsequent antibiotic. After washing my shoes, I continued to wear them, holes and all. My right shoe tended to leak in the rain.

I excuse new parents for not having the experience or knowledge to make reasonable health decisions. Everything freaks out new parents - rashes, fevers, one bout of vomiting, moles, funny-colored poop, yellow mucous, fevers, yucky tongues, flat feet, ear-pulling, penis-pulling, fevers (I know I mentioned fever three times, but this is a big one!), constipation, diarrhea, and fussiness. The same folks that study pregnancy like an obstetrician, attend childbirth classes, and read books on childcare, tend to loose it when Junior gets a runny nose. Since most childhood afflictions are self-limiting, when there is nothing to treat, I use these wasted visits as educational visits. Education tends to last longer and have less side-effects than medication.

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Home Office Make-Over

2010-02-01T08:34:00.000-05:00

It was reminiscent of a warehouse after an earthquake. Unlabeled, cardboard file boxes were stacked in the corner and in front of the bookcases. Various piles of papers were lined up in some quasi-organized fashion. There were two file cabinets, but nothing was filed - they were used as drawers. Desk drawers were filed with any number of things: ink jet cartridges (both new and empty), blank CDs, a few thousand pharmaceutical company ink pens, a sushi knife, carefully hidden scissors (so my wife won't take them), lots of business cards, random pieces of paper with phone numbers without names to go with them, old keys, a few hundred disks that no longer fit the computer.

In the office itself were four computers (only one that I use), three printers, two scanners, two telephones, two wireless modems, a skull, several hundred books, my varmint gun, a Celestron telescope, an antique pharmacy scale, three sets of hand-carved crutches, and a huge glass display case of my prized collection (award-winning, I might add) of antique laxatives. I could go on...

My walls held an eclectic collection of art, fine sculptures, a plastic "butt", two clocks with incorrect times, and a plethora of advertising signs (Fallout Shelter, Do Not Bed Sheep in this Area, No Smoking, Duffy's Cough Syrup, Pharmacy, No Dumping, etc.).

As a former bedroom, there was a closet in the room. It held even more file boxes, tax records, a twenty pound bag of assorted rubber bands that I bought at an auction, old cell phones, a hundred pounds of Costco batteries of all sizes, old cameras, lenses, expired 35mm film, and two walkie-talkies with a range of 20 feet (in good weather, without obstructions).

I found some treasures, too, like some traveler's checks that I forgot about; enough to help pay for some of the new cabinets.

Needless to say, I had a cluttered, disorganized, dysfunctional, and dusty work space. For the last eight years, my wife has been harping at me to get an office make-over. I resisted, of course, since I knew (basically) where everything was located within that clutter. Sadly, it was my (inside) man cave. My other man cave is the garage. I have a four-car garage that only has room for one car, especially now that I have gutted my office down to the drywall. The old desk, file cabinets, and book shelves are now in the garage.

A friend and I installed a ceiling fan and light, ripped out the carpet and put down a hardwood floor, and installed some additional plugs (you can never have enough plugs). My wife volunteered to paint it (I hate painting). I sort of pride myself that I can do many different things, including carpentry, raising chickens, operating a backhoe, building sheds/fences, and installing irrigation systems. However, I have met my match. Apparently, I do not have the skill or patience to install crown molding. After some embarrassingly short cuts, improper angles, and mental anguish, I am having someone else do it.

We have always saved stuff for our adult kids. ("Don't take that to the dump, maybe XX will want it.") We still have boxes of their toys and Little League trophies. The fact that our youngest child is now 30, you would think we would give it to them. Every time we try, they make excuses. Next time we visit, we are going just leave it in their garages, so they can save it for their grandchildren.

I made at least two attempts in the past to get this office make-over, but never followed through after getting the shocking bids for built-in desks and cabinets. This time, I was going to do it. It was a locally-owned, family business and the price was reasonable. They are installing it today as I write this blog post. I am using my wife's computer. A few minutes ago, the carpenter (who arrived two hours late!) informed me that my room is not "absolutely square" so his cabinets may not fit "exactly". I guess as long as they don't hang out the window or keep me from closing the door, it will be fine. The cabinet under my window as four inches too tall, but he is modifying it. I insisted that I had not lowered the window since he measured.

Because he arrived late, he informed me that it is going to take a second day to install them. I think that is what he said. It was hard to hear him because the dogs are still barking at him and his empty truck. I really want to go upstairs can check the progress, but I am afraid...very afraid. There is a lot of drilling, sawing, hammering, and swearing going on.

I really envy those people who can manage their papers, collections, and clutter. I am trying, and I pledge that I will get rid of some things. Years ago, when we packed up, lock-stock-and barrel, and moved to Michigan from California, I was going to do it. Instead, I took every thing to Michigan, and then hauled it back again two years later, along with the stuff we accumulated there. I can really understand when kids pull out their hair when they clean out their parents' homes after they die or head off to the nursing home. My brother and I did it for our mother several years ago, throwing away plastic flamingos and brass monkeys. So, I guess our kids will be doing it for us someday.

I think that an ideal home would have one large bedroom; a living room that includes an uncomfortable, pull-out couch (for short-term guests); a big-screen television; a kitchen with one of those great, restaurant-quality, eight-burner, Viking stoves; a sunny backyard with room for a garden, and 30-car garage with room for a wood shop and at least one car. Someday.

Five Six Friends with Cancer

2010-01-28T11:46:00.005-05:00

The older we become, the more likely we will have friends that will have cancer. In the last year or so, five close friends and relatives were diagnosed with various types of cancer. I am pleased to say that three are "cured", and two are under intense treatment.

Lymphoma: She was in her late fifties; never smoked a day in her life. Her only addictions were her grandchildren, traveling, and Bonsai trees. We were going to go to Europe with them. It would have been our first trip; they have been there many times and would be our guides. A few suspicious lymph nodes appeared in her neck. These were not the painful, reactive nodes we see with sore throats or dental infections. These were hard and fixed. Her doctor didn't like them either and sent her for a prompt biopsy. Once lymphoma was diagnosed, she underwent chemotherapy at a major cancer center. Today, she is in total remission, visiting her grandchildren, and as a Master Gardener, teaching Bonsai classes. Europe will still be there when we decide to go again.

Breast Cancers: She was also in her late fifties; a teacher and my sister-in-law. Because we had to cancel our Europe trip and had the time off, we decided to visit her and my brother. When we called to announce our visit, they had just left the doctor's office. Her annual mammogram showed a possible cancer; a biopsy confirmed it. After her lumpectomy, radiation therapy, and tamoxifen, she is now cancer-free. She hopes to retire this year to have more time to play.

Last year, a WebMD colleague - the person who edits the All Ears blog - also was diagnosed with breast cancer. She has undergone aggressive treatment and she, too, is doing well. She is taking time to walk with other cancer survivors and raising money for more research. I have never met her personally, but shared in her struggle and rejoiced in her remission.

Brain Cancer: It hit him without warning, like a lightening strike. Our best friend was preparing lunch for a visiting colleague when he suddenly lost his ability to speak the words he was thinking. Fearing that he was having a stroke, his wife called 911 (prompted after a phone call to us first). It wasn't a stroke. It was a brain tumor. As a matter of fact, it was the Mother of all Tumors, the Big Kahuna - an advanced-stage glioblastoma, the same tumor that recently took the life of Senator Ted Kennedy.

It has been nearly a year now; a year of brain surgery, radiation therapy, repeated rounds of chemotherapy, a few ER visits for unexpected seizures, repeated MRIs /PET scans, second opinions, and third opinions. He is holding his own right now, spending time with his children, grandchildren, seeing some great shows in Vegas, and enjoying the time he has left. He knows that his prognosis is not good, but still hopes for that miracle. If anyone deserves a miracle, it is George. We are going with him and his wife to the next consultation visit.

Prostate Cancer: He was one of my best friends in college and still is. On a routine examination, his PSA (prostatic specific antigen) was very elevated. A biopsy of his prostate was suggested. It wasn't a routine biopsy, either. The surgeon nicked an artery that would not stop bleeding; he nearly bled to death. Thinking that a person can only cheat death once in their lives, he hoped his biopsy would be negative. It wasn't. His prostate has been seeded with radioactive "rice" (brachyotherapy) and it has worked like a charm. He considers himself cancer-free and has done a long bike ride to celebrate his successful cure.

Lung cancer: I have known Harv for over 35 years. Together, we helped form the California Academy of Physician Assistants (CAPA), an organization that is still thriving with thousands of members. He was a smoker - a heavy smoker. This resulted in some pretty severe emphysema, so he has been on oxygen. Two weeks ago, like my friend, George, he suddenly lost his ability to speak an intended word. It was not those "brain-farts" that we all get from time to time; this was a serious loss of communication. He lives alone now in Arkansas, but knew he needed medical care quickly. A CT of the brain found a tumor; two, actually. A CT of the lung found the source. Harv has lung cancer that has metastasized to his brain. This week, he is undergoing gamma knife surgery, followed by chemotherapy. He is afraid, but is not letting a little cancer slow him down. He is still planning a cruise, going to his Navy reunion, and planning his annual trip to CAPA in October. He said that he was not surprised at getting lung cancer. As an astute medical clinician, he knows the reason, but his addiction to cigarettes was just too strong for him to quit.

As I have mentioned many times in the past, my father died of lung cancer at age 39. He was a smoker, too, compounded by his asbestos exposure in the Baltimore shipyards. He had a lung removed and endured painful cobalt radiation before he died six months or so after his diagnosis. This was in 1957, long before there was a specialty called oncology.

My brother has had a melanoma on his chest in the past. This is puzzling since he does not prance around without his shirt, even though he is a sailor. He, too, is a cancer survivor, cured by removing this early lesion before it caused additional trouble.

We need to take better care of ourselves, at least as well as we take care of our cars. The same people who become worried when they don't change their oil ever 3,000 miles, are really the same people who have not had a physical examination and baseline lab work for years. In the end, we will all die of something - humans do not live forever. Cancer is among us and we need to be diligent on looking for those suspicious signs and symptoms. Detected early and treated aggressively, cancer is no longer the automatic death sentence that it once was. We are slowly winning the battle, one survivor at a time.

FYI: My PSA and lipids are good. I passed my cardiac stress test with flying colors. I recently had a brain MRI for my tinnitus, so I know I do not have an occult brain tumor. My brain-farts are clearly due to something else. I have never smoked. I don't drink alcohol. I am happily married (married men live longer). I wear seat belts. I have no lumps in my man-boobs or moles that are suspect of melanoma.

I do need to eat more responsibly, lose 30-40 pounds to shake my Santa image, get a colonoscopy (so I can blog about it), and get my blood pressure in better control. Knowing what to do is the easy part; doing it is the hard part.

I would like to live several decades after I retire. I have places to go...things to do...family, friends, and dogs to love...patients to see....WebMD board postings to answer...and lots more stuff to write about.

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I Remember a Time...

2010-01-26T14:01:00.002-05:00

I remember a time when people took more responsibility for the cost of their own health - a time when considerably fewer people had health insurance than today, if at all. If people became ill, they paid for a medical visit, just the way they pay to get their car repaired or pay for groceries.

I remember a time when medical care was more affordable, even when you compare today's higher salaries. People paid the doctor directly, paid for their reasonably-priced prescriptions, and they got better. Because even a small doctor's fee was a barrier, people tried "self-care" first. No one rushed to their doctor on the first day of cold. If you didn't get better after several days of chicken soup, Vicks Vapo-Rub, and St. Joseph's aspirin, maybe you would see the doctor, or the doctor would come and see you at home. No one used the emergency room for primary care - only true emergencies.

I remember a time when medical providers were trusted and held in high esteem; lawyers were few, and those were trusted, too. The idea of lawyers advertising on television for victims was considered ridiculous. Like today, doctors made mistakes; they missed diagnoses. Being held in high esteem did not mean omnipotent. Honest mistakes were just forgiven.

I remember a time when doctors could diagnose you by taking a careful medical history and examining you. They did not depend on expensive lab tests or advanced imaging studies like MRIs and CT scans. They listened and they touched. They utilized their carefully-honed diagnostic skills and were right most of the time. They treated a variety of illnesses with simple medications and people got better.

I remember a time when people trusted vaccines. Vaccines kept us from getting polio and measles. Vaccines were free and we were willing to stand in line to get them. No one seemed to get adverse reactions, other than sore arms. If we did get sore arms, we did not complain or call an attorney. No one became autistic. We had autistic children in the 1950's, but we did not call them that.

I remember a time when families took care of their special-needs children, and their aging relatives. There were few skilled nursing facilities, at least none that we could afford. If God gave you a child with Down syndrome or Grandma had a stroke, you loved and cared for them just the same, in your home. It was not the responsibility of the State to provide the care.

I remember a time when we had school nurses that were permitted to actually do nursing, not just call parents to come and pick up their kids. School nurses would fix wounds, treat headaches and tummy aches, and even kiss a few boo-boos. School nurses were there to listen to children who were having problems at home.

I remember a time when people took pride in their work, no matter what they did. Shoddy workmanship was rare and doing a good job was considered standard. If you bought a Chevy or a Ford, you knew it was made well. (The Edsel was an exception, of course.) Made in America meant "quality", Made in Japan meant "cheap". A plumber would fix your water heater the first time, or come back and do it again...for free. Car mechanics seemed to know what they were doing, even without on-board computers telling them. Mechanics did not charge $90 an hour. Refrigerators, stoves, and automobiles were made to last decades, so they were unusually reliable. Minor problems were fixed by the homeowners. If your car needed an oil change or new tires, you did it yourself.

I remember a time when kids could play outside, even in the front yard, without fear of abduction or molestation. You knew your neighbors and your neighbors watched out for each others kids. Kids happily played games because there were no video games, iPods, computers, cell phones, or movies on demand. Television was free but we only had three channels. It was okay to lose at a game, be picked last, or not make the team at all without having your parents intervening because of hurt feelings.

I remember a time when not everyone had a phone or a television. Long-distance phone calls were unbelievably expensive. Many people had party lines - two or more families sharing the same phone. You had to listen for your individual ring. Television screens were small and pictures were in black and white. Any colors that we saw were in our imagination. We knew the sky was blue, grass was green, and Lassie was brown/white. There were few stations and the reception was generally poor. Even then, we could have easily become television addicted, but our parents made us go outside and play.

I remember a time when teachers could give the grades you earned. School days were longer and homework could be finished in less than an hour, so kids had time to play and just be kids. Teachers and principals could exercise reasonable corporal punishment (a paddle) for bad behavior and not be put in prison for it. Your butt and pride were momentarily hurt, but adverse behaviors were rarely repeated. I spent my share of time standing in the corner because of talking, and yes, I had a few spankings at school which were duplicated when I went home.

I remember a time when a child's first experience at school was in kindergarten. There were no preschools or day-care. The kindergarten teacher taught us to count, learn our ABC's, and learn our colors. Learning to read was the responsibility left to first-grade teachers. We did not start preschool as soon as we were potty-trained, and we still went to college anyway. Early childhood education focused on behavior, not algebra. Children from foreign families were expected to know English before attending classes.

I remember a time when playing on a playground was at your own risk. If you fell from a sliding board and broke your arm, it was not the fault of the city or the sliding board manufacturer. It was your fault and your parents knew it. Fathers and sons could make a backyard tree house without a building permit. Kids rode bikes on the street, and drivers looked out for them.

I remember a time when parents would do anything to support their families, including taking menial jobs to put food on the table. The government would offer subsidies like cheese, flour, or peanut butter when families were struggling, but no one handed out cash. The idea of being on welfare (or "relief") was embarrassing and short-lived. It was not a way of life for generations.

I remember a time when parents cooked at home and we all ate at the table. We ate a lot of macaroni and cheese and stews. The smell of homemade bread still evokes memories. We did not go to fast-food outlets or restaurants. School lunches were packed in brown paper sacks or in cool lunch boxes with the Lone Ranger and Tonto. Tonto was not looked upon as being a stereotyped Native American - he was an Indian.

I remember all of these things, but things were far from perfect. We have made some important strides since the 1950's:

Cars may be more complicated, but they are safer. This is good, since they are faster and not made of steel. We now have seat belts, safety glass, air bags, electronically-locked windows/doors, built-in roll bars, and impact-absorbing bumpers. Kids are restrained in the backseat like astronauts, not standing or jumping from the back to the front.

Kids and motorcyclists are required to wear helmets. Although there have been remarkable advances in neurosurgery, not all brains can be fixed.

People are recycling now. In the 1950's, it was common to throw trash out of car windows or dump it along the side of a country road. We did recycle soda bottles - they were worth two cents each!

People are more tolerant of different races and alternative lifestyles. If you were gay in the 1950's, you kept it to yourself and were forced to lead a very lonely, cloistered life. Black people do not have to sit in the back of a bus (or the back of the classroom like they did in my integrated, first-grade class). There are better opportunities now for all minorities, but we still have a way to go.

There are more and better vaccines now, preventing illnesses that killed and maimed many of my childhood friends. Vaccines are not perfect, but they are infinitely better than the diseases they prevent. I look at an iron lung in the medical museum, and rejoice that those days are over.

We now have a larger and more comprehensive drug formulary, treating diseases that were once a death sentence. Like vaccines, not all drugs are perfect, but I would not want to live in a world or practice modern medicine without having that pharmaceutical armada. Drugs are generally safer. Remember that the 1950's gave us thalidomide

It seemed like everyone smoked in the 1950's. Most people did not know that smoking was a form of population control, as fathers, mothers, and grandparents died in the thousands due to the adverse effects of tobacco. There is overwhelming evidence that cigarettes will eventually kill you, but the young and stupid are choosing to allow history to repeat itself.

Medicine is more advanced - better surgical techniques, better diagnostic technologies. The practice of medicine may have suffered, however. Gone are the days when a doctor stayed at the bedside of a dying patient, or treated a sick patient, whether they had money or not. Doctors still have hearts and many of them still do these things, but they are the exception rather than the rule.

I miss the simplicity of the 1950's. In my opinion, they were truly "Happy Days", but what did I know? I was a kid. Would I go back if I could master time travel? Maybe; as long as I could bring some of our good things with me.

What do YOU remember?

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My MRI

2010-01-25T18:46:00.003-05:00

Liz Henry / CC BY-ND 2.0

When medical providers become patients, we often have similar issues. We complain if we have to wait, moan about filling out forms, especially forms that are asking for private information that you don't think anyone should know, like your social security number, birthday, and of course, your weight. I purposely put the wrong social security number or none at all. No one has ever called me up to tell me that it was incorrect, so I know it is not needed. I can handle identity theft, but I am not going to be honest about my weight. The only time that I was honest about my weight was when I was teaching with the University of California - Davis. One of my jobs was to evaluate medical students at their rural clinical teaching sites. A pilot would fly us in to some scary-looking dirt runways, so it was important that he balance the plane properly - equal weight on each side. I did not want to be responsible for a crash simply because I put on some pounds over the holidays.

So, I lied a little bit about my true weight to the MRI tech today because I knew it was irrelevant. I had arranged an "open" MRI with a bigger chamber for those of us who are claustrophobic. I knew I would fit. Besides, the MRI was of my brain and it weighs pretty much the same as it did in high school.

They made me take off all of my clothes, except my underwear, making me wonder which brain they were imaging - the big one or the smaller one (Men, of course, have two "brains" which direct many of our activities). I donned the gown, open in the front, but I kept on my black socks and shoes. I am glad there were no mirrors. I was directed to sit back in the waiting room. I knew what I looked like based on the stares and some subtle smiles I detected from the other patients. I stared at them, too, for a little revenge.

I didn't really talk to anyone in the waiting room, since I have discovered two things about myself. When I am anxious (MRIs are stressful for me), I evolve into a comedian, or become sarcastic. I was fighting those feelings. My first challenge was with the eight pages of forms I had to fill out. I had an appointment for this test about a month ago, but when I arrived, more than thirty minutes early as they requested, they were one hour behind. They told me to go out for breakfast and come back! I was not hungry, and besides, I had developed a nice cough. Trying not to cough while lying on you back for an hour was not something I could really accomplish, so I rescheduled. My appointment today was for 12:30 PM (lunch time for most people), so I decided to ignore the "come in early rule" and arrive promptly on-time. I insisted on keeping all of the papers I filled out last month so I could use them again. The receptionist handed me new ones, so I gave her the ones that I had completed already. Confused, she accepted them as long as I would sign and re-date them. Nothing had changed, other than the fact I was a month older.

I had been ordering them for my patients for years, so when I had my first MRI about 15 years ago, I did not think it was going to be a big deal. I was wrong. If the smaller MRI chamber was any smaller, I would have needed to be naked and covered in KY jelly in order to slip inside. As it was, my arms were jammed in my side and my nose an itch or so from the top. I felt like a cannon ball. I have never been a fan of tight, closed-in places and this was the worst. I handled it with a lot of mental distraction, but I will never order another MRI for one of my patients without first explaining it to them, and offering them an anti-anxiety medication.

My second MRI was in an open one. It wasn't like being in a tube at all. The "open MRI" that I was in today wasn't the same. This one was like a large vise. It was open on the sides, but my nose was still itches from the top of this flat, metal chamber. Having it open on the sides is not that helpful, since you are not permitted to move your head during the scan. So it was back to the mental distractions again. I did take a half dose of Xanax before I left home and I am sure that helped. At one point in the long scan sequence, I woke myself up with a snore. So it wasn't that bad. I slept through most of it, apparently.

I had an IV half way through the MRI to further enhance the image. Although I couldn't see, the technician commented that I was bleeding.

"Why are you bleeding so much? Are you taking aspirin or an anticoagulant? "No. I am pretty sure I am bleeding because you put a big hole in my vein and my blood tends to leak out."

I was pleased to be able to be sarcastic. It was building up inside.

I wanted to look at the films, but I will be a good patient and wait until the results are downloaded to my electronic medical records. The purpose of today's MRI with contrast was to see why my tinnitus has changed. Of course, they are looking for tumors. I don't suspect they will find an underlying reason; we rarely do, but we have to check anyway. Like most clinicians, I handle some of my own medical care, but I let other professionals work up my tinnitus. Tinnitus is as frustrating for the patients as it is for the clinicians trying to solve it. I become just another one of their patients - a little sarcastic at times, with a few outbursts of humor, occasionally inappropriate, but at least I am not a whiner.

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Using the Emergency Room for Non-Emergencies

2010-01-22T14:32:00.008-05:00

I was working in our after-hour clinic last night. Technically, we are the step before the emergency room, since most of our patients are classified as having "urgent" problems - things that need addressed now and cannot wait until morning. Emergency rooms are supposed to be used for serious and life-threatening problems, such as a heart attack, stroke, certain lacerations, serious head injuries, potential fractures, or injuries sustained motor vehicle accidents. Only two of the dozen patients that I saw last evening had urgent medical problems. Ten patients could have easily waited until the next day during normal office hours.

Why do people continue to use the ER for non-emergent problems? I have several theories:

1. Some people do not know if their problem is serious or not. If you are having chest pain or severe abdominal pain, you often think the worst. What if I am having a heart attack? Acute appendicitis? These can't wait for a next day appointment. Personally, I would much rather see a potential heart attack that turns out to be "just gas", than to know that they delayed treatment in order to research their symptoms on the Internet. When in doubt, use the ER. For potential life-threatening situations, call 9-1-1. Time and time again, I hear of patients trying to drive themselves to the ER in order to save the ambulance costs.

When people need advice, they often need it in a timely fashion. In defense of some people who show up with non-emergent problems, they did try and call and get advice. Either the doctor-on-call did not return to the call, or the ultra-conservative approach of advice nurses advised them to go to the ER.

Periodically, I have someone getting miffed because it takes me longer than expected to respond to their question on one of WebMD's message boards. As much as I try to explain that WebMD is not your doctor's answering service, or that health experts are not on-line 24/7, they are not pleased. I will still get an occasional message about someone thinking they are having a stroke. For Goodness sake people, if you think you have a life-threatening issue, get off of the Internet and go to the ER!

2. People do not have any alternative for care. Even knowing that their medical problem is not life-threatening, such as an itchy rash, many people will use the ER anyway. They should be going to a primary care medical office, but many people have not established themselves with one. They don't know where to go. When they need medical care for a current illness, even if it is not considered an emergent problem, they are unable to get an appointment. It is easy to get discouraged when the receptionist tells you that the doctor can see you for a sore throat in two months.

But I am still puzzled why someone would want to pay thousands of dollars for ER care, when they can go down the street, find a more-appropriate urgent care facility and pay less than a hundred dollars. Many "Doc in a Box" medical facilities are popping up in chain pharmacies and big box stores. In some communities, you can get your throat examined, eyes checked, teeth cleaned, tires rotated, and stock up on toilet paper and hot dogs all in the same visit. Of course, if your community does not have an after-hour or urgent care facility, you may be stuck with the ER, if you are medically unable (or unwilling) to wait until your doctor's office opens the next day.

3. Convenience. If you have nothing better to do for several hours and you have a non-emergent medical issue, using the ER is going to be an ordeal. ERs are fast, if you have a true emergency, but painfully slow when it is determined that you do not. ER nurses are trained to triage - treating the most critical cases first. Your itchy rash will not only be at the end of the list, it will most likely stay at the end of the list as other more critical and urgent cases arise.

Many people still feel that the ER is a "first come/ first served" facility. Many will even ask where they are on the list, like a number at the bakery. Although ERs are obligated to see anyone who comes through those big doors, they are under no obligation to hurry, or put the itchy rash in front of someone who has just been in a serious car accident. True, you can go to the ER at 3 AM and be seen, but it is far from convenient care.

4. Insurance Issues. Some insurance companies cover ER visits, but do not cover outpatient medical visits. Typically, ER use requires a higher co-payment ($75-$100), whereas a person may have to pay the full cost of a primary care visit (about the same). An ER visit for a simple, non-emergent problem can cost THOUSANDS of dollars - money that someone has to pay, either the insurance company or the patient. Some patients with non-emergent problems who go to the ER without prior insurance authorization have been faced with paying these bills. You need to read the fine print of your policies, especially if you have a penny-pinching HMO.

5. No insurance. There is a growing trend for the uninsured and undocumented (illegal) immigrants to use the ER. If they have no assets, the state will pick up the tab (assuming the state has any money). Billions of dollars are spent each year for care of undocumented aliens - one of the reasons for California's financial crisis, and often one of the reasons that bankrupt hospitals who are struggling to stay in the black. When hospitals charge $20 for a Tylenol tablet, or $32 for a "dressing" (just a band-aid) to the insured, this is often to offset the free care that must legally be provided.

6. Inexperienced Parents/Oblivious Adults. Adults, who routinely ignore their own potentially-serious chest pain, will call 911 for a minor cut, fever, or nosebleed. With sirens blazing, hook and ladder trucks along with a cadre of ambulances often show up at residences with panic parents running around aimlessly. Not to waste a paying visit, many ambulances will simply transport them to the ER. People who arrive by ambulances will be promptly examined and roomed - a fact that many frequent-flyer ER users seem to know. You may be roomed, but once it is determined that you do not have anything serious, you will lie around for quite some time before being examined, treated, and released.

7. Presumption of Expertise. Many people feel that ER doctors, like those on television, are the cream of the crop; the highest trained and most skilled of all clinicians. Don't' get me wrong, if I am in a major car accident, I want to be in the ER. Those trauma docs are amazing and save countless lives and limbs. However, ER docs are not Jacks (or Jills) of all Trades - they are not pediatricians, ENTs, or dermatologists. They do see a lot of pathology, but when it comes to basic, primary care issues, many miss the boat.

A child seen in the ER with ear pain is most likely going to be diagnosed with a "middle ear infection" and given amoxicillin. This is the classic "treat 'em and street 'em" approach. Many times (not always), the diagnosis is wrong and the dosage is sub-therapeutic. ER docs may not be up on the current treatments recommendations for kids, so they will dose a child like we did in the 1980s. They may diagnose a middle ear infection without even seeing the eardrum! When I end up seeing a child the next morning and find their ears completely occluded with wax, there is no way under the sun that this child was properly examined (or even treated).

When a child with ear pain does NOT have a classic ear infection, it requires a more thorough and time-consuming medical evaluation. Sadly, it is easier for some overworked ER clinicians to just shoot from the hip, hand the patient a prescription for an antibiotic, and send them on their way - quick, easy, and harmless. But is it? Putting a child on an antibiotic without a clearly established diagnosis is never good medicine.

I testified as an expert witness on a malpractice case in Chicago a few years ago where a child was diagnosed as having an "ear infection". He ended up being admitted just a few hours later with meningitis and nearly died. This child is now seriously brain-damaged. The hospital is a few million dollars poorer, but money for lifelong care doesn't bring back this child to normal... ever.

8. Patients are advised to go to the ER. Call your doctor's office about an hour before they are ready to close, perhaps on a Friday, and try and get an appointment for your sore throat. The receptionist, with little or no medical training in most cases, will send you to the ER. Call after hours and get the answering service, tell them of your problem, and the doctor will call you back (eventually) and tell you to go to the ER. Advice nurses hired by our own medical office for after-hour issues tend to err on the conservative side and send many people to the ER when they could have easily waited until the next day.

9. The Worried Well. All medical practices have a cadre of "frequent flyers" - worried patients with good insurance who have a lot of time on their hands, are perhaps a bit of a hypochondriac, and use the ER frequently. A headache is a brain tumor until otherwise proven by an MRI - the ER is good place to get a quick MRI. Belly pain is not gas, but a ruptured aneurysm. Neck pain is meningitis, of course. All of the convincing on the phone by clinicians can not discourage them from heading to the ER. Knowing that even hypochondriacs get seriously ill sometime, many medical providers are quick to dump them on the ER.

10. Those that truly need emergency care. The last time that I used the ER was for a kidney stone. I diagnosed myself in the clinic and decided (bad decision, incidentally) to drive myself to the ER. I barely made it, stopping frequently to vomit, scream, etc. I was so out of it by the time I made it to the ER that I couldn't remember where to park or the location of the front door. In my pain-laden stupor, I walked through the ambulance entrance and loudly announced, "I have a kidney stone. Can someone please help me?" In a flash, I had an IV, pain medication, and a CT scan to confirm my self-diagnosis. Great care, I might add.

I then waited another three hours for my wife to finish her own patients and take me home. She has no problem making me wait, knowing that I was in good hands.

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Give Your Immune System a Chance

2010-01-12T10:00:00.003-05:00

Miracle antibiotics have only been around since the mid-1930s. Prior to that time, all cures were orchestrated by our immune systems. What didn't kill us, made us stronger. Yes, people died from infections that can be cured nowadays, but for the most part, people were immunologically strong.

Antibiotics are truly miracles, and they have saved countless lives since their inception, however, it has not been without a price. Umpteen thousands of shots of penicillin were given to soldiers in World War II to combat battlefield infections, or the recreational cases of gonorrhea. Penicillin will not touch gonorrhea now; the bacteria having built a strong resistance over time.

My introduction to antibiotics began in my youth. I can still remember the buttocks sting of a penicillin shot. It seemed that no matter what was wrong with us; Dr. Moats gave the same, painful shot.

WebMD's Ear, Nose, and Throat message board allows me to see a cross-section of how patients are being treated (mistreated), not just in the U.S., but across the world. Time and time again, people are diagnosed with a simple cold - a viral illness - but are given amoxicillin anyway. Antibiotics are clearly not indicated for viruses, yet they are shelled out like Halloween candy. Why? Some clinicians feel that patient demand them. Other doctors admit that they just give an antibiotic prescription to "shut 'em up". Yes, it is quicker and easier to hand out a prescription for a (worthless) antibiotic, than to take the time to explain to a person why it isn't needed. This blatant practice of dispensing unnecessary antibiotics is coming back to bite us in the butts...big time!

People hoard left-over antibiotics (there should NEVER be any left-over). They openly prescribe and give it to their friends and other family members. They keep expired antibiotics in their medicine cabinets. They buy antibiotics while vacationing in countries that do not control their distribution. They smuggle it back in the country, hidden in clever places, so they can self-prescribe. Medical care is really expensive, so why not be your own doctor and pharmacist?

When you give an antibiotic, like amoxicillin - clearly, the most popular - to a person with a viral infection, what do you think happens? They usually get better. The cure is falsely attributed to the amoxicillin and the medical provider gets credit for the miracle cure. It is rare that the patient realizes that they would have gotten better anyway. Viruses are self-limiting, lasting about a week. When a patient seeks care on day three and is given an antibiotic, they will be considerably better on day four, the typical time that viruses get better anyway.

So, what's the harm? Antibiotics are good. We have antibiotics in our foods, meats, and bath soaps. There are even counter tops and cutting boards that are “anti-bacterial". Traces of antibiotics are in our water, too. The harm is that unnecessary antibiotics circumvent our immune systems. If your immune system is not “challenged" from time to time, it becomes weaker and less-effective. When this happens, you must have external antibiotics; it may not be an option anymore.

In my medical youth, strep was either treated empirically (by characteristic examination findings) or by a culture. The culture took at least two days to get a result. By the time you were informed that you had strep and were treated, you had it for several days. Recurrent strep throat, common today, was not as common 30 or 40 years ago. Those few days waiting for the results gave the immune system sufficient time to build antibodies - antibodies that would fight the next infection. And, because your blood was rich in antibodies against strep, those next infections were few and far between.

Enter the Rapid Strep Test. First, it took a few hours to find out; now, the “yeah or nay" results take only minutes. A person wakes up with a sore throat, finds out they have strep an hour or so later, and is promptly treated. Good medicine? Perhaps not. In our efforts to make fast-treatment medicine like fast-food restaurants, we have circumvented the remarkable human immune system. It didn't really have to work at all. A month later, we get strep again...and again over the next year or so. Our tonsils, an important part of our immune response enlarged in response to this invader. Enter the ENT who takes them out.

Should we return to the pre-antibiotic era again? I hope not, but now is the time to find a happy medium. We cannot, and should not dispense antibiotics just because someone wants them, someone is afraid they may get sicker, or just to shut up a demanding patient. This seemingly innocent act of handing out an unnecessary antibiotic prescription is really the root of our problem.

Studies have shown, over and over again, that the vast majority of middle ear infections will resolve spontaneously in a few days, whether you take antibiotics or not. So, why use them at all? Infants often need them, since their immune systems are often not adequate. The “frequent-flyers" - kids that have had dozens of prescriptions for past ear infections - often need them because their immune systems are not strong. Kids in day-care often need them because they are exposed to pathogens that may be stronger and more resistant, from kids that are “frequent-flyers". The monster may be already out of the closet. Early antibiotics are usually needed in people with weakened immune systems from diabetes, asthma, or cancer. I am talking about everyone else.

In most cases, we need to count to three...or even, four (days) before taking antibiotics. And, we should never take antibiotics as a preventative. We need to take antibiotics ONLY when a susceptible BACTERIAL infection is present. I often read in postings that people were given antibiotics “just in case" - to keep them from getting sicker. Where did these medical yahoos get their training?

All I am asking is to give your immune system a chance. Make it work for you. It's really okay to be sick for a few days just to jump start your immune response. It's okay to allow your body to have a fever; don't try and mask it with acetaminophen or ibuprofen, unless you need it for pain or discomfort. Humans existed on this planet millions of years before the discovery of amoxicillin. The most powerful antibiotics exist within you, if you just give it a chance...a few days, at least. If things are going downhill and you are not getting better, then and only then, consider medical intervention.

Medical care IS expensive. Millions of people do not have insurance. I have always been a proponent of self-care, but self-care does not mean self medicating with old antibiotics or someone else's antibiotics. Perhaps the best thing that you can do to prevent getting sick is to not interfere with your body's immune response. Trust those millions of years of evolution. Trust that you can get access to care if and when you need it in most cases; there is no rush. Each time that we become ill is really not a failure of our immune response, but an opportunity to get stronger.

The same people that have unsubstantiated fears of vaccines - perhaps the most natural way of preventing serious illnesses - will not bat an eye about taking handfuls of potent antibiotics. Why is that?

When you are ill, stay home. Don't expose others and don't be a martyr by going to work sick. Feeling crappy is your body's way of saying, “Stay down!" Listen to it. The world will not come to an end simply because you miss a deadline due to illness. If you were in a serious car accident, you couldn't go to work, so stay home when you are ill.

Schools freak out when a kid misses a day. Missed days mean money - usually federal or state funds dependent on days of instruction per child. Schools want those doctor notes in order to be paid. Of course, children are often unnecessarily taken to the doctor just to get those precious notes. If sick kids stay home until they are well and no longer contagious, they will not spread germs to others, resulting in a domino effect of more sick kids and work-missing, sick parents. Parents have totally lost the right to make a decision to keep their sick kids home. To make matters worse, parents have been known to lose their jobs because they stayed home sick, or stayed home to care for ill children.

Congress and the Administration are debating health care reform, but we have a lot of reforming to do at the primary care level...and at home. It's okay to fix a broken system, but first we have to find where things are broken.

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Do You Know ALL of Those Eels?

2010-01-11T11:51:00.010-05:00

One of my favorite places in the world is New Zealand. It has been over a decade since our last trip and I have longed to return. I must be a Kiwi at heart. If all goes well, my wife and I would like to go again in 2011, this time with my brother and sister-in-law. It is not too late to start planning the trip, especially if I am going to burn off some of my frequent flyer miles. It never fails, every time that we plan a trip out of the country, something happens. This time, it is the underwear bomber. The last time that we went, it was a international manhunt for the first World Trade Center bombing. To make matters worse, the Pope was in Australia.

Flying is stressful enough without having to worry about terrorists. I am going to need to heavily sedate my wife - a serious white-knuckle traveler. We are not going for a year, but she is fretting about it already. If New Zealand wasn't an island, she would make me drive.

I wonder if New Zealand has changed. Ten years ago, it was idyllic; not unlike America in the 1950's. Prices were reasonable, people unbelievably nice, and the scenery breath-taking. We traveled from the tip of the North Island in Russell to Queenstown in the South Island. I loved the food, especially farm-raised venison and lamb. It is said the New Zealand has more sheep than people.

We watched thousands of rowdy teenagers whoop it up on New Years, only to wake up the next day and help clean up the town. Order was kept by two polite policeman who made sure no one was drinking (everyone was drinking). My mouth dropped the following morning when I saw those same teenagers, now with hangovers, sweeping the streets and picking up broken glass.

After a week of traveling, we made it to Nelson, in the South Island, and planned on kayaking in famous Abel Tasman Park. The weather was not cooperative - a cold rain and wind, lots of wind. Wind is the big nemesis for kayakers, and I did not want to get blown out to sea. I picked up our Lonely Planet guide so see if we could find something else interesting to do.

I found it. About 30 km from where we were staying was a man that had "tamed eels." I thought this was bizarre enough to try and find this place.

There was a handmade, cardboard sign nailed to a telephone pole. We nearly missed it. All it said was "Eels" with an arrow pointing down a country lane. We drove about 4-5 km and only saw one, quiet farmhouse at the end. A dog barked at us. Neither one of us wanted to knock on the door, but I had driven this far, so I headed for the front porch.

After a few, nervous knocks, an elderly woman came to the door.

"Yes?"

"Ah, I am sort of looking for trained eels."

"That will be a dollar."

"My wife is in the car, too."

"That will be two dollars." I paid her. Leaving the door open, she turned and walked away.

Any minute, I was expecting her to see her come back, holding an eel. After about five minutes of waiting at the door, I asked again.

"Excuse me. Where are the eels?"

"Just a minute; my husband will take you." An elderly man, perhaps 80, was putting on one of the yellow rain slicker suits, complete with a vinyl yellow hat and pants. He had a big Coleman-type cooler. I assumed the eels must be in that cooler. Wrong.

"Come with me," he said, in a gravelly, strained voice - a voice of someone recovering from a stroke. His gait was slow and careful. He was carrying that cooler.

At this point, I thought maybe he was going to set those eels loose in the yard. I called for my wife to get out of the car, and bring the video. I had no idea what to expect.

He started walking slowly away, indicated that we should follow. He came to a swaying, suspension bridge - clearly handmade - and crossed it without hesitation. We, of course, hesitated. It was high and traversed a large river. The next three suspension bridges that we crossed were even more hairy. He just kept walking, holding on to that cooler. He started to briefly interview us.

"Are either one of your German?"

"No. Why do you ask?"

"Eels don't like Germans."

I didn't really ask why, but he implied that his eels are very intuitive and can sense the presence of Germans. Germans eat eels, and apparently they are not happy about this.

I guess we walked a few miles in the dribbling rain, crossing all of those bridges, each named for one of his kids.

"How much further?"

"We are almost there." I was still curious about the contents of his cooler.

New Zealand Longfin Eel
Photo: Gusmonkeyboy

As we crossed the last suspension bridge, we headed down to a stream area. I carefully walked the muddy path after him and was immediately shocked by what I was seeing. There were HUNDREDS of eels in this clear stream. Although they apparently have poor vision (part of our traveling lecture), they seemed to know we were coming.

I expected eels about six to nine inches long; the diameter of a snake. These were not the eels you see swimming around in aquariums. These were eels with a capital "E". They were at least three FEET long having the girth of a python! They were not only swimming to the bank of the stream, they were coming out! Several dozen were slithering up a wooden ramp.

Our tour guide told us that he has been feeding and caring for these eels since he was a little boy of seven or eight, when he found them. I am guessing that this was at least seventy years. He opened the cooler. It was filled with big chunks of meat. We paid two dollars (NZ) for this experience. He must have had ten dollars worth of meat in that cooler.

He impaled a piece of meat on a stick and held it out to the crowd that was gathering on the wooden ramp. The jumped up, snapping at the meat, showing their sharp, needle-like teeth. The eel lecture continued...

"This eel is about 40 years old. This one is a little younger. The one with the scar on her head is only about 25 years old. They are all girls. They go to the sea when it is time to breed. The boys wait for them."

Of course, all of these two hundred or so eels looked the same to us. It was like pointing out one particular fish in a school of them.

My wife was now feeding meat to the eels using his stick. She had scrambled out on a flat rock for a better view. There were eels all around her. Secretly, I was hoping she would fall in so I could get a great video of her madly running across the surface of the water.

Then, my wife asked the question of the day.

"Do you know all of these eels?"

He carefully scanned the slithering, black herd of eels, hesitating as he pondered his response.

"No. I don't know that one. Never seen her before."

Our lives are truly enriched by the interesting characters we encounter by chance. For me, it is often a cute little child, asking a probing question in my office. It could be the proprietor of a country store, or a barber with stories. We felt like were invited into this ordinary man's extraordinary life, if only for a brief moment.

I would be surprised if the ravages of time haven't taken him away, or perhaps, out to sea with this eels. He would be well over ninety now. I plan on trying to find the Eel Man again, but I am not optimistic. I would be thrilled, however, if one of his children or grandchildren took over this lucrative eels biz.

Next to getting a gallon of huge raspberries at an unattended, roadside "honor stand" (you just pay and leave the cash in a box, making change if you needed it), this was the best two dollars that I have ever spent - a million dollar experience for the price of a cold drink.

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Near Drowning Remembered

2010-01-06T19:38:00.008-05:00

The phone call came out of the blue. It was from an old college classmate - someone that I have not seen for over 30 years. Jim found my Blog and read every one of the posts and decided to give me a call. He and I had a special bond. Not only were we in the same small medical class, shared hospital call, and shared clinical rotations, we also shared a near-death experience back in early 1970's. This is longer than my usual blog post, so please bear with me. I promised Jim that I would write about it.

Tygart Valley River, Belington, WV
jeffschuler / CC BY 2.0

Jim received a rubber raft for Christmas and was biting at the bit to use it. Our little college town in West Virginia had a docile river running through it, under an old covered bridge. Although the Tygart Valley River was prone to flood once or twice a year, the spring run-off was just a trickle. After a long winter of snow, just seeing the sun come out was empowering. Jim called me and wanted me to float down the river with him from Belington to Philippi - an estimated 8-10 miles of lazy floating. It sounded great, so I was on board. Jim did a bit of research about this stretch of the river and was assured by a local that it was safe.

Our wives, both RNs, had worked the night shift so they were sleeping. We didn't tell them of our plans, thinking we would be back long before they woke up. We had another classmate give us a ride to Belington, a fifteen minute trip. He dropped as off at the river and off we went, floating down a calm stream on a warm, spring day. A stress-reducing trip, perhaps lasting three to four hours was expected.

We were wearing life jackets - those old-style, orange ones. I can't remember, but we may have been in shorts and t-shirts as well. We did not bring anything else - no food, matches, rope, etc. - just the raft, plastic paddles, and two naive guys.

An hour down the river, things were looking more promising. The current had picked up to the point where we felt we would be home in less than two hours. Distance is difficult to judge when a river is snaking through high, verdant hills. The scenery was pretty. There were still some pockets of snow in the shaded area. The river temperature was probably in the high 30's.

Tygart Valley River Falls
Jon Dawson / CC BY-ND 2.0

As we rounded a bend, the river became very fast. Off in the distance, we saw mist and heard the roar of cascading water. A waterfall! What the hell was a waterfall doing there? We started to madly paddle upstream to slow down our descent, but to no avail. In less than a minute, we plunged over a waterfall; backwards and probably still paddling like those morons you see on cartoons.

As soon as we hit the bottom of the waterfall, the raft flipped, dumping us into the ice-cold river. It was like being in a washing machine - when you tried to swim to the surface, you hit bottom. This happened over and over again to the point where we were terribly disoriented.

Jim was spit out first and had scrambled on to rock downstream. When I momentarily surfaced for a well-needed breath, I heard him shout. I couldn't see him, however. As if we didn't have enough trouble, Jim and I were both blind as bats. We both lost our thick, corrective lenses in the turbulent falls.

I decided to go with the flow and allow the river to take me downstream, perhaps to an area not churning like a demented blender. I hoped that the flow would take me toward Jim. He grabbed my wrist as I was whisking by and held on with a death grip. My weight, multiplied by the awesome force of that river, was more than he could handle. I slipped away and disappeared under the water. Although he didn't know it at the time, I was swept under the rock he was standing on.

Jim, thinking I would be popping up downstream, headed in that direction. Even with his diminished ability to see, I was nowhere to be seen. Minutes...yes, minutes, pasted with no sight of me anywhere. At this point, well-beyond the ability for people to hold their breath, he was convinced I had drowned. He headed back up to the higher rocks for a better view.

Meanwhile, under the rock and under the water, I quietly waited for death. I gave up struggling. The straps of my life preserver were hopelessly caught in driftwood. I was not even cold. It was becoming quieter. I started to think about the irony of this situation. I had two major fears of dying: one was drowning, and the other was being trapped in a tight cave. I was experiencing both. I had only been married a few months, so I had just taken out a life insurance policy. I had made only one policy payment. They say that your life flashes before your eyes moments before you die, but all I thought about was how pissed the insurance company would be paying out my death benefits so soon.

It became even quieter. The sounds of the river were muffled; barely audible. Then, I felt like I was floating. I guess I expected to see a bright light and my dead relatives pointing the way. My next conscious thought was feeling wind in my hair. For some reason, I raised my head and took in a breath. I was expecting a flood of water; something that I had fought desperately to avoid, knowing this would be the end. The air kept coming in...and in...and in. My head felt like it was only an inch thick - the worst headache that I have ever experienced, but the pain proved that I was alive!

The sound of me gasping for air caught the attention of Jim, still search the river for a floating body. I had popped up so near him, under the very rock that trapped me, that he reached down and grabbed my t-shirt. I was dead weight (but at least I wasn't dead!). He pulled me onto the rock. The severe lack of oxygen gave me no use of my arms or legs - they were contorted into tetany (involuntary contraction of muscles). My vision was blurry (mostly since my glasses were at the bottom of the river). Jim told me for the first time on the phone that I had the worst nystagmus (the rapid twitching of my eyes) he had ever seen. My chest felt like an elephant was sitting on it and I continued to cough water and suck in air.

It was nearly an hour (estimate) before I could stand or walk. I was terribly disoriented, which was made worse by my visual impairment. Every thing was a blur. Jim was anxious to head down river to see if we could find the raft. Personally, I had no interest in getting back in it, even if we found it.

We walked for hours on the south bank of the river as it meandered deeper into the canyon. There was a railroad track on the north bank, if we could only get over there. The idea of going back into that cold river to swim to the other side was madness. A few miles down river, we spotted a large pipe crossing ten or fifteen feet above the river. We started scooting across the pipe, but I couldn't do it. Not being able to see; still a bit disoriented from the lack of oxygen to my brain, I had the common sense not to tempt death again in the same day.

It was getting dark and colder. A few times, I had fallen into some crevices, when my just-as-blind guide failed to tell me to step over them. I hit a few trees, too. Soon, we realized that another tributary of this river was cascading down. We were on a peninsula - couldn't cross either river at this point. It was now completely dark.

We had no shelter, so we piled up as many fallen leaves (mostly wet) and crawled under them. We overcame our homophobia and spooned all night to stay warm, shivering in teeth-clattering synchrony. It was one very cold night, I can assure you. We were hungry and thirsty. Jim refused to drink any water, fearing hepatitis. I drank it, though. After what I had just been through, hepatitis did not concern me one bit.

Back home, Jim's wife had called my wife to tell him to get home. My wife said that she thought I was with Jim. It only took a few minutes and some investigation to realize that the raft was gone. The classmate that dropped us off in Belington confirmed that we were, indeed, on the river. The local authorities were called.

Along side of the Tygart Valley River
Jeff Turner / CC BY 2.0

My wife went to the men's dorm to get some help, screaming out for Hally, my best friend. Hally, hearing that there was a woman yelling his name, did not immediately emerge from the safety of his dorm room. Once he did, he was apprised of the situation and a search team was organized. They were going to search up the river, along the railroad tracks, from the covered bridge.

By the following morning, the entire college campus was aware that we were missing and presumed dead. Classes were canceled and busloads of volunteers joined the search. A helicopter was commandeered from one of the local coal mines and started an aerial search.

As soon as daylight came, we emerged from our wet leaf shelter and decided to turn around and walk back to Belington, something we should have done in the beginning. Walking along the river was treacherous. Not being able to see made it worse. We decided that we should climb out of the canyon and head south. We knew there was a road somewhere in that direction. It took hours of hand-over-hand climbing to emerge at the top of the mountain. Jim felt that he could see well enough to get a better idea of where we were, but all we could see was more mountains. While resting at the top of the bluff, we heard the helicopter.

The helicopter was flying low in the river, exactly where we had been sleeping a few hours ago. We waved and shouted, but they were a mile away and below us. They made several more passes up and down the river. If we had stayed, we would have been rescued. We decided to climb back down to the river. It took another hour or so. Then, we waited. We waited at least half a day, but the helicopter did not return. Not wanted to stay another night, we headed back up to the top of the mountain again. No sooner than we reached the top, the helicopter returned, making more low passes. It was getting dark (again), so we decided to keep heading south.

Someone found Jim's boat and pieces of a life preserver earlier in the day, several miles down river from the falls. The fire department was dragging the river below the falls. Hooking into something, they radioed that they had found at least one body. It turned out to be a deer carcass.

Tygart Valley River, Grafton, WV
Jeff Turner / CC BY 2.0

In a few miles, we came upon an isolated cabin. Jim was thinking "food". I was thinking about that movie, Deliverance. After all, this was West Virginia. She wouldn't let us in, but a nice woman gave us water and a peanut butter sandwich to eat on her porch. She did not have a phone or electricity. She directed us toward another house a few miles away that had a phone. I often jokingly stereotype mountain folk, but people in West Virginia tend to be the Salt of the Earth; just down home, God-fearin' good people. Sure, there is that occasional banjo-playing, sex-crazed, gun-toten', toothless hillbilly hiding behind a stump, so you can't be too careful.

As the last rays of daylight were fading, we made the call home. We were alive and needed a ride. We were both checked and released from the hospital and thanked all of the volunteers. I thanked Jim for saving my life, but secretly blamed him for getting me in this situation in the first place. Of course, it wasn't his fault - I joined this ill-fated, poorly-planned expedition voluntarily - just one of the many stupid things that I had done in my life so far.

Throughout our lives, we remember these close calls like it happened yesterday. I still kayak, but no white water. I prefer glass-smooth lakes or ocean bays - where I can see the shore and civilization. I always wear a good life preserver and have emergency supplies. I don't like to spend much time underwater, not even snorkeling. I still do not like tight places, like tunnels, caves, or crawl spaces. I don't like having an MRI.

It was wonderful to hear from Jim again. He doesn't white water raft anymore either, and guess what? We both have intractable tinnitus. I don't think it is related to this white water experience, just our age, but who really knows? I may have sustained more brain damage than I realized. Jim did say that I repeat myself occasionally in my blog.

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Birth Rate Rising Among Teenagers

2009-12-28T14:28:00.002-05:00

WebMD (12/21, Boyles) reported that, according to a paper in the Jan. issue of the journal Pediatrics, "for the second year in a row, the birth rate among teens increased in 2007." Specifically, "teen births increased 5% between 2005 and 2007, following a 34% drop between 1991 and 2005," researchers from the CDC's National Center for Health Statistics found. In fact, "in 2007 – the last year for which figures are available – the birth rate among teens rose by about 1%, with 42.5 babies born for every 1,000 teens aged 15 to 19."

Our practice has a high percentage of adolescents, and those adolescents have a relatively high incidence of sexually-transmitted conditions – pregnancy being one of them. In spite of aggressive sex education programs, the availability of confidential contraceptive services, and condoms available just about anywhere, you would think that an unplanned pregnancy would be rare. Sadly, it is not.

Preaching abstinence or providing knowledge of what to do to prevent pregnancy is not sufficient. A person has to apply that knowledge in a practical way and exercise that judgment. I asked a teenage boy if he agreed with the belief that the "average teenage boy thinks about sex a hundred times a day". He thought about if for a few moments, doing some mental math, and said, "Yes, that’s about right."

Condoms are 100% ineffective if left in the package, in a wallet, or on the shelf at the pharmacy. They are considerably more effective when consistently used on the penis. Perhaps the biggest excuse I have heard for not using condoms is that they did not have any. Apparently, the idea of not having sex apparently was not an option. A high school buddy, faced with the "no condom" situation, decided to use a plastic sandwich bag! Another excuse is that condoms decreases sensitivity for the man. My retort is that teenage boys, given a choice of no sex, or sex with a condom will always choose the sex. Personally, I think teen boys should wear TWO condoms all of the time. If sensitivity is an issue, they can remove one of them just before having sex. Obviously, the irony of this joking statement may not be truly appreciated when I counsel them.

The condom broke! This definitely does not happen as often as people claim. If they did break often, the companies would be out of business. As a demonstration, I once saw a person put a condom completely over this head. He then blew it up the size of a carnival balloon. It did not break. A claim of a broken condom usually means "no condom used". By claiming it broke somehow exonerates the user of personal responsibility.

Teenage girls presenting with irregular or painful periods is often a smoke screen to start oral contraceptives with a parental blessing. Teens do have painful periods at times, don’t get me wrong, but the ones who claim they have never been sexually involved in front of the parents, often fess up the truth in private. Knowing that they have had unprotected coitus justifies testing for sexually-transmitted diseases (STDs). A relatively large number will already have Chlamydia; a few with Gonorrhea; and some with both.

When a teenagers consider themselves capable of making an adult decision to have sex, then why can’t they take it one step further and inform their parents? Most parents, faced with a sexually-active teen, would do what they can to see that unwanted pregnancies and/or STDs do not happen. Parents are never happy when they discover that their teenagers are having sex, but they are rarely surprised.

Several years ago, my PA wife was examining a teenager in her family practice clinic for a watery discharge. Mom was in the waiting room. The examination quickly revealed the reason for the watery discharge – she was in labor, and that was amniotic fluid. Her water broke. An ambulance was called, and the surprised mother who did not know her teen was even sexually involved, was informed that she was going to be grandmother. I would have loved to have overheard the phone call to her Dad (aka Grandpa).

Of course, not all teen pregnancies go to term. Some teenagers elect to terminate them early with a therapeutic abortion, which can open up a lot of psychological issues. Some teenagers have the maturity to put their baby up for adoption to a two parent family. Teens that continue their pregnancies will need to grow up very fast. One of my patients sincerely felt that it was her parent’s responsibility to care for her new baby so she can go to school and still "hang out" with her friends. It is relatively unusual for the baby’s father to step up to the plate, and physically and financially care for the child. Pregnant teens can go to Continuation Schools to finish their high school education, with classes in parenting thrown in. These classes are absolutely essential. It is relatively easy to get pregnant. The years of parenting to follow will not always be smooth (A pregnant teen's own parents will attest to this).

Pregnant teenagers often elect to continue to the pregnancy and put the baby up for adoption. This may be the best option in many cases. Not only would this baby be placed with (usually) a two-person adoptive family who desires a baby, the teenager will be able to go back to their former life as a teenager, student, etc. This can be a win-win situation, but adoptions are not that simple. Teenagers often change their minds, much to the pain of the adoptive families. Biological fathers and even grandparents often complicate matters by challenging the details of an open adoption, requesting contact, visitation, etc. A friend of ours who adopted a baby from a teen mother was approached by her family asking for money – about twenty thousand dollars! This is illegal of course, so this demand for cash was disclosed to the judge. Mothers, whether they are teenagers or not, have a maternal bond that cannot be easily severed, so extensive counseling is required prior to these important decisions.

Some teen girls plan to get pregnant. They feel that having a baby will be fun ("They are soooo cute!"), just like babysitting. If they get pregnant, maybe their boyfriend will not go off to college and marry them instead. They will surely live happily ever after. Society does reward the irresponsible. Pregnant teens can petition to become emancipated minors and actually move out of their parent’s house. Welfare programs will provide them with basic necessities like free or subsidized housing, food, job-training, free medical care, and even transportation in some geographic areas. They way some teenagers view life; this is not such a bad deal. Recreational sex can develop into "procreational" sex.

Just like vaccinations, it is much easier to prevent a disease or condition, than to treat them. Millions and millions of dollars have been spent on sex education programs, from abstinence programs to contraception, yet teens continue to have unprotected sex and have unplanned pregnancies. Parents may continue to preach morality and abstinence, but may also provide condoms, or accompany their teens to clinics for other forms of contraception (just in case), and of course, pregnancy tests. Our kids' babysitter (age 15), a bible-carrying child from a Fundamentalist Christian sect became pregnant by their minister’s son on a church retreat. After her abortion, she ran away from home, married a sailor she hardly knew, got married, and had three more children, one right after another. Twenty years later, she is divorced and still cries about having that abortion.

Mistakes do happen and for some, the sexual debut may be unplanned. Teenage love and sexual feeling are painfully powerful; parents need to remember this. Teens are famous for "taking chances" – sexual roulette can be the name of the game. Date rape situations where alcohol and/or drugs are involved are all too common. I spent several years doing evidentiary medical examinations during these situations. Disproportionate dating ages where the girl is 15 and her boy (man) friend is 18 or older is a significant factor in sexual activity, yet many parents permit their younger teens to date men.

Parents always hope their teens are not sexually active, but often accurately suspect when their kids are having sex, but fail to be confrontational or proactive about dealing with it. I have had teen after teen swear to the All Mighty, that they are not having sex, only to admit it freely when given a confidential opportunity. Teenagers will lie with conviction when it benefits them. As a clinician, I struggle with supporting this naïve child, insuring her legal privacy, while at the same time, sympathizing with the parents who have to step in and pick up the emotional pieces of a life interrupted by bad decisions.

Gone to the Dogs

2009-12-23T05:21:00.000-05:00

For the last three months or more, our home and lives have literally gone to the dogs. Our female Sheltie had six puppies; we decided to keep two instead of just one. They are now nearly four months old, weigh a tad over 20 pounds, and have more energy than you can imagine. The mother dog is doing fine keeping them in check, but she is only two years old and a puppy herself.

My wife and I are both medical providers. In the past, we worked the same 12-hour shifts, but now we are working opposite shifts so someone is home with the puppies. Our property is not fenced, so it seems cruel to keep them in the house or on a covered, wooden deck for this long period of time, especially in the winter months were it is either bone-chilling cold or raining much of the time. I plan on making a large, fenced dog run, but I will need to wait until the snow melts now.

Our house is a disaster with dog toys all over the place, including toys that they have created, like my wife’s panty hose, my socks, shoes that we forgot to pick up, empty plastic water bottles, and shredded newspapers and magazines. They have lots of rawhide to chew on, but they prefer couches, rugs, or end tables. They love to jump up and eat the leaves off of the Ficus tree. For these reasons, we decided not to decorate for Christmas this year. It would be only a matter of minutes before they ate some of my wife’s precious, heirloom decorations made by our now-adult kids. My wife’s favorite ornament was made 27 years ago by our now- 31 year old son, Alex. It is a clothespin wrapped in a piece of paper. The head of the clothespin has a crop of Rastafarian-like black yarn. This is the baby Jesus, of course. She would not like this ornament devoured by the dogs.

There are finally housebroken, with only a rare accident. They are doing well in obedience school, but do have a mind of their own. For instance, they decided to chase the neighbor’s car down the road for nearly a mile! Shelties are opportunists – they like to chase things that are already running away (or driving away in this case) so they can take credit for a successful chase. They have learned to sit and lie down on command, and we are working on “stay”. We were also taught a command called “leave it” – a cease and desist command used to stop them eating something they are not supposed to eat, or to not chase cars or the UPS driver.

Shelties are herding dogs that love to run (and bark). We found a dog park in our community and have started to take them there once or twice a week. First, we want them to get used to the car ride (they are doing great; the mother dog is still freaked out thinking she is going to the vet or groomer). And second, we want them to be more socialized to other dogs and other people.

My brother in Maryland has one of the puppies. He and his wife are absolutely in love with her. The puppy goes with him everywhere, including visiting our elderly mother in a nursing home. She has quickly become a member of the family.

This weekend, we were puppy-sitting for another of the litter. It took Emmy about five minutes to become part of the pack again. She enjoyed the dog park as well. As a matter of fact, a little girl came up and asked to pet them. After a few minutes, she said that one of those puppies looks like Zoe’s dog (it was).

I get a kick looking a people and their choice of dogs. Some people even start to look like their dogs (or vice versa). There were two gruff-looking men in a pickup truck bringing in a very dainty, well-groomed and pampered Pomeranian. I would have picked them as the Rottweiler or Pit Bull crowd. On the flip side, there was a petite woman with a huge, out-of-control German shepherd. Maybe they should switch dogs?

Harry Cheng /
CC BY-SA 2.0

I wondered if I look like a Sheltie, so I looked in the mirror. I think that I am more English sheepdog.

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Snowed In - The Donner Party Revisited

2009-12-22T06:11:00.000-05:00

Photo: Rod Moser

In the wake of our country's preparedness for the H1N1 pandemic, I recently had my own untimely challenge of my preparedness for an emergency.

We don't get snow very often in our area of Northern California, but when we do, it is a test of our local community's response, as well as my own responses at home. When I lived in Michigan for a few years, they may have considered our recent blizzard just flurries. People in snow country are well-prepared, both in equipment and responses. Right now, the East Coast of the U.S. is buried in a foot or two of snow. People in those areas have the snow shovels, ice scrapers, snowmobiles, and emergency equipment ready and waiting. Unfortunately, I was caught off-guard.

We live about 2700 feet, at the top of a mountain, about an hour from where the Donner Party was stranded in a Sierra blizzard over a century ago. The one mile long private road leading up to our home is unusually steep and narrow; primarily shaded from any sunshine by the surrounding terrain and large trees. Our power comes from overhead wires, not buried utilities. Our water source is from a well. Our source of heat is fuel oil and electric blower, and we do have a fireplace with a large supply of split wood. Hot water and cook stove is propane. We have a cell phone so I called in to cancel my patients at the clinic. I was not the first to call off due to the weather. One of our vehicles is a four-wheel drive truck. I even have a big tractor with a front loader and backhoe. We have enough food to last quite a while, including egg-laying chickens. Deer, rabbits, squirrels, and turkeys come by nearly every day, a backup supply of meat when the big Earthquake happens. In comparison, we were definitely better off than most people with our multiple sources of "energy" and equipment.

Several years ago, I was given a huge Honda generator, once owned by a dear friend who thought the grid would go down at the turn of the millennium. He was VERY prepared - generator, six months of stored food, gun, and ammunition. He even had a boat at his dock in case Water World suddenly happened or the polar icecaps melted. He never got to use his generator, shoot his guns at mutants trying to get in his house, or eat his freeze dried stash of food. I guess that is good, but he always seems a bit disappointed that Armageddon didn't happen as he and others had predicted. He passed away a few years ago, and this beautiful, unused generator was sitting idle in his son-in-law's garage. Seeing my coveting eyes one day, they just gave it to me. I was ecstatic.

Electricity is essential. Electricity powers the well pump and pressure tank so we can flush the toilet. We have a wood stove and fuel oil furnace, but the blowers are powered by electricity, of course. We have candles and lanterns for light and a nice Scrabble game when the television is out. Internet in our rural area is a joke, even in the best of weather. When the satellite dish is filled with snow, or the trees are heavily laden with the white stuff, it is not likely we will get a signal.

This summer, I paid an electrician to put in a transfer switch, so when my power went out, I would be able to simply flip a switch, fire up this big generator, and invite the neighbors to our warm, well-lit house. Things never work out as we plan.

Photo: Rod Moser

We woke up with about 14 inches of snow and it was still falling. Our blacktop driveway was a sheet of ice, perhaps made worse by the fact that I failed to turn off the sprinklers. My citrus trees were covered in snow; limbs hanging down to the point of snapping off. The two cars were buried in snow. I put a tarp over the chicken yard to keep in dry in the rain, but the wet snow was causing it to sag. The chickens were inside, afraid to come out. They were chickens. In less than an hour, we had no power. My neighbor frequently tells the story about losing power for a week in a winter storm. No problem! I have a generator.

I trudged through the snow only to find that the battery was dead. Pulling a rope starter on this behemoth is like trying to start a tractor trailer with a flashlight. After a few hundred pulls and no-starts, I was exhausted. I forgot that I had drained the gasoline. I usually have about ten gallon of gasoline around for the mowers and such, but there was less than a gallon in the cans. I have two cars filled with gas, but did not know that newer cars have devices that prevent siphoning gas. I put the gas that I had in the generator, and pulled some more to no avail. I spent about an hour reading the manual that I had downloaded a year ago. Apparently, I was doing everything correctly, but since I had not serviced the generator, it probably had a clogged (or frozen) fuel line, clogged fuel filter, or something. I am not a mechanic and I was getting darn tired of pulling that rope. I needed a battery.

I have a spare 12 volt battery in the garage for a trolling motor, but that last time I used it was two years ago. The chance that it had enough juice to fire up the generator was slim, but I had to give it a try. The battery sparked, so I hooked it up and Eureka! It kicked on, I flipped the switch. Let there be light! With less than a gallon of gasoline in that generator, I estimated that my enthusiasm would fade in about an hour.

I had to get gas...somewhere, so that means I will need to venture out to a service station. Service stations run on electricity and power was out everywhere. I thought about walking out, but after falling on my butt several times on the black ice, I decided that this wasn't going to happen.

Summer fires are a seasonal threat in our area, so I had scoped out an escape route in the event that a wild fire was blocking our only legitimate exit. My escape route involved going through my elderly neighbor's yard, down his long driveway, to another road. This is quite easy...in the summer; not so simple when the area is buried in snow. These are all private roads, so no one will plow them. I discovered as I tried to plow my driveway that my tractor is much too light to get a grip on black ice, but it did move enough so that I was able to get my truck out from our down-sloping driveway. I put the truck in four-wheel low drive, threw the gas cans and a few shovels in the back, and headed out my fire escape route.

The snow was even deeper and the ice slicker on this leeward side of the mountain. My neighbor's unplowed driveway was steeper than I had remembered, complicated by the fact that I could not even locate the road. I aimed for the clearing between the trees and hoped this was the road. The two mile journey down the back of this hill took about an hour, but I made it to the plowed freeway. I located a busy gas station, filled the cans, and had an anxiety attack knowing that I would now by driving up the hill that I just went down. At least I will have my tracks to follow. After another hour of slipping, sliding, and sphincter-tightening spins, I eventually made it back home. I could hear the generator still running, and filled that near empty tank with good ol',over-priced, Middle East petrol.

For the next day, we celebrated the omnipresent chugging of the generator, sat by the wood stove, watched the news about the storm on television, and ate hot soup. If we had chestnuts, they would have been roasting on the open fire. We just had acorns, and they suck. We checked on our neighbors, but they were doing fine with candles and fireplaces. Our three dogs thought that we put the snow out there for their personal enjoyment and didn't want to come in It was a Snow Day. It would have been nice to be a child again, and sled ride down our black-iced hill, but of course, we would have hit a tree and been killed, only to be subsequently eaten by our snowbound neighbors.

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Sick Children During the Holidays

2009-12-21T06:06:00.002-05:00

No parent wants their children to be ill, but there is nothing like a big holiday to bring out the parental fear of illness. Germs really do not care if it is Christmas or Chanukah; or if you are traveling to see relatives, or having fun at Disneyland. When the bug strikes; the bug strikes. There really little that can be done to prevent most childhood, viral illnesses – the cause of the vast majority of infectious.

The week before Christmas in a primary care office is filled with the worried well. These are people that are not sick, but fear they will be sick tomorrow or the next day.

"We are leaving in the morning on a plane flight, and I want to make sure that he doesn’t get sick. The last time we flew, he got an ear infection."

First off, planes are not the cleanest places in the world. As a matter of fact, they were prominently listed as one of my Twelve Dirtiest Places. Why? There are just too many people, many of who are already ill or becoming ill. Additionally, planes are not sanitized between flights. Sure, someone picks up the trash and old newspapers, but NO ONE opens those tray tables and sanitizes them before new passengers come on board. Think of all of the dirty tissues that may have been sitting in a pile from the previous passenger. They may cursory clean the toilets, but as soon as the first person uses it, it is contaminated. The people sitting behind you and in front of you may be coughing and sneezing. People at your new destination are carrying viruses that you are not immune to, and what is the first thing they do? They hug and kiss you to make sure you are exposed. It is enough to make you sick just thinking about it.

People are always surprised that they or their children become ill 24 to 48 hours after a plane trip. I am never surprised. As a matter of fact, I tell them to expect to get ill. Illnesses are the price humans pay sometimes for going out of their immediate environment.

After age six, the immune systems of children are pretty tough, having been challenged in day-care, preschool, or kindergarten by exposure to infectious diseases. Parents only know the diseases the kids actually get, but not the ones they didn’t get. Every day, children are literally bombarded by pathogens, but most of the time, they are pathogens they have encountered before. In other words, they have developed immunity to their "herd" – the people in their families and classmates. When you travel, the kids are entering an alien world of new pathogens. They will be protected from some of them by their acquired immunity, but some new ones will make them ill.

Untimely illnesses are just that…untimely. A cold at any other time, other than holidays or while you are traveling, is much more acceptable and tolerated. No one wants to search out an Urgent Care facility in a different city on Christmas Eve, but sometimes, this is what you will need to do.

We don’t live in germ-controlled bubbles, nor should we. Exposure to viral illnesses is not unlike getting vaccinated. Each exposure… each illness… helps challenge and build our immune systems. Our past illnesses really make us stronger and more resilient to future viral attacks. We all share a planet filled with germs. We hang out with people who carry germs. Nearly everything we touch, breath, or eat has potential, disease-causing pathogens. Without our constantly improving immune systems, humans on this planet would be rare; very rare.

The next time that you or your kids get a cold, think of it as an immunological blessing – a free immunization.

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Medical Darwin Awards - 2009

2009-12-18T14:28:00.001-05:00

I have often heard that one out of four people are weird or bizarre. If you think of your three closest friends, and they seem "okay", then it must be you. I am not so sure. For over three decades, I have been in a primary care medical practice, either in family practice, urgent care, or pediatrics. Primary care often means "first encounter". It also means that the provider has a unique opportunity to see human behavior at it's weirdest. You will never know what is behind door number two.

Picking out the weirdest medical stories of the year was a challenging project, since many health stories are so bizarre, no one really is supposed to talk about them (health information privacy), but we do. These stories were extracted from various news agencies. The first three are dedicated to senior citizens; the last two are from my own practice.

When you gotta go, ya gotta go

Veteran marathoner Jerry Johncock, 81, was four-fifths through the Twin Cities Marathon in October when he was overtaken by a medical problem common to men of his age: urinary blockage. As he stopped to discuss his plight with officials, noting that he would have to quit the race to get to a hospital before his bladder burst, a spectator overheard the conversation and offered him the use of a "spare" catheter he had in his car. Johncock repaired to a rest room, administered the catheter, and returned to finish the race. [St. Paul Pioneer Press, 10-7-09]

Jerry is one tough cookie: Running a marathon at 81, and tough enough to catherize himself through that swollen prostate. Over the years, I have seen patients peeing in the sink or the waste can. I have had patients pull little dogs out of big purses and allow them to pee on a stack of paper exam gowns on the exam room floor. Working in pediatrics, you quickly learn the kids pee anywhere and anytime, including when you are examining them. I have always wondered about distance runners or long bike races. How do they pee? The secret was recently revealed to me by a colleague's husband who is a professional bike racer. If the gotta go, they just whip it out to the side and let if fly. Usually a sympathetic team mate will steady the bike and block the view, hoping to have the favor returned at some point. So, now you know why aerial cameras suddenly pan out when watching a group of bikes riding suspiciously close together. It adds a whole new meaning to the term "whizzing by".

Oxygen Tank Bandit Strikes Again

(Nov. 3) -- An oxygen mask not only helps you breathe, it's a pretty good disguise, at least for one bank robber.The FBI is looking for a 60- to 70-year-old man who has robbed at least four banks in Southern California, in and around Rancho Sante Fe. In each heist, surveillance cameras show him carrying what authorities believe is a small oxygen tank with plastic tubing that runs up to the suspect's nose.

It was bound to happen. Millions of elderly people are living off of Social Security in a time of inflation; dealing with the rising cost of food, medical care, and pharmaceuticals; their meager savings eaten up by financial institutions. It was only a matter of time before the elderly start robbing banks. It's enough to take your breath away - To Air is Human.

Somali man, 112, Marries 17-year-old

(Oct. 29) - A Somali man who claims to be 112 years old has married for the sixth time, and he hopes to have children with his 17-year-old bride.

Hundreds of people attended the wedding this week in the town of Guriceel in central Somalia, according to reports Thursday by the BBC as well as in The Daily Telegraph and The Guardian newspapers.

"Today God helped me realize my dream," groom Ahmed Muhamed Dore said, according to The Guardian.
The bride, Safia Abdulleh, did not comment, but her family said she was "happy with her new husband" -- even though he is nearly a century her senior.

BBC reporter Mohammed Olad Hassan, who is based in the Somali capital, Mogadishu, said Dore told him he was born in 1897 and he has a traditional birth certificate, written on a goat skin by his father.

Dore has 13 children by his five previous wives. His oldest son is 80. Three of his wives have died, but the remaining two consented to the new wedding, as did the bride's parents and the groom's children.

Altogether, Dore has 114 children and grandchildren.

But he said he hopes to have more children with his new wife, who is young enough to be his great-great-granddaughter.

Have any of those pirated vessels off the coast of Somalia lost a large shipment of Viagra?

What's it like to lay an egg?

I reported this in my All Ears Blog in January, and think about it often when I collect eggs from my chickens. He was about twelve years old; home-schooled and perhaps a bit bored, or at least experimental. He was seen in our clinic for constipation. It had been days since he had a BM; and by the time I saw him, it had been nearly a week. He was very uncomfortable, as you might imagine. During my examination to determine the extent of his stool impaction, I found a foreign body in his rectum. I couldn't quite identify it by touch, or by direct visualization using an anoscope, but it was plastic and smooth. He denied doing anything (of course), but states something may have entered the back door when he fell in the shower (Happens all of the time. Not!)

I couldn't remove it in the office; the ER and the gastroenterologist couldn't do under sedation, so it was off to the operating room, where both halves of a plastic Easter egg were removed along with several feet of his damaged colon. He did fine after his diversion colostomy.

The moral messages of this story: Curious kids will do anything, and lie about it. People can't and shouldn't lay eggs. Home-schooled kids need to be carefully monitored and kept busy.

Mystery Disease or Mental Disturbance - Morgellons

Posted on August 25, 2009 by Bizarre Medical News

I have seen a lot of bizarre human behavior in my career, but I have never seen this one. I have had some methamphetamine "tweakers" come in claiming they have bugs under their skin, and more than one patient, initially felt to be psychotic, with a live bug in their ear, but when it comes to Morgellons, I am still waiting to see it. Hold on! I think I see one. No, sorry….just belly button lint.

A patient presents with sores and itching all over their bodies. This can be dozens of medical conditions, but when they hand you a bunch of various color fibers that they claim came out of your skin, you turn and open the door…just in case. There are numerous cases reported in the literature, but to date, no one has found a logical medical explanation for this very odd condition. Theories range from worms and parasites, to plant fibers and even, alien abductions.

Unless I actually saw this happen, I would be at the top of the doubter's list; but for the bizarre factor, this has got to top my list.

Blogging - Updates from Blogs Past 2005

2009-12-17T06:49:00.002-05:00

I think I posted my 365^th Blog today. I was reading some of my old ones from 4 years ago and felt many needed updating. Four years is really not a long time in the scope of life, but life sure does change; often in the blink of an eye.

Four years ago, we were worried about the Bird Flu; now it’s the Swine Flu (H1N1). Many of the same issues four years ago are still with us, perhaps wrapped in a different package. New issues will arise. There are days when I can’t think of a topic to Blog about, and days when the ideas flood so fast, I have to write them down on a napkin as I drive.

Tuesday, November 29, 2005
The BIRD FLU....Media Hype or Real Threat?

The Avian (bird) Flu scare turned out to be just that…a scare. Yes, there were some deaths, but it was the fear of an uncontrolled pandemic that set the medical world on alert. At this time, it was felt that migratory birds would be carrying this deadly virus down their migratory routes, infected everyone in the United States. The Federal Government stockpiled huge quantities of Tamiflu should this occur. Recently those hoards of antiviral medications were released to combat a new threat – one that has nothing to do with birds this time. The H1N1 was originally felt to be a swine flu, but later discovered to be a unique (novel) virus. The good news (if there is ever good news) is that stored (and now expiring) doses of Tamiflu were available for this current pandemic. There are also rumors that cases of H1N1 have peaked, but not before over 50 million Americans got it; nearly one out of six people. There is nothing like a pandemic, or at least the threat of a pandemic, to get people’s attention.

Sunday, November 27, 2005
Why do kids put things in their ears (or other places)?

Things have not changed in this arena. Several times per week, I am digging out something in a child’s ear, nose, or other bodily orifice. With all of those retained beads, coins, pencil erasers, beans, peanuts, etc., nothing will every top this one:

A mother came in with an anxious child who claimed he put a "toy" in his nose. On inspecting his nostril with an otoscope (the instrument used to look in ears), I saw the bottom of two, tiny feet. It was relatively easy to grasp and remove this object – a tiny plastic baby. The shocked mother exclaimed that it was the Baby Jesus from her miniature Nativity set. Jesus was returned to the safety of the manager in time for the holiday. I took a few beads out this week, and a chunk of candy cane (must have felt interesting), but nothing quite as interesting as Jesus in the nose.

Friday, November 25, 2005
Rod Moser - just like a dog...

I still laugh when I think about this little child stroking my hairy arm and announcing that I am "just like a dog". We kept two of the Sheltie puppies from a recent litter, so my wife is always accusing me of putting them on our bed. One night, I felt her touching my leg in a near-sleep stupor, saying, "Get Down!"

Obviously, I am just like a dog. I would like to say that I work like a dog – full time in the clinic and WebMD – but, I am not sure where that expression originated. My dogs – three of them – do not really work, but they sure add to our daily chores. I guess their job is to just love us unconditionally.

Friday, November 18, 2005
Broken Glasses - Quite a trip...

In this Blog topic, I mentioned my broken glasses on a trip. I have learned my lesson, now. I travel with THREE pairs of glasses. Of course, my most recent glasses did break at the frame weld after only a few weeks. It took a month to get new frames and they came in with a different color! Tortoise shell! Great, now if I ever get to Miami, I will fit right in. I need to see, so for now, I wear them. I hope my bronze ones come in soon.

Monday, December 12, 2005
A Christmas Promise

I have had some incredible things happen in my lifetime, but nothing really compares to the time that I helped Santa deliver presents. If you want a "feel good" story for the holidays, take a few minutes from your busy life and read this old Blog posting. This really happened, and there is not a Christmas season that I don’t think about it.

Wednesday, December 14, 2005
Miracle Cures - Quackery

Quackery continues to be making a big comeback. Numerous television and radio ads, especially on cable or satellite stations, are still promoting male enhancement and baldness cures, to other memory enhancers and other miraculous nostrums. It is difficult to pick up a magazine anymore without seeing those ads. There are people selling miracle devices that increase gasoline mileage to a hundred miles per gallon. There were snake oil salesman in the 1800’s and their descendants are still trying to sell it. I have a personal collection of a few hundred of those quackery items, many that are on display at the Gold Country Medical Museum in Auburn, CA.

Friday, December 16, 2005
The BACK is the most important part of the body

The back may be the most important part of the body, but pain medication seems to be high on the important list, too. The other day, I saw an 18 year old in the clinic, complaining about back pain. He had missed a few days of class and work, and needed a note, and something to help him sleep. His examination was unremarkable, other than his obvious anxiety. He claims that codeine makes him sick, and ibuprofen and Naprosyn do not help. The only thing that really helps, so he claimed, was marijuana. He asked me for a prescription for medical marijuana. I turned down his request, of course. He understood and said that for $100, he can get a prescription from a doctor that comes to rock concerts.

Monday, December 26, 2005
Sleep, Snores and Studies

My wife insisted that I have a sleep study due to my (periodic) snoring and possible apnea. I tried to do the test, but the person having a sleep study in the next room snored soooooo loud, that I was unable to fall asleep. Of course, another reason was all of the wires glued to my face and head, the blood pressure cuff on my arm, the pulse oxygen clip on my finger, and a band around my chest to measure my respirations. For a person that has to remove his ring and watch at night in order to sleep, I found this contraption uncomfortable beyond description. Since that time, I have complained to my wife about HER snoring, something she denies. I presented her with some video evidence of her snoring, and she is off my case now.

Some Final Words…
I would like to thank all of you who read my Blogs and refer others to this site. WebMD had to twist my arm to be a Blogger, but once you get the Blog Bug, it’s difficult to stop. Your comments (even the bad ones) have been encouraging and thought-provoking – they have made me a better Blogger.

Have a wonderful New Years, and join me in my Fifth Year of Blogging; sharing random chapters from my professional and personal life.

Diamonds and Bedbugs

2009-12-15T06:34:00.001-05:00

It was a late night call from my daughter’s boyfriend. He needed to talk to me right away. It had to be something bad – an accident maybe? A parent always thinks the worst first. Then, it dawned on me. They were leaving for Hawaii in the morning, so maybe it wasn’t bad news.

I was called so that he could ask my permission to marry my daughter. This was one of the two caveats that my daughter established years ago, if they were to be married. The other was a big ring. Chuck had done both. He even emailed a photo of the ring to me to get my comments.

It was a beautiful sentiment and an even more beautiful ring. His biggest dilemma now was how he was going to present it. Would it be sitting on a beach at sunset? At a fancy restaurant, perhaps hidden in a bowl of poi, or at 35,000 feet over the Pacific on their flight over?

They had planned this trip last year, but Chuck’s job responsibilities required that it be canceled at the last minute. This year, they rented a house on the Big Island, a short walk to the beach. An anxious day later, I got a call from my daughter.

"Dad, I am getting married! My ring is beautiful. I wish that you could see it."

Of course, I informed her that I had seen the ring. She was so happy. We talked about all things they were going to do, from a helicopter tour of the volcano, to kayaking, snorkeling, and just driving around. The stage was perfect, but it was the romantic calm before the storm.

A few days later, I got another call; a medical one. My wife and I receive about two medical calls per week from at least one of our five (adult) kids. It could be about them, or one of our grandchildren, but we are really on-call 24/7.

"I have bites all over me and they itch like crazy!" I resisted the urge to say it was the Love Bug, but I knew that the tropics are filled with all types of biting creatures.

"Chuck stripped are bed and there are bedbugs! We saw them! I am totally freaked out, so I made him go out and buy an air mattress. We are sleeping on the floor of the living room now."

I imagined that she was madly scratching as we spoke. I advised her to go out and buy some hydrocortisone cream and some Benadryl. I knew that bedbugs were making a comeback in hotels and motels, but a house rented from a friend should have been a safe haven.

I couldn’t resist this next comment as we ended our conversation.

"Congratulations on your engagement. Have a wonderful vacation. Good night, and don’t let the bedbugs bite!"

"Nice, Dad."

The next morning, she sent me an email with several attached photos of her bites. The bugs really took a liking to her. I hope that my treatment suggestions were helping. I decided not to call and check up on her. I didn’t want to "bug" her.

ADDENDUM: Apparently, it wasn't bedbugs, but a contact (allergic) dermatitis to a laundry detergent. My daughter and I found out another genetic similarity - we are both allergic to Tide. I finally spoke with her yesterday, and she is improving.

White Coats - The Image of Healing

2009-12-14T13:40:00.000-05:00

I have been asked to speak at an upcoming White Coat Ceremony for a Physician Assistant master’s program in the San Francisco Bay Area. After a grueling 15 months of didactic training, these new health care professionals will be heading out for a year to their various clinical rotations clad in a new garb. The white coat has been a symbol of the medical profession for a long, long time – over a hundred years. The White Coat Ceremony is a time-honored rite of passage by new medical professionals who are now entitled to wear them.

Nursing students go through a capping ceremony, but nurses do not wear caps anymore, so they now have a pinning ceremony. Medical providers do not wear hats. Someone once told me that their heads were too big to wear them. Medical professionals (most of them) do wear White Coats.

The White Coat Ceremony is like a quasi-religious, priest-like ordination. The medical students are graduating from sitting behind a classroom desk or medical library computer to the clinical portion of their training, where they will be touching patients (in the medical sense, of course). Usually this ceremony will be held in a large auditorium, filled with proud parents, significant others, grandparents, and bored siblings hoping there will be refreshments afterwards.

Maybe the Hippocratic Oath will be read. Speeches will be made (I plan on a short one), about stuff like caring, or professionalism, or journeys, or new beginnings. This will be followed by a lot of handshaking, hugging, picture-taking, and back-slapping at the conclusion of this sacred ceremony. For the recipients of this new honor, the White Coat Ceremony is a very big deal. Students have spent umpteen hours studying, cramming for tests, practicing their examination skills, in preparation for the clinical year. I still wonder, however, if someone is going to have a shirt that says, "I pay $35,000 a year for my medical education, and all I got was this white coat."

Over 40 years ago, when I was just 18 years old kid, fresh out of high school, I donned my first White Coat. The white coat was part of a uniform that consisted of navy blue pants (from men), a light blue shirt, dark blue tie, black shoes, and get yes – navy blue socks (black socks were not permitted). Of course this was 1969, so it didn’t take long for us to protest. We started wearing some of the wildest-looking neckties ever, different color shirts, and of course, any color socks that we chose. We liked the white coat. Not only did it look cool (and professional), it had lots of pockets to put our stuff – stethoscope, otoscope, penlights, pens, notes, food, etc.

After graduation, I moved from the wilds of West Virginia to take a clinical job in San Francisco – an unbelievable cultural transition. A white coat was required for this position; the tie was optional, but since I had so many, I wore them anyway. I wore a white lab coat every day in my practice. It became so much of my daily life, that I once wore it to a grocery store. I forgot that I had it on. When someone asked me to slice them some lunch meat, I realized that medical professionals are not the only people who wear white coats or jackets – butchers wear them, too. The optician that fits me for glasses wears a white coat; so does my dentist. My veterinarian wears a white coat (sort of). The pharmacist at Safeway wears a white jacket. I once went to a mechanic who wore a white coat. He felt that his white coat gave him permission to overcharge me, not unlike the medical profession. My barber used to wear a white jacket, but now my barber is a woman with purple hair.

Five years later, I moved to a more rural area of Northern California. In this family practice, no one wore white coats, let alone ties. Some of the docs even wore sandals. I got me some Birkenstocks and joined them. I haven’t worn a white coat in my practice for nearly thirty years. I still have one, but it doesn’t fit anymore. This is sort of ironic since I have to talk about the importance of wearing white coats.

Just because those coats are white, does not imply that they are clean. They are certainly not germ-free. Medical professionals go from patient to patient, in the hospital or clinic, wearing the same white coat. Of course, there are also wearing the same necktie, dragging it across contaminated surfaces, and the same stethoscope. Hands are washed (usually) between patients, but this too, is an inconsistent practice. All of these things tend to attack the traditional white coat.

Many medical providers consider themselves to be a separate species from their patients. A number of critics believe white coats create a sense of entitlement to trust and respect that is unhealthy and in turn, may foster an elitism that promotes this myth. A white coat does not entitle the wearer to have white power. A medical provider has to earn respect; respect does not come with donning a white jacket.

Not all white coats are the same. The chief of the service walks into a patient room with his freshly-starched (sometimes) white coat flowing, with students following like little ducklings. The first things you may notice is that the higher ranked you are in the medical world, the longer your white coat. The full professors of medicine, the chief surgeon, all wear full-length coats. If some had their way, their coats would be so long that they would have a long white train, perhaps carried by a cadre of lowly interns. The medical students and residents may wear three-quarter length coats, or required to wear little white jackets (half coats). It was be sacrilegious to show up wearing a white coat longer than the head honcho. No one would wear those polyester dentist jackets that unbutton on the side like Ben Casey -- much too geeky.

Some doctors love their white coats. Many will have their names prominently embroidered on the pocket, along with their name tag and picture identification. This keeps other doctors (and medical students) from stealing their white coat. Most doctors have several white coats that end up in the hospital laundry at some point. There is always a fear that your coat will never return, or that it will return and someone else will snag it. When you see doctors walking around in poorly-fitting coats, sometimes with a different embroidered name peaking out underneath a plastic name tag, this is probably a stolen coat.

The white coat will mean different things to different people. Older patients, remembering the pomp and formality of medicine past, may view the wearer of a white coat as having power, absolute knowledge. They would not consider questioning this Ivory Tower authority. Others may view the wearer as someone who is an equal partner in managing their health care issues; caring more that the provider cares, rather than what he/she wears. Some may see a white coat as simply being standoffish. To a child, fear may be his or her immediate reaction to seeing a white coat.

It is really not the White Coat that matters, but rather the person INSIDE that white coat. Whether you are wearing it or not, your White Coat will always be there; perhaps invisible to others. Just the way a yarmulke is a tribute to God, or a military uniform reminds the soldier that they are serving their country. Like a wedding ring, or an academic hood, the White Coat has become an enduring symbol in our culture and special part of our history. I may not wear a white coat in my own practice anymore but I wholeheartedly support and respect those who chose to wear them.

SANTAitzed for Your Protection

2009-12-07T07:00:00.006-05:00

Matti Mattila / CC BY 2.0

I would hate to be one of Santa's helpers' this year, or even Santa for that matter. With the H1N1 flu still in a pandemic stage, and the seasonal flu anxiously waiting in the wings, being a department store Santa is more risky this year. Even Santa is going to have to practice some protective measures.

Most community outbreaks of influenza start in high-density areas, transmitted by humans who have lower hygiene standards. Yes, I am talking about our kids, especially those in day-care or elementary schools. Not only are children, with their lower immune systems, more vulnerable to catch influenza, they are the ones most likely to spread it to us innocent adults. Schools may have janitorial service but it would be highly unusual for the janitorial crew to routinely take the time for proper surface disinfection - sanitizing stair rails, water fountains, sinks, toilets, door knobs, desks, light switches - on a daily basis. It just doesn't happen. Any adult who has seen an elementary school bathroom knows what I am talking about.

Matti Mattila
/ CC BY 2.0

Anytime that you see long lines, it is either people in line for the flu vaccines or they are standing in line to see Santa. People often say that the flu vaccine gave them the flu. Biologically, this is not really possible, but you can catch influenza simply by standing in line. The line for Santa is filled with children of all ages - some coughing, some sneezing, some with snotty noses - and nearly all of them with contaminated hands. I would surmise that Santa's red outfit is about as contaminated as you can get - worse than doctor white coats or neckties. Santa's beard may be dripping with Strep or H1N1 for all I know. No one really wants to culture Santa or his attire. I would not surprise me to see some careful Mom spread out a protective tarp on Santa's lap, just like the ones used in shopping carts, before plopping down little Billy.

Most Santas are old men. Older men are statistically more likely to develop serious complications from influenza. Fat, old men are even more likely to have influenza complications; those who smoke are even higher. Santa's helpers would be well advised to be immunized. Most viruses, including the influenza viruses, have short incubation periods - less than a day in many cases. Day one on the job, Santa may be doing fine. Day two might be a different story. Not wanting to lose his job on the second day, mildly-ill Santa may show up for work anyway. Day three may find Sick Santa with his own festive snot clinging to his beard, sweaty and hot in his red garb. Day Four, Sicker Santa may be nauseous, or squirming between breaks, holding back those peristaltic waves of diarrhea. I suspect I will see an episode of Dirty Jobs with the host donning a Santa suit some day.

Matti Mattila
/ CC BY 2.0

What about the real Santa? Santa is certainly getting up there in years. He is relatively sedentary, working only a day a year. He has a diet high in carbohydrates and fats, and he drinks too much milk. Santa is morbidly obese. There is a very good chance that he is hypertensive, diabetic, has high cholesterol and heart disease. Santa probably has BPH (benign prostatic hypertrophy) which requires him to urinate often. Suspicious toilet flushes on Christmas Eve, or telltale yellow stains in the snow on the rooftop would be strong evidence of this.

Santa is often seen smoking his pipe, making him a prime candidate for lip cancer, throat cancer, and of course, emphysema or lung cancer. Santa is exposed to known carcinogens found in chimney soot, and of course, the coal that he puts into the stockings of naughty kids (including me, once.) And, to make matters worse, Santa is self-employed and may or may not have health insurance. The North Pole is not known for its readily available hospital facilities or emergency medical services. Santa - the beloved icon of Christmas - is a time bomb.

Fortunately, the real Santa has little face-to-face contact with children anymore, delegating those tasks to volunteer Santas in the field. He does open mail, and checks his lists (twice) for the naughty and nice. He really should make a sick and a well list, perhaps requiring a doctor's note before coming down the chimney. A child may be "nice" but very contagious; or naughty and relatively disease free. You don't know.

When you don that Santa suit, whether you are the real Santa or not, you have certain responsibilities and obligations, and you have job-related health risks. Hoping for a Safe and Sane Christmas season, I offer the following suggestions:

Suggestions for the Department Store Santa Helpers:

All Santas must be well-immunized and free of communicable disease. Doctor notes required.

Have a big roll of plastic wrap for the Moms to pull off and put on Santa's lap, changed between kids.

Have an elf or Mrs. Claus spray Lysol or some other disinfectant after each kid. Attach one of those "SANTAcized for Your Protection" papers like you see on motel toilets, back on Santa's lap.

Have two "immigration" stations before seeing Santa: One station should have public health nurses, checking immunization records, taking temperatures, and doing a screening exam for contagious illnesses. The next station should gown up the kids in hospital-quality paper gowns and masks.

Kids that are found to be ill cannot see Santa. They will be placed on the naughty list until well.

Santa should wear latex gloves, not permeable wool mittens. Latex-free gloves shall be available for those allergic to latex.

Fake Santa beards should be changed at each potty-break, and a fresh one attached. Naturally-bearded Santas will need to wash their frequently-kissed faces with a disinfecting solution. Frequent hand washing is a must.

Santa suits that are contaminated by kid vomit, snot, pee, drool, or stool must be immediately changed. The Department Store shall have decontamination showers available.

In lieu of candy canes as treats, carrot sticks should be offered. Carrots thrown back at Santa should not be washed and reused.

Sick Santas should immediately leave the throne and be replaced by a robot Santa.

Suggestions for the Real Santa:

Get serious about your health risks. You don't want a kid traumatized for life seeing Santa get CPR in his living room. Lose the pipe. Lose some weight. Lose the reclining chair. Be a role model.

Just because kids leave milk and cookies does not mean you have to eat them...eat ALL of them. Chuck 'em in the fireplace. No one will know. Spill the milk on the kitchen floor; the parents will blame the kids.

Consider using the door instead of the chimney. Not only is it bigger, it is also more SANTAtary.

It's okay to pee outside; privately in the bushes or behind the chimney. It is not okay to pee IN the chimney or on any Christmas lights.

Clean up after your reindeer.

Gifts for every kid all over the world in one night? In this economy? Think about cutting back this year, maybe only giving gifts to the kids that were REAL nice. It sends a message to those sort-of-nice kids.

Consider giving cash, like Obama.

If a house smells like Vick's, don't hang around. Vick's equals Sick's.

Put only wrapped (and sealed) gifts under the tree. Don't bring or deliver gifts of raw ground beef or pork (Meat-o-Grams, Pork of the Month Club)

Tamiflu makes an excellent stocking stuffer.

A Family in Transition

2009-11-30T09:28:00.002-05:00

Adam Baker
/ CC BY 2.0

She always makes us sign a guest book - a collection of names and statements from visitors to their home. As usual, she handed it to me. Before writing anything, I went to the first pages to see what others had written. Fifteen years ago, I commented about the wonderful Thanksgiving dinner that we just had, and how much we enjoyed the fun. We have had a lot of Thanksgivings together, so when we were invited to join their family again this year, we immediately accepted. We were also invited to have Thanksgiving dinner with some other friends and even our adult children, but we turned them down. Our two families have been close for over two decades. Fifteen years ago, our kids were just teenagers, and times were different. I read their off the wall comments in the guest book, too. You would think that English wasn't their first language.

While waiting for the turkey to finish cooking, we would gorge on lots of munchies. Sometimes, we would play games, like Pictionary or Charades. We shared stories and took pictures. There are over twenty years of pictures of us standing in front of their never-lit fireplace. Every year, every dinner, the predominant theme was laughter. Well, gluttony, actually, but with a lot of laughter, too.

Our friends have four adult children. One lives on the beach in Southern California and has adopted the gnarly, surfer-dude persona. Two live in houses or condos just a short drive away. One lives in the same room as she did when she was a teenager. She graduates from college next week, and hopes to live there for a while longer. Two of their four grandchildren were there for Thanksgiving.

This Thanksgiving was different. There was an undertone of sadness. This was a family in transition, for their patriarch has terminal brain cancer. No one really mentioned it, but I know we all thought it. This could be our last Thanksgiving with George. George is a highly-intelligent man, a university professor, anthropologist, world traveler, writer, and amateur chef. I saw him struggle to find the right words, or remember where certain utensils were kept. He was anxiously trying to cut the turkey, make gravy, and keep this dinner on-time. He had refused kitchen help, but he finally asked his older son to take over his traditional job of carving the turkey. As they stood, side by side, at the stove, carving this beautifully-prepared turkey, I felt a confusing wave of sadness and joy come over me. Knowing the adolescent struggles with the older son, it was heartening to see that he had truly become a fine man. He was handling this untimely transition with maturity and caring, spending as much time with his father as he can.

George's only daughter recently moved home. She is handling this transition entirely differently than her brothers. She is still very self-centered in her private life, text messages while she is pretending to listen to conversations. She left as soon as the dinner was over to visit her friends, and didn't offer to help prepare the meal or be involved in the clean-up. I know that she has a deep love for her father and family, but she seems to constantly avoid these family gatherings, not unlike the ostrich hiding its head in the sand. She must be struggling with her father's cancer, but trying not to think about it.

The youngest son, home from his (family subsidized) beach abode, cleaned the house all morning as his share of the dinner preparation, and jumped in to keep up with dishes. He is struggling to find his own career path and may be lost without his father's guidance. He proudly wears his father's necklace, recently given to him. Although he lives his own life, you can see that he still needs parenting. He is not finished growing up.

The second oldest son is married with two young children. Bryan had his own struggles growing up, but with his family's support, he is now a homeowner, gainfully employed, and enjoying his role as father. He had a good role model. His wife is Filipino, and a wonderful cook and mother. For the first year or so of their marriage, they lived in the family home. It was during this time and the formative years that followed, that Connor, age five, firmly bonded with George. Together, they planted a vegetable garden this year. Connor's woodpecker-like cackle and unbridled energy seemed to be the only laughter this year. Losing his grandfather is not going to be easy for him. He does not know he is ill. I lost my father when I was six, so my heart goes out to him. Philip is only ten months old. Sadly, he will not remember George, other than seeing photographs and videos.

Indy Kethdy / CC BY-SA 2.0

And, finally, there is us. We are not relatives, but we are, indeed, family. We have accepted that his cancer is terminal, and we are proud that he doing everything that he can to extend his life and maintain normalcy. We know that his functional days are sadly limited and that he is a man in transition. We know that this may be our last Thanksgiving together, but we are truly thankful that he is here for this one, surrounding by his supportive family, and still taking charge in the kitchen...and in his life.

George may have a brain tumor, but the tumor definitely does not have him.

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The Power of Acceptance

2009-11-23T11:15:00.011-05:00

Lida Rose / CC BY-ND 2.0

Not all things in medicine can be cured, or even adequately treated. There are definite limitations of medical science. While medicine has made leaps and bounds over the last few centuries in the on-going battle with microorganisms and disease, there are still conditions that just defy all the powers of science and technology.

If you happen to be the person who gets the bad news that there is "nothing more that can be done", this can be a tough pill to swallow. People leave the medical offices feeling frustrated, often angry. Many cannot believe that all diagnostic and treatment avenues have been explored. Many will seek "second opinions" - an important step that I encourage often. Two medical heads are always better than one in these more difficult cases. Not all doctors are the same, and two different people viewing the same test results, hearing the same medical history, or even examining the same person, can often come up with entirely different perspectives. Patients often see this as ambiguity. Many will tend to believe the second doctor, over the first. There is really no evidence that the second doctor will be correct, although I once heard that the "Early bird gets the worm, but it is the second mouse that gets the cheese."

I have a good friend that was diagnosed with brain cancer - The Big Kahuna, as he calls it. It is a stage IV glioblastoma; perhaps the worst of all brain cancers, and the one that recently took the life of Senator Ted Kennedy. Although he remains optimistic that his aggressive radiation and chemotherapy will extend his life beyond the dismal estimates, he is also an intelligent realist. He knows his changes of a cure are dismal. We all hope for miracles, but do not really expect them. Statistically, if statistics are really the answer, he may have another year. He accepts this. His acceptance of his fate has really brought him peace. Having a terminal brain cancer is like falling off a high cliff and going down real slow. At some point, you give up the idea that you can flap your arms real fast and land safely. You have little choice but to accept your fate.

I look at our brave soldiers coming back from Iraq or Afghanistan missing an arm or leg, or both, from a roadside bomb. An optimist would stay that a life was spared, but a realist would tend to focus on the missing parts. During their long rehabilitation, healing must take place in the mind and soul, as well as the body. Missing limbs will not come back, and it takes time to accept and appreciate the parts you do have left. Technology has given us artificial limbs - the best the Uncle Sam can buy - but, of course, they are never the same as the ones God gave you originally.

I saw a little ten year old in the clinic last night. She is a type I diabetic, wearing a high-tech insulin pump. It was a surprise to the family when she was diagnosed, but now it is second nature to adjust and regulate her insulin, monitor her blood sugars / ketones, and carefully watching her diet. Diabetes is currently incurable, but very, very treatable. The insulin pump cost the parents - out of pocket - about $4000, and looks like a iPod. Because she wears it all of the time, she also wore it to soccer practice. Her over-zealous coach, thinking she was listening to music, snatched it from her belt and threw it in the weeds. I would have loved to seen his face when ther mother informed him that he just threw a very expensive piece of essential medical equipment away. Fortunately, it did not break.

One of the more common complaints on the Ear, Nose, and Throat message board would have to be tinnitus - ringing in the ears. There can be hundreds of causes for tinnitus, and in many cases, it will resolved spontaneously. However, tinnitus can also be permanent. About nine years ago, while working on WebMD, I suddenly felt a wave of nausea, dizziness, and tinnitus. The vertigo went away in a few weeks, along with the nausea, but like many people, my tinnitus remained. I now hear a high-pitched whine 24/7. In the last few weeks, it has become louder, so I am off to see my own ENT. As a clinician, I know how difficult tinnitus is to treat, so I am not expecting a miracle, but it would be nice to know why I am experiencing this recent exacerbation. I think I have accepted the fact that my tinnitus will not just "go away" some day.

Smokers have to accept a lot of risks. At over six dollars a pack now, smokers have to accept that their habit is very expensive; perhaps not as expensive as a cocaine addiction, but a pack a day is going to eat into those dwindling profits. Smokers have to accept that they will most likely experience some significant health problems - cancer, emphysema, etc. Smoking is so risky in fact, that many smokers feel that putting on seat belts may be a moot point.

Humans have no choice but to accept their mortality. Like it or not, we will all eventually die. We may die of old age in our 100's, die prematurely of some unexpected disease, or be killed in an automobile accident. Many people who are deaf (not all of them) would like to be able to hear. People who have limited mobility, would love to be able to run and climb again. People who have diabetes and must check their blood sugars regularly and adjust their insulin, would rather not do this. To accept life, we have to accept that life is rarely perfect. At some point in our lifespan - no matter how long that ends up being - we will have to accept a some challenges; challenges caused by disease, aging, or accidents.

Once we accept that things may not always turn out the way we planned, or accept the fact that medical science has definite limitations and not all illness or life challenges can be cured, or effective treated, then we can be at peace. We will never know what is around the next corner until we get there. We can live a lifestyle as healthy as we can, but at some point, even healthy people will die.

Lee Jordan / CC BY-SA 2.0

I once read that "Good Health is the slowest form of dying." So true. It is much more comforting to accept life as it is, rather than what we wish it might be. We need to celebrate each day. We need to make the best out of the limited time that we have. We need to honor those that have died prematurely by doing those things that they did not have a chance to do. We need to hug more and complain less. We need to compliment people that do good things, and ignore those people who do not enhance our existence.

Life, even an imperfect one, is truly a gift.

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Iowa Cat Contracts H1N1 Influenza

2009-11-13T09:00:00.002-05:00

A Discussion of Zoonoses

First it was ringworm; now this. According to the Washington Post, a cat in Iowa (name withheld) is believed to be the first case of H1N1 in a domestic animal. It is thought that the cat caught it from a human, although it has not been labeled Human Flu by concerned veterinarians. The 13-year old cat, now recovered, did not comment. At the present time, people in Iowa should continue to feed and pet their cats.

Maybe it's Iowa? The 1918 Influenza Pandemic that killed millions worldwide actually started in Iowa, too. People in Iowa blamed Spain. Recommendations to evacuate the State of Iowa have not been issued. People should not panic.

The H1N1 flu has also been confirmed in two ferrets, which both died. It was not clear if the ferrets lived in, or recently visited Iowa. H1N1 has been found in turkeys. That's nice to hear with the upcoming holiday. My property is overrun by turkeys, so maybe I should consider thinning the population as a public health project?

I guess it is only fair -- pigs and/or birds are the primary reservoirs for influenza that transmits to humans. I sure hope that dogs aren't next. I am not sure I could live in a world where dogs can't kiss you or lick your hand. I sort of like cats, but they rarely are the "lick you in the face" species. I definitely would not be allowing a ferret near my face.

Animal to human transmission of disease is called zoonoses. Probably the most common zoonotic disease that I see in my clinic (other than ringworm - tinea corporis) would be giardia, an intestinal parasite that can live in water sources. Those water sources, like streams or rivers, are typically contaminated upstream by animals that poop in or near them. Of course, fish always poop in the water, but no one seems concerned about this obvious fact. Giardia causes annoying bouts of diarrhea and impressive, both in volume and smell, intestinal gas - two symptoms that would seem to be incompatible, let alone socially problematic. Kids, not known for their high levels of bathroom hygiene, can easily spread Giardia in day-care facilities and schools, and eventually to their parents. I coined my own team for kid-borne diseases called "Pedianosis".

There are hundreds of zoonotic diseases. Perhaps the most famous of zoonotic diseases would be AIDS. HIV infections were thought to be a mutation of a monkey or chimpanzee virus, contracted by humans in Africa that decided it would be a good idea to eat them, or more disturbingly, have carnal relationships with them (an unlikely rumor). One minute, you are having a little monkey tartar; and then you become unusually ill.

Lyme disease, contracted primary from deer ticks is becoming more common as growing populations of deer exist closer to humans. A different tick carries Rocky Mountain Spotted Fever. The son of a medical provider in our clinic came down with Lyme disease a few years ago, thought to be transmitted by a tick found on lizards! My home of course is also a lizard sanctuary. I tend to leave them alone, although the do periodically scare the crap out of me when they peak out from rocks. My initial fear is that his head represents a SNAKE! Wild turkeys apparently cannot catch or desired to eat lizards.

Fleas living on rats caused the Bubonic Plague that killed half the population of Europe in the Middle Ages. Cats have fleas, but fortunately not Bubonic Plague-carrying ones. Bats, skunks, and feral dogs can carry deadly rabies. Pet turtles (as well as eggs and poultry) can carry salmonella. E.coli can be found in meats, especially improperly cooked ground meats sold at certain, unnamed fast-food restaurants. Even snails (not escargot, one of my favorites) cause some serious diseases. Perhaps, the world's most dangerous creature, the one that causes most of the deaths worldwide is the lowly mosquito which carries malaria, yellow fever, and a few other killers.

A few minutes ago, I saw a young man who was bitten on the hand by a feral cat that was living in a car (convertible, if you should inquire) at the auto repair shop where he works. His well-meaning boss offered a cash bonus to anyone who successful caught the cat. The cat was not pleased when he was incarcerated in a plastic milk crate, so he decided he would bite the hand that caught him. It was an impressive infection. At least he didn't get H1N1.

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Never Use a Waterpic to Remove Earwax (And Don't Let Your Doctor Do It Either)

2009-11-10T08:01:00.003-05:00

There is an interesting posting on the Ear, Nose, and Throat message board from MollieMae01: Water Pick Injury:

boltron / CC BY-SA 2.0
"My 2 year old daughter was being checked for an ear infection (She is in good health and has never had any ear problems or infections before. We also had her ears tested a few months ago by a specialist and they were fine.) and the nurse used a water pick to clean the wax out for clear viewing. My usually quiet daughter screamed like we were torturing her and when the nurse removed the water pick from her ear canal a substantial amount of blood followed."

During the California Gold Rush, huge amounts of rocks and dirt were removed from ancient bedrock by a technique called hydraulic mining (Placer Mining). Water was fired at high pressure to loosen compacted earth. As a matter of fact, my neighbor has an old hydraulic nozzle sitting in his yard as a display. Until this method was outlawed, millions of dollars of gold was extracted. Of course, the sludge clogged streams and rivers, causing devastating floods; the land was marred forever.

Hydraulic mining is not unlike the ear lavage. To safely extract impacted ear wax, it must first be softened, and then it needs to be washed out with a GENTLE stream of warm water. The key point here is "gentle".

The Waterpic was hot in the 1970's. Designed as an adjunct to dental hygiene, the Waterpic proved to be an effective tool, especially helpful for those with braces. It didn't take long before people started finding other, non-dental uses. These were untested and unapproved uses not condoned or encouraged. We had one in our family practice that we used to irrigate wounds, and yes, irrigate ears that were impacted with wax. The most important lesson that we learned was adjusting the force of the pulsating stream. High settings had the potential of splash-backs. You really didn't want to have contaminated water splash back in your eyes or mouth! If the high setting was used for cleaning out the ears, it could easily rupture the eardrum. I must say, that on the low setting, it seemed to be an effective irrigation tool as long as you were careful. The problem with this unapproved use was cleaning the instruments. Medical offices, as you know, are not the cleanest places on Earth. The Waterpic was primarily plastic, and plastic cannot be adequately sterilized between patients. In a busy medical office, you never knew what it was used for previously. After a short while, the Waterpic was permanently abandoned as an ear or wound irrigator. It probably ended up at Goodwill.

Speaking of unintended uses, Q-tips are not promoted as a tool to remove earwax, but yet, they are used for exactly that purpose. Some people - and you know who you are - are literally addicted to Q-tipping their ears every day after every shower. Many will go through their entire lives thinking earwax is dirt, or implies that you are an unclean person, and must be removed. Earwax is one of the most beneficial substances made by the body. It protects the delicate lining of the ear canal and it is antibacterial (prevents skin infections). It should NOT be removed, unless of course, it is deeply impacted. And, in most cases, earwax is deeply impacted BECAUSE people are using Q-tips to pack it in, just like loading a Civil War cannon.

Welch-Allyn, a respected manufacturer of fine medical tools and instruments, re-invented an ear irrigator several years ago for clinic use. It, too, had a pulsating stream, powered by the water pressure from our faucets. The clever design even created a vacuum to catch the extruded chunks of wax. Always a fan of new gadgets, I got one. After using it a few times, I found it cumbersome and messy. My old method actually worked better. It is now sitting in a box somewhere in our clinic. The special faucet adapter is still attached, but I doubt I will use it again. I guess that some clinicians really like it.

The trick in cleaning out the ears is really related to visualization. Unless you can actually see what you are trying to clean out, it is not wise to blindly dig in an ear, let alone try and wash it out with a stream of water. The rubber bulb syringe that comes with commercially-available ear-cleaning kits can work, but the stream is really a bit too large. I always have this fear that someone will fail to read the instructions and jam the bulb syringe in the ear and squeeze. This, of course, would be an automatic eardrum rupture. Since this is the same (or similar) bulb that parents use to suck snot out of their baby's noses, they may think that can suck out earwax. You cannot. If you try and suck out earwax with a bulb syringe, you will simple suck out (and rupture) the eardrum.

Since you can't really look inside your own ear, you will need a trusted friend or partner with a home otoscope. If you start inviting people over to your home, asking them to look in your ear to see if you have a wax impaction, you are going to lose a lot of friends. The Japanese - a culture that seems to be obsessed with clean ears - does have a fiberoptic video device for those who really want to peek inside their ears. I have never seen or used this home model video otoscope, but I suspect the resolution is not that good. Besides, there is always going to be an odd spatial orientation that you will need to overcome. I would love to be able to have a good video otoscope unit in my office so I can show patients their ears, but good ones are really cost-prohibitive. So, the bottom line: If you are going to be cleaning out your own, or anyone's ears, you need to have an otoscope to look FIRST.

A painful, potentially-infected ear should never be washed out...by anyone. In a medical setting, we often have to remove cerumen (earwax) in order to adequately examine the eardrum, but we use a wire loop or cerumen spoon. This is NOT the same as Grandpa digging wax out of his ear with a bobby pin or paper clip. Medical providers learn how to do this, and they have the ability to actually see (with an otoscope) what they are doing. Anyone who blindly digs in their ears with homemade instruments is really a fool. It is only a matter of time before you rupture your eardrum. Q-tips are also Weapons of Ear Destruction, causing many of the unintentional ruptures that I see in the office.

If I do need to lavage an ear, I have several instruments that I use. There is the metal syringe that can be autoclaved, and of course, my homemade ear lavage unit made from a 20-50 ml syringe and a piece of IV tubing or intracath - items not available at the local Walmart. It is really not the tools, but the skill of the person using the tool. I am not bragging, but I have never met a wax impaction that I couldn't beat. It may take me a while, and I may consider blasting from time to time, but in the end, I do get it out. Unlike ENT offices, I do not have an ear vacuum device. I could sure use one though, if my medical group would see fit to cough up the capital expenditure funds. Since my homemade unit costs less than a buck, they are less inclined to order one.

Unlike the old days, I would never use a Waterpic to wash out an ear. If your doctor has one, just say "No thank you." If you see one at Goodwill, don't buy it. If you have one at home and are tempted to use it, I hope I have changed your mind.

If you know what you are doing, have the right equipment, and common sense, ears can be safely lavaged out at home. Sometimes, it is best to leave the job to a medical professional.

Da...da...da...da. Da...da...da...da. Wax Man!

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Teenagers Are Just Adults That Haven't Finished Cooking

2009-11-09T11:01:00.009-05:00

Last night was my granddaughter's 16th birthday party. As a gift, we have been working on a video tribute to her. My brother spent countless hours weaving a video tapestry of hundreds of her photographs into a beautiful, unbelievably-touching masterpiece. He used three songs; one for each segment: The Eyes of a Child, Please Remember, and She's a Butterfly.

There was not a dry (adult) eye in the crowd of 75 last night. The tears were flowing from gaggle of six grandparents - including two that flew in from Texas for the party, an impressive gathering of uncles/aunts, and the of course, her circle of friends. There was even a very proud great-grandfather in the crowd who became teary-eyed when photographs of Shelby and her now deceased great-grandmother, his late wife, faded onto the large, projected screen.

Shelby's Grammy Sandwich/Photo Credit: Rod Moser

Why did they cry? Memories. Nearly every adult in that room has known Shelby since her first breath. This birthday celebration was held just a few miles from the now-closed Mather Air Force Base where she was born - one of the last babies to be born before the hospital was decommissioned. Her father was in the Navy at the time, during the first Gulf War. Shelby's mother had just gotten out of the Navy. Shelby's great-grandfather, recently deceased, was a Navy officer in World War II. People remembered when she was born, and of course, those that are no longer with us.

Her father (my stepson) is not an overly emotional man, but when his daughter left her cadre of friends to come and hold his hand, it did not go unnoticed. Maybe this helped set off the sob-fest? Even the littlest kids liked it, although they seemed to laugh more at the random naked/bathtub pictures or pictures of Shelby missing two front teeth. The adults cried. Some tried to hide it; others openly wept. Kudos to my brother, the producer, and of course the countless hours he spent at his trusty, and occasionally temperamental, Mac.

Shelby's biological mother left the family when she was only five; her brother was barely two. She has had little or no contact with the children since her untimely departure for a different life. If she ever sees this video, she will cry, too - perhaps for those many years that she missed and will never get back. My stepson became both mother and father for many years before he remarried. Shelby now has a loving stepmother and a new little brother. It was this collective love that has sustained her through these often-painful years, and the reason why she is such a lovely, intelligent, and caring young woman today.

My medical practice has a large population of teenagers. To some people, this would be terrifying, but I really like teenagers. I like the ones that tell me they have been accepted to Stanford or USC on academic or sports scholarships. I even like the ones with pierced lips, spiked hair, ugly tattoos, and their butt-cracks exposed. Teenagers in every generation have expressed their independence a various ways - their clothes, their music, their rebellion against everything adult-like. However, time continues to change attitudes, mannerisms, and fashions. Slowly but surely, like it or not, teenagers evolve into the same adults they now disdain. Teenagers are just adults that haven't finished cooking yet.

Sixteen years seems like a dash. I was working in the Mather Emergency Room the day that Shelby was born. We were there when she went to Disneyland for the first time, learned to ride a horse, swim with a dolphin, and won a 4H ribbon for her rabbit. Sixteen years later, Shelby was sitting on the floor with me, helping with the birth of six new puppies. Sixteen years from now, I expect that I will have already paced around a waiting room (perhaps, more than once) waiting for the birth of a great-grandchild. Sixteen years after that, I may just be a memory in the lives of my children, grandchildren, and (hopefully), great-grandchildren. Maybe when she hears the song, Remember Me, she will do just that.

Don't just give a gift card or money in an envelope. A birthday is a celebration of a life in progress, but it is also a reminder that all of us are getting older. The only birthday gifts that really endure are memories - the precious memories that we help create, preserve, and cherish.

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Pet Friendly Hotels?

2009-10-30T07:10:00.006-04:00

It has been a while since I have traveled with my pets, since my adult dog, Lexi, hates the car. She shakes and trembles, lies on the floor of the back seat and then throws up. It may be anxiety, since her only car trips now are to the vet or to the groomer - both not high on her list of places to go.

"Herman" / Photo: Rod Moser

Two of my Shelties loved the car. One would actually chase cars while IN the car. We had a van at that time, so she would sit on the front seat until she saw a car, and would then run all the way to back barking at it as it passed. This was annoying. Herman, my late buddy, would try and come with me all of the time; even when I was going to work. As soon as I would open the door, he would jump in. He would lie on the front seat and lick my right hand which rested on the center console. His fearlessness around cars lead to his injury a few years later when his big, bushy tail got caught under my rear tire. He was not able to recover from his injuries after extensive surgery and had to be humanly euthanized. This was one of my saddest days.

About a week ago, I had to take a few days off to put, Cali, one of Lexi's six puppies on the plane to Maryland on Pet Airways. Since the flight left from Los Angeles, about a 7-8 hour drive, my brother and I had to leave the night before. Finding a pet-friendly hotel was a bit more challenging than we anticipated.

There are dozens of hotels near the Los Angeles airport, as you might imagine, but the surrounding communities are not the safest places to stay. We did find a hotel that allows pets near the airport but the reviews were not good; scary in fact. One reviewer referred to this hotel as worse than the Bates Motel. Another advised us to lock our car and doors at all times. We figured that this pet-friendly hotel may have also been crack-friendly and prostitute-friendly, so we canceled our reservation.

There are lots of Internet sites that list pet-friendly hotels, but pet-friendly does not necessarily imply that they are wallet-friendly. Some were terribly expensive, including one pet-friendly hotel that has a one hundred dollar, non-refundable pet deposit! That is $700 in dog money! The lowest pet fee was fifty dollars. Since we were only staying there for about nine hours, we felt those fees were ridiculous.

Photo: Larry & Jeanette Moser

We finally found hotel (one of the chains) located two hours from the airport that allowed pets and did not charge an extra fee. What would this one be like? It turned out that this hotel was one of the cleanest, nicest, reasonably-priced, safest places that I have every stayed - The Hampton Inn Santa Clarita. I think they deserve a plug for being pet (and human) friendly. There were many dogs there, including some scary-looking, but well-behaved pit pulls, but not one was barking or running amok. We did sign an agreement to pay for any pet damage, which of course, there wasn't any. I would stay at this place again, even if I didn't have a pet. They even had a hot breakfast in the mornings that was darn good. I blogged about The Dozen Dirty Places in the past, listing hotels high on this list. I can truly say that this hotel is an exception. If I did the list, I would put my living room or my home office on the list instead.

Photo: Larry & Jeanette Moser

Cali made it safely to Maryland after her thirty hour journey; a longer flight than we originally anticipated. My latest report from Maryland is that she is excelling in house-training and has already been fitted with her life preserver for the boat. It is good that she is house (boat) trained quickly or you could have a whole new meaning for the area on the boat called the Poop Deck.

Photo: Larry & Jeanette Moser

Unlike most of my other dogs, Cali is the one that does not seem to mind car trips. She has already visited my elderly mother (she will be 88 next month) in the nursing home and has made many local car outings without the least bit of car-sickness or anxiety. Out of the six puppies, it seems that my brother got the "good one", although I think all of them are wonderful.

When we go out of town, we hire a house/pet-sitter. In a few years, we would love to buy a tent camper and tour our own country, hitting the best of our National Parks. I would love to take the dogs; not that they would enjoy the trip, but so we wouldn't have to leave them. My brother and sister-in-law do many car (and boat trips) so having a travel-friendly pet is essential. I am glad they got one. Since we have accumulated a menagerie of sorts - three dogs, two cats, tropical fish, and 14 non-egg laying (so far) chickens, we will need that pet/house-sitter for a long time, I am sure. We fantasize with the idea of retiring pet-free, but neither one of us can imagine a life without having a dog (or three) to love and pet.

Photo: Larry & Jeanette Moser

Are You Right-Eared or Left-Eared?

2009-10-29T08:24:00.004-04:00

Dean Shareski / CC BY-SA 2.0

What happened to in-flight entertainment? On my recent flights, there were no movies, no headphones for music, and no magazines. I long for the day when flight attendants would cruise the cabin, handing out a variety of magazines. Now, we have to buy our own magazines (at airport prices) and books, bring our own food/snacks, and supply our own entertainment.

The guy across the row from me was happily watching a video and wearing those noise-canceling headphones, periodically chuckling. As soon as the movie was over, he had one of those new electronic books, and started to read a novel. This man was prepared. I bought a TIME magazine at the news stand, but read it all waiting for my flight to leave. This is equivalent to eating all of your popcorn before the movie starts. I started leafing through those in-flight magazines (Spirit) and found an interesting article that I would like to share.

Did you know that 72% of people prefer to listen with their right ear? It is not really due to the fact that you are right-handed either. The left side of the brain specializes in language processing and is neurologically wired to the right ear. Consequently, the right side of the brain that deals with emotional cues is wired to the left ear. Two Italian researchers found that requests spoken into the right ear generates more positive responses than those uttered into left ears.

I find this very interesting, since I am one of those right-eared people. If I hear something subtle outside, I will turn my right ear to the noise. I tend to keep my wife on the right side when she is talking, too. She sits to the right of me when I am driving, and on the right when we are at the movies. When she nags me, she is usually on my right, but now that I have this information, I may turn my left ear in her direction. Of course, I do have tinnitus which is primarily in my left ear, so I suspect my right ear has more acute hearing.

We don’t have any young children in the house anymore, just dogs and puppies. We do have grandchildren, however, so I am going to try and voice those requests to pick up their stuff, or take a shower, etc. in their right ears, hoping of course, for those positive responses. I am going out on a limb here because I don’t think teenagers really respond to either ear, but I am going to try it on our 16-year-old granddaughter.

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