All Ears

C. Everett Coop

2009-06-30T10:02:00.001-04:00

To honor (sort of) the former Surgeon General of the United States and fellow anti-smoking advocate, I have officially assigned his name my new construction project. Dr. Koop is very talented and well-spoken pediatric surgeon and has probably never had a real coop named after him. The "C" in this case stands for chicken. I have called my new chicken coop C. Everett Coop. I was going to call it Chicken Ranch II, but I think there is a Nevada brothel by that name.

http://www.flickr.com/photos/bigbold/ / CC BY 2.0

On my recent days off, I decided to construct a chicken coop and covered enclosure. Not only will I be able to get fresh eggs (eventually), I will have a ready source of manure for my floundering organic garden that was recently destroyed by an unseasonable hail storm. I also read a recent article in Newsweek or Time (I can't remember since I get both) about feeding chickens flax seed so they will lay eggs that are high in Omega 3 fatty acids! I am going to get some super-eggs.

My research indicates that a four chickens will lay about 20 eggs a week. Since it is just my wife and I, I decided that I needed fourteen chickens, to allow for some attrition. Doing the math, that would mean that I would get about 70 eggs a week; close to six dozen. This will be enough to supply the neighbors and feed our adult kids and grandkids.

We live on about three acres so finding a place for the coop away from the house was quite easy. It would be nice to have real free-range chickens, but their life expectancy would be relative short since we have an abundance of hawks, who love free-range chickens. We also have a wide variety of other chicken-eaters, like coyotes, raccoons, possums, bobcats, and one mangy-looking cougar that visited the neighborhood a few years ago. I am sure the coop will be attracting them. My pregnant Sheltie was very interested, too. She spent a great deal of time yesterday herding them around the chicken yard.

My first job in coop construction was to make the entire enclosure predator-proof. It is four feet off of the ground, well-ventilated, and built better than my house. It even has a Plexiglas skylight. The enclosure is made with welded aviary wire, buried deep on the bottom to discourage the diggers, and completely covered over the top for those circling birds of prey. I figure that I spent about $400 on construction costs; the equivalent of 200 or so dozen eggs.

On Father's Day, there was a Chicken Sale at the local feed supply – buy five chickens at 33% off and get the sixth chicken free. I spent about $25 on the chickens. You can't beat that deal. I bought 14 young chickens of four different types, all purported to be good egg-layers. It is going to be several months and a few hundred pounds of chicken feed before I see any eggs, but they have been doing quite well on the manure part.

As a child in rural Pennsylvania, my grandmother always had chickens. I would love to gather the eggs. In high school, I worked the summer and weekends at a game farm, raising bobwhite quail (about 10,000 of them!) and ring-necked pheasants. In the winter hunting season, it was my job to "salt" the corn fields of a paid hunting reserve so hunters could (attempt to) shoot them. I would dump about 24 quail in a heap and they would just sit there until the hunting dogs made them fly. As cruel as it sounds, most of the hunters were such bad shots that only about a thousand of them were killed by the end of the season. I know; I was the one that had to clean them. The rest of the quail and pheasants just flew away and apparently lived a long and happy life.

We had a quail hen house, so it was my job to collect these tiny eggs. We put them in a cool environment until I had a few hundred. I would then put them in the incubators and count the days. About half-way through the gestational period, I would candle the eggs to see if they had a chick or not. It didn't take long for hundreds of these little birds to be swarming around. From egg to mature bird only took a few months.

I am just assuming the most of my chickens are girls. You really can't tell when they are still young. I don't really plan on having a rooster in my hen house, so I am not going to have to deal with baby chicks. If I do get a rooster out of that group of chicks, at least he will be far enough away from the house that he will not wake me up early.

Because they are only about a month or so old, I have been keeping them inside the coop, but now that the weather is a blistering 102°, I have allowed them out in their covered enclosure. At first, they were reluctant to walk down their ramp, but now, they love it. I gave them some lettuce from the garden (it was too bitter to eat anyway) and they had a picnic. I watered down their shavings today to help cool the area. Chickens do not regulate body heat very well, so they are sensitive to both cold and heat, but particularly heat. The chickens will be used as layers. I certainly don't want them roasting just yet.

More Tidbits from the Medical Literature

2009-06-18T21:33:00.003-04:00

H1N1 Flu (Swine Flu) Now Upgraded to the Highest Pandemic Threat

For the first time in over 41 years, the World Health Authority has declared this new strain of swine influenza, a global pandemic. This disease has now spread to over 74 countries with over 30,000 (reported) cases with some deaths. Millions more are assumed to have been infected, however. In the normal (annual) seasonal flu epidemic, about 250 to 500 thousand people, mostly the very young and very old, will die worldwide. When I was six years old (1957), two million people died. The pandemic of 1968, when I was in high school, killed a million. This is actually small compared to the 1918 Flu Pandemic that killed 40-50 million. WHO warns that the flu pandemic has the potential of infecting up to two BILLION people worldwide.

Although there have been numerous conflicting opinions, one really knows how this will end. Will this first wave of the H1N1 virus mutant to a more lethal, virulent strain in the next 6-12 months? Health authorities are planning the worst-case scenario. Things may get bad – very bad. The first batch of swine flu vaccine is nearly ready, so expect the demand to be high.

In my own practice, flu fear has dwindled. No more frightened people showing up "flu-related". Fear may drive action, but complacency could be our worst enemy.

Government (finally) takes regulatory control over the tobacco industry

It always seemed strange to me that the government subsidized the tobacco industry, while simultaneously paying for much of the $100 billion in tobacco-related health costs. For as long as America grew tobacco, this industry has been running amok in my opinion, starting with the suppression of data on tobacco addiction and overall health hazards. This new bill will help the government regulate tobacco, as well as how it is advertised to new, younger customers.

I spent my entire childhood avoid secondary smoke exposure. Unfortunately, the exposure was cut in half for a few years after my father (age 39) died of lung cancer. My mother remarried a cigar smoker, and the blue cloud of smoke returned. As long as I can remember, I have been a vocal, anti-smoking zealot; to my family and, of course, to every patient that smokes. If I smell tobacco, see cigarettes in a purse or pocket, they will not leave my office without a stern lecture. That's the way I take control. As far as tobacco products are concerned: Gone would be Good. Read on about the new (unregulated) electronic cigarettes.

Hats Off to WebMD

The Internet has changed the way consumers share and find health information. Gone are the days when books, often outdated by the time they were published; and misinformed friends and relatives were the only sources of health information. A recent survey found that over 60% of adults go on-line for health information. The leading health information site is (and always will be) heavily-trusted WebMD. Although I have worked for WebMD for nearly a decade, I have yet to tap its seemingly-unlimited health resources. In a time where inaccurate, false, and misleading information floods the Internet, it is comforting to know that sites, like WebMD, are a button-push away.

Many people have lost their jobs (and health insurance) and are relying more on self-care skills now, using the Internet, especially WebMD, as a valuable, educational resource. WebMD is not there to replace your medical provider, but is certainly one of the best places to go for accurate health information.

Electronic Cigarettes – Who needs them?

Electronic Cigarettes are the rage in China and Japan. It looks like a cigarette. It lights up. It has nicotine to give the user this lift/buzz that they seek. It does not emit secondary smoke to annoy non-smokers. They are expensive, but then again, so are cigarettes. Manufactures claim they have all the advantages (what advantages????) of smoking without the hazardous, cancer-causing chemicals. Really? There are no well-controlled, scientific, or medical studies to back up those claims; just assumptions. What happens if children start using them? Nicotine is really not an innocent chemical. It speeds up the heart, increases blood pressure, and a dozen other things. Nicotine is addictive.

As a child, smoking parents were common. Cigarettes were relatively inexpensive; as little as 30 cents a pack. Doctors smoked. People in the movies smoked. Teachers smoked. Cool people smoked. All we had were candy cigarettes to hang off our lips and pretend to be cool, blowing pretend smoke in the air. Some kids thought candy cigarettes were so cool that as soon as they could, they started smoking real cigarettes.

Electronic cigarettes may not cause cancer, but who needs them? I guess we will soon have electronic cigars or pipes; maybe even some electronic donuts so we can eat them and not get fat.

I agree with the health experts on this one. Don’t buy them and don’t blindly trust the sellers claim that they are harmless.

Shots Hurt! How to Ease the Pain for Kids (and Parents)

2009-06-15T13:37:00.000-04:00

It breaks my heart to give injections to kids, but they are definitely necessary. Vaccinations save lives and sometimes we must give an injection of an antibiotic. Either way, shots (usually) hurt and kids know it. Before kids turn two, we are poking them with needles about twenty times.

Pain is always in the mind of the beholder. I have seen infants goo and smile as they were given multiple vaccinations in their thighs. I have seen big ‘ol high school football players beg and plead, trying to get out of a tetanus shot. Yesterday, a teenager fainted during a routine vaccination and hit her head on the floor. She had been hyperventilating in anticipation of the injection.

As a child, our small town doctor would make house calls. It seemed that no matter what you had, he would always seem to find a (painful) shot to give you, like penicillin. An injectible antibiotic that we often use is called Rocephin (Ceftriaxone sodium). This one can really hurt and sting, unless it is mixed with lidocaine, an anesthetic agent. Mixed with sterile water, this one will definitely get your attention. Often used to treat sexually-transmitted diseases, I have known ER docs that will use the sterile water mix so it WILL hurt, reminding the recipient to use safe sex practices next time.

In the 1950s, school and public health nurses would come to our classroom and give routine vaccinations. I can still see some of my classmates freaking out about them. Some would try and run away and others would cry. The crying would increase in intensity as soon as the alcohol swab was used. Some would just stand there, stoic and in shock, as the school nurse administered them.

The armed services are notorious for their group vaccination efforts. They line those frightened recruits up like cattle and use pressurized air injection guns to give multiple injections. Like the traditional needles, air injections can hurt just as bad; sometimes worse if they move. Air injection guns can tear the skin.

Some people like shots. Some of my Hispanic patients actually ask for shots, feeling that injections work faster and better than the same medication in pill form. An old osteopath that used to work in our group gave ALL of his patients, at every visit, a shot of vitamin B12. Of course, unless you had pernicious anemia, this shot was just a placebo, but his patients always seemed to feel better after their vitamin injection.

Insulin-dependent diabetics have to give themselves shots once or several times per day. At first, many are reluctant to do stick themselves, but after a short while, they are no longer bothered by doing this simple procedure.

Parents are now refusing vaccines more and more. Unfounded fears of autism and even fears of subjecting their kids to pain are common reasons. The pain of most injections is usually brief. The fear and anticipation of getting a shot is often worse than the shot itself. Our medical assistants give injections all day long. They are fast, efficient, and often over before the kids know it, but there are still some things that we can do to minimize the discomfort.

A Baker's Dozen Things That Can Be Done to Reduce Injection Pain

Attitude plays a big role. If the parent AND the medical provider are supportive and calm, the child will feel confident and will not nearly be as frightened.

What’s in a name? The word "shot" is really a scary word for kids under age 7 or so. Bad guys are "shot". I use the word "booster" when they need to get a vaccination, or sometimes I call them "power boosters" since the vaccinations help them get strong. Booster is a much nicer word.

Choices. Children tend to like choices. If a child is going to get one injection, I ask them if they "Would like a shot or a booster?" Then I ask if they would like ONE or TWO (they only need one). I can extend the choices to "Would you like a big needle, or the little, tiny needle that we use for babies?" Or, "Would you like it in your arm, leg, or EYE!" When given those choices, they will pick (a) one booster, (b) with the baby needle, and (c) in the arm or leg, NOT the eye.

Honesty. Will it hurt? I always answer honestly and say, "Sometimes. But, if it does, all you need to do is tell the nurse, and she will take it out right away!" Think about it.

Empathy. Tell them that you understand that they don’t want any shots but in order to go to school, you have to have it.

Distraction. Do what you can as a parent to distract them from any anticipated pain from the injections. Hold your baby or child snuggly; reassure them that you will be help. Babies who are breast fed while they are getting vaccinations tend to cry or react less, or you can nurse the baby afterwards to calm them down. When I have to inject a toe for a toenail removal on a teenager, it can be quite painful. I have noticed that the ones who bring their music on iPods have less pain response.

Order of Shots. Nurses need to give the least painful shot first. A new Canadian study found that when you must give the DTaP vaccine (diphtheria, tetanus, and pertussis) and the Prevnar (pneumococcal conjugate) vaccine at the same visit, giving the less-painful DTaP first is much easier on the kids.

Give a little sugar. Newborns boys getting circumcised require an anesthetic injection in the penis (ouch!). Several studies have shown that a sweet liquid (sugar water) placed in a nipple, that the babies are unusually calm. Under six months old, a pacifier can be dipped in a sweet liquid for a sweet distraction. A sugar-free lollipop, usually after the injection, is a good bribe for younger kids.

Numbing medicines. EMLA cream (lidocaine-prilocaine) or cooling sprays can be used to temporarily numb the skin for injections. These are particularly helpful for planned blood draws or when a child may need an intravenous injection. EMLA needs to be put on an HOUR before the injection, and of course, applied to the site where the injection will be made. The cooling sprays only last precious seconds, so the nurse needs to be fast – very fast.

Direct Pressure. A little plastic device called a Shot Blocker creates a bit of "neurological confusion" to those pain sensors on the skin. There are some tiny spikes on the back of the device that will block much of the pain of an injection. And, of course, rubbing a recently injected site can also help afterwards. I once saw an old nurse slap a teen's butt real hard before giving a gluteal injection. It worked, although he was a bit surprised.

Tylenol? Many parents will give a dose of Tylenol (acetaminophen) before coming in for routine vaccinations. Personally, if I were getting five shots, I don’t think that Tylenol would really help my pain, but many parents feel that it does.

Not all vaccines are "shots". The FluMist influenza vaccine is a good example of an effective vaccine that does not require a needle. It is expected that more and more vaccines will have non-injection alternatives in the future.

Use Combination vaccines. More vaccines in one syringe; one needle is really the goal. We now routinely use a five-in-one vaccine containing the DTaP, Hib, and polio vaccines. My dog and cat gets a seven-in-one vaccine, but of course, animals are not children. More combination vaccines are on the horizon, but they need to be well-tested before giving them to our children.

Until we have those painless, Star Trek-like "neck injections" that cure just about everything, medical providers will still need to needle around from time to time. We can help the kids, but for the rest of us, my advice is to just Grin and Bare It.

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Do I have breast cancer? Would you please check my earwax and smell my armpits?

2009-06-12T09:20:00.001-04:00

Medical discoveries are often made accidentally, like the bread mold that hallmarked the discovery of penicillin. Researchers are always finding interesting associations between diseases and examination findings. Some tend to be so unusual and bizarre that few people even believe them. A recent association between the quality of earwax and armpit odor to breast cancer risk is one of those.

Primary care clinicians see a lot of earwax. If there is such a person as a Cerumen Connoisseur, that would be me. The quality, consistency, and even the amount of earwax (cerumen) a person makes is really genetically determined. Asians tend to have dry, flakey earwax, whereas people of African descent tend to have more-sticky, wet earwax. Why? It just is. I really don’t pay that much attention to this normal, protective coating for the ear canal, as long as it is not in my way for examining the eardrum. If there is a wax impaction, I will remove it. If not, I leave the earwax where it belongs.

People are unusually troubled by the appearance of any earwax. They put earwax in the same disgusting category as snot or toe jam. Most people consider earwax yucky or dirty and feel it should be routinely removed by Q-tips… NOT. I am constantly defending the protective qualities of normal earwax and beg people to give up this unnecessary and potentially-dangerous Q-tip habit.

Now Japanese researchers feel there may be a genetic link between breast cancer risk and extremely-unpleasant underarm odor and wet ear wax. Now, before you go sniffing your pits and digging in your ears to see if you have wet earwax so you won’t have to have a mammogram, read on.

I have been to Japan. Even on those crowded subways and trains, I can’t really recall a body odor problem (unlike Europe!). Granted, I was about a foot higher in altitude than other people, but cleanliness in Japan is a virtue and perhaps using deodorant is more routine. I was approached by a person handing out samples on a crowded street corner in Shibuya. She was giving out samples of a cerumen spoon – a little, dangerous-looking instrument for scooping out excessive wax. This would be much more dangerous than the dangers imposed by the soft, cotton-tipped "wax packers" that Americans use. I guess if you scooped it out, you could certainly look at it to see if it was wet.

According to Kathleen Doheny of WebMD Health News, Japanese researchers studied a gene called ABCC11 (Remember this; it will be on the test); variations that are known to be associated with an increased risk of breast cancer. They actually developed a 30 minute DNA laboratory test to check for this gene variation. I have no idea if this test will become common practice and used as an important screening test in future. The study is fascinating to me – a lover of bizarre and obscure research.

I wonder how the researchers determine if someone has extremely smelly armpits, say versus just smelly armpits? I see a lot of patients with very smelly feet. I wonder if that is linked to anything. I don’t anticipate I will be doing a study on that anytime soon.

Breeding Lexi

2009-06-10T07:17:00.001-04:00

Her little snout was sticking through a hole in the fence sniffing the air. She was frightened and whining; trying to get out. I felt like crap leaving her there, but if we are going to successfully breed our Sheltie, this is what has to be done. I called the breeder later in the day, and Lexi was hiding in their backyard, occasionally coming out to sniff the place where I was standing. That comment really made me feel super-guilty.

Lexi is a bit over two years old now and the younger of my two dogs. The older Sheltie, Maggie, is over 14 years old, blind, deaf, and arthritic, but still hanging in there. Maggie is the mother of my favorite dog, Herman, who tragically died about two years ago. I bought Lexi a few weeks after Herman died. Lexi, short for Lexipro, was my canine antidepressant and has served that purpose well.

Lexi went into heat about ten days ago. We wanted her to have just one litter of puppies before having her spayed. We have been waiting for the right time, and summers are the best time. We located a male, owned by the same breeder that we used so long ago for Maggie. His name is Connor, a very handsome, intelligent, and regal-looking male sable Sheltie. When Lexi and Connor are together, they look like twins.

Like in the past, we have our puppies (assuming the breeding is successful) promised out to family and friends. We are very choosy as to who will get one. My brother in Maryland has requested one. He almost took a puppy from Maggie's litter 12 years ago, but chickened out at the last minute. He even arranged to fly back to Maryland with the puppy. This time, I expect I will have to drive to Kansas and meet him half-way to make the exchange. I would not want to ship a little puppy by air. Our neighbor with three children would like one, too. He has a fenced yard with lots of room for an active dog to roam and the kids seem very nice. The kids are patients in my practice. And, of course, I will keep a puppy, even if there is only one. Maggie is getting very old and does not tolerate the energy of the younger dog, so a new puppy will give her a break and be Lexi’s companion.

Having a litter of puppies is not something everyone should do. It is a lot of work, but those little Sheltie puppies are so darn cute. I held Herman from day one and he was the best dog ever. I really want to do that again - pick out my puppy, or better yet, have the puppy pick out me. Herman had chosen me.

My medical assistant called me over the weekend. One of her four dogs, all pit bulls, had a litter of eight puppies. This was an unplanned, but not unexpected pregnancy, since none of her dogs are spayed or neutered. We have never had any problems finding good homes for our Shelties, but a pit bull puppy, although cute, tends to grow into a very large, often cantankerous animal. Caesar Milan, the Dog Whisperer, loves pit bulls. Any dog, given enough love and care, will become a long-time companion.

I hesitated breeding a dog again for several reasons. Knowing that there are lots of pets at the shelter, I thought about calling Sheltie Rescue. Many of those dogs have been traumatized or not carried for very well. If I was retired and home full-time, I would adopt an unwanted adult dog. Adopted dogs often do have well-established adult dog habits, and those habits may not be compatible with my other pets. I have two shelter cats; one belongs to my wife. The other cat belongs to Lexi. Yes, my dog has a cat. They love each other hang out most of the day. At night, Lexi sleeps in our room. The cat sleeps where ever she wants. If she happens to be outside, she will peer through the window and call for Lexi to come out. They take turns chasing each other to the point that Lexi can now climb up certain trees.

Conner and Lexi successfully bred (twice), so 63 days from now, we should be having a litter of puppies. I will be prepared with a new whelping box and changing my work schedule so we will be home with them for the first month so they will be well-socialized. We have hired our 15 year old granddaughter for the month of August to be the puppy-sitter. She is in 4H and is thrilled to participate. If I can arrange it, I would like to bring the puppies to a local nursing home so they can be handled by lots of people.

It has now been a week since the breeding and Lexi is doing well; enjoying the enhanced prenatal diet (she is now eating like a horse) and the extra exercise. Prenatal care is just as important for dogs as it is for people.

I will keep all of you posted.

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Computer Tracking...You?

2009-06-03T13:03:00.001-04:00

In our area, it started with Safeway. They wanted you to join the "Safeway Club" so you can get discounts on various items that you buy. Safeway, of course, will be keeping track of your purchases from now on. If you are a woman, do you really want Safeway to know when you are having your menstrual period? Or, when you buy a pregnancy test? If you drink or smoke, do you want your grocery store to have this information? If you decided to buy two dozen rolls of toilet tissue on sale, would they try and sell you some Kaopectate? They claim their data collection is for their marketing, but if they have this information, I bet it can be "shared"? Am I not entitled to some privacy? In days past, on the cashier knew what you bought. I still dislike when checkers make comments about my groceries.

I use an online service to order DVD movies. It didn't take long before, I started getting these messages: "Since you liked Twilight, you may like Lost Boys." Actually, I am not a fan of either one of these vampire movies that I rented for my teenage granddaughter, but now Netflix thinks I am into teen vampire movies. They are always suggesting movies that I have absolutely no interest in watching. Thanks, but no thanks.

Because my rural area does not have cable, I get Direct TV. I am absolutely sure they have ways of knowing what I like to watch. It is not that I have anything to hide about my viewing habits, but do you really want strangers, even anonymous computers, to know this much about you?

Two of my good friends have cancer, so I was buying some books from Amazon over the weekend. At the same time, I bought a few books on dementia from my brother who is caring for our aged mother with this disorder. I am also a big fan of history and was fascinated by the early colonization of Australia, one of my favorite places to visit. I bought a book called the "Floating Brothel" about the shipment of women from England to serve those early colonists. It was a great story on PBS, so I wanted to read the book. Two weeks ago, I bought three books on raising chickens and how to build a chicken coop.

Based on my Amazon purchases, I am a demented man, perhaps with cancer, who enjoys reading books about brothels and raising chickens. They even suggested other books that I might enjoy about prostitutes, raising ducks, or holistic cancer treatments. If I ever decided to run for public office, these things may be difficult to explain.

My wife is addicted (she denies it) to catalog purchases. Much to the horror of our mail delivery person who stuffs hundreds of catalogs into our mailbox every year, she continues to get more and more things from companies she has never heard of. I bought a bar mitzvah necklace from a company that sells primarily Jewish items. I am now on a dozen or so solicitation lists related to Judaism. I bought a rifle at a sporting goods store a few years ago after a coyote ate my favorite cat. I now get regular letters to join the NRA. I can see why people pay for things with untraceable cash, rather than credit cards. If you get lots of catalogs, save them and line them up. See if you can guess at your demographics by the things people are mailing you.

Of course, your own computer tracks you. If you are unlucky enough to acquire some unwanted spyware, there are many people that track you. Company computers are capable of tracking virtually any keystroke you make. My company is tracking this future Blog right now, assuming they have nothing better to do. Our medical group has over 500 technical people that poke around when they have free time. I love it when I call tech support and they can remotely control my computer. Never do online banking from work. You never know when some disgruntled tech support person is going to clean out your bank account.

I try to never give my email address out when I know I will be flooded by marketing and advertisements. I get an email a day from a popular chain bookstore now with my coupon du jour. Since I typically work 12-hour stints, I never really have time to use those coupons. Even if I do get a chance to head for the bookstore, I never remember coupons. I recently gave out my email address to an airline so I can be informed of specials. Every day I get a "ding" to inform me of inexpensive trips to places I don't really want to go.

Someone is definitely tracking people by their age. In the last few years, I have been getting unsolicited mail for cremation services, long-term nursing home care, and other geezer-appropriate services. I even got several of these things ON my birthday. I sort of expected a form letter that started, "Now that you are getting closer to death, we thought we would introduce you to our funeral services." I think AARP sold my name, and all I was trying to do is get a hotel discount.

Like millions of other Americans, I signed up for the "do not call" list. I think I get more calls now. I found that if you donate money to injured firefighters, you get a dozen calls from other benevolent organizations doing similar fund-raising. It is always nice to hear later that five cents out of every dollar you donate gets to the organization; 95% are for administrative costs. Once you are on the list, you cannot get off the list.

I am really getting sick and tired of running out of a shower with a towel wrapped around me to hear another one of those computer-generated calls about my vehicle warranty expiring. In an attempt to stop the calls, I even tried to play along. When the man on the phone asked me the make and model of my car, I told him that I thought he must have that information since he knew it was expiring. He hung up. I have received no less than twenty of these calls in the last few months, even though it is well known that this is just a scam.

Both of my cars have over a hundred thousand miles on them, but I still get calls from one of the dealers telling me they are looking for used cars like mine. How do they know I still own it? This is an attempt, of course, to lure me back to the dealer to buy a new car. My truck dealer went belly-up in the economic downturn, so he doesn't call me anymore. I avoid buying a new car; to me it is like getting a colonoscopy. Occasionally you need them, but you hate to go through the steps to get one.

Speaking of that, my health care system also tracks me to inform me of needed tests, and sends me a letter. I guess they would send an email but our system does not have that capability as yet. The reason? They are concerned about privacy!

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Interesting Tidbits from the Medical Literature

2009-05-26T07:02:00.003-04:00

More on Losing Health Insurance
It is worse than I thought. Up to 14,000 Americans per day may be losing their health benefits during this economic downturn (a nice term for "crisis") according to a report by the Center for American Progress and Health Care for America Now.

"Approximately 2.4 million workers and their families have lost the health insurance their jobs provided since the current recession started in December of 2007, according to an analysis by Nayla Kazzi at the Center for American Progress. "

"More than 51 million Americans under age 65 do not have health insurance as of January 2009, and millions more drift in and out of coverage as their employment and financial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65 - nearly one in three - went without health insurance for some period in 2007 or 2008."

(See "When You Have No Health Insurance or Money" blog post). More and more people are being qualified for the government's Medicaid program - millions of people are already enrolled and the number is growing. If families try to purchase private insurance, they need to expect rising costs there as well (assuming they are healthy enough to qualify and do not have any pre-existing health problems).

And More on COBRA... It Strikes Employers, Too
The economic stimulus package will subsidize 65% of the COBRA health insurance costs for up to 18 months. Some companies feel that this will be an additional (and costly) burden to companies who have to pay the administrative costs to manage this program for laid-off workers. Personally, I think the minor administrative costs are the least a company can do for these disadvantaged workers. In a way, it was nice for our government to help out.

Get Ready for the Upcoming Epidemics
Most young families have never seen measles or Hib-related diseases, but that may change soon. There have been pockets of Hib and measles cases popping up across the country. There were about 400 cases in the U.S. last year. Unimmunized families may see them first-hand, unfortunately. As more and more families opt not to vaccinate their children due to unfounded fears that they cause autism and other developmental disorders, those diseases will surely return - perhaps with a vengeance. Measles has never left and continues to be among the leading causes of death in children worldwide. I suspect that families without health insurance will also be skipping these important vaccines.

According to the CDC, there were 131 cases of measles in 2008, the most since 1996. Most experts feel that this resurgence of measles is due to the highly vocal anti-vaccine movement.

Swine flu may be less serious than we expected, but expect an unprecedented vaccine campaign in the fall. Not only should a swine flu vaccine be available, but we will still have our usual and customary annual strains that take about 35,000 lives each year. Anticipating the circulating strains is becoming more and more difficult as these ancient viruses mutate and change. The World Health Organization fears that up to two BILLION people could be infected by swine flu if the current outbreak turns into a true, global pandemic

Speaking of Vaccines
The pneumococcal conjugate vaccine, Prevnar, which has been protecting infants and children against seven of the more common streptococcal strains is now going to be even better. A newer, improved vaccine called Prevnar 13 will be adding protection against six additional strains, offering even more protection against pneumonia, meningitis, and yes, even the dreaded middle ear infection.

In the last decade, the insertion of tympanostomy tubes for recurrent ear infections has increased 35%; a whopping 85% increase since 1996. Although there has been an active campaign to reduce the astronomical amounts of antibiotics used in the management of pediatric ear infections, the overall usage has not drastically improved. Many parents feel that tubes are a less-risky alternative to frequent antibiotic use.

Cell Phones May be Contributing to Hospital-Acquired Infections
First they blamed dirty hands, then stethoscopes (rightfully, so). A few years ago, a study proved that our neckties (I stopped wearing them and I have a great collection of medical ones) may be spreading dangerous pathogens. Now, cell phones are being blamed for the spread of MRSA (Methicillin-Resistant Staphyloccoccus auerus) - the superbug in a study of Turkish hospitals. It doesn't surprise me at all. Since I do not carry a cell phone with me during clinic hours, this does not pertain to me. Computer keyboards and other hospital equipment may also be contaminated. Personally, I consider EVERYTHING in the hospital potentially contaminated. I hate touching elevator buttons ("Can you push three from me, please?) and I never touch stairway banisters.

Electronic Medical Records (EMR) "Depersonalize" Medicine
I read a New York Times story about how EMRs are going to transform medicine into a highly-efficient machine, saving billions in healthcare costs. This is not without a big price, however, in the social arena. Not only do medical providers have to spend additional time documenting their medical records (not all medical providers are good typists!), but computers have created yet another depersonalized barrier in the medical relationship.

We have used EMRs for several years in our office, but I rarely use the computers in the exam room during the encounter unless I am just briefly checking lab results, etc. I just do not want a flat screen between me and making eye contact with the patient, I am sorry. I find it terribly disruptive to have a medical provider typing away as a patient is talking. I experienced this as a patient with my own medical provider. As in the past, I still jot down my notes, only to type the later, in the comfort and quiet of my own office.

We get less than 15 minutes allotted for each patient visit. I am not going to waste 12 minutes of that precious time by typing notes.

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The Media and the Worried Well

2009-05-22T08:18:00.003-04:00

Every morning I watch the local news to see what kind of medical problems and issues I will be discussing that day. If there is a story about a new case of West Nile Fever in the area, I will be getting calls as soon as the phones open. A Lyme disease case was diagnosed thirty miles from here, so I will get a few of those calls, too. These calls come from a large group of media-inflamed people called the "Worried Well" - well people that think they might be ill, or at least, exposed.

A rash that would have been otherwise ignored is now a target lesion characteristic of Lyme. A fever that would have been previously attributed to a viral infection is now the H1N1 (swine) flu. I saw two, perfectly-well boys, ages 7 and 9, last evening because the father felt they had swine flu. Apparently, they had a particular rare type of swine flu - one that had no symptoms. They have not traveled to Mexico, although they were in Venezuela last year to visit relatives. They had no contact with others who were ill at school; and there were no reported cases in that particular school or city. The answers to all of the H1N1 medical screening was a flat negative. No symptoms. No contacts. Well kids. I literally had to argue with the parents that a screening test was not only not indicated, the Health Department would refuse to run it.

This recent influenza pseudo-pandemic is a prime example of media hype, not unlike yelling "Fire" in a crowded theater. I really can't fault the CDC and the Health Departments for going on alert, even high-alert, but the media fed the fires of fear that drove people into a frenzy. Tents were set up to screen people outside of standing-room-only emergency rooms. People, whose only contact was with a cooked pork chop, demanded to be tested and treated. A local Catholic school was closed after one case was found (not a bad idea), but several more schools were closed in neighboring communities "just in case". There were no firm guidelines on school closures. Each hour, I would get an email from our lab or from the Health Department on how to collect and store the viral swabs and where we should send them. Our clinic ended up sending several dozen cultures of suspected cases over the last two weeks. We have yet to hear about any of them.

If this potential pandemic was a test of our public health system's response to a biological emergency, I am not sure we passed. The first day that I sent the proper viral swabs to the local health department, they were closed due to budget constraints! Millions of doses of Tamiflu - an antiviral flu medication - were sent to the border states for possible public distribution. The federal government had bought tons of these expensive drugs during the last flu scare - the bird flu - when it was assumed that we would see millions of cases of a deadly strain spread by birds along their migratory routes. It didn't happen, obviously. It was sure financially-convenient to have this new swine flu emerge since those medications were due to expire anyway. I had two courses of Tamiflu in my medicine cabinet from the bird flu that I didn't take; it was expired, too. Oh, by the way, the companies that make Tamiflu and Relenza (another anti-flu medication) are ecstatic.

This morning, I had a heated thirty-minute counseling session with a mother who did not want to give her healthy five-year old any more vaccines in preparation for kindergarten for fear that he would get autism. Yes, autism exists, and yes it is being diagnosed more and more in the U.S. (Although not so often in other countries where the exact, same vaccines are used.). There is absolutely no scientific evidence that autism is directly or indirectly caused by any of the vaccines, or combination of vaccines, or the preservatives in the vaccines (which, incidentally, no longer exists). Of course, these medical claims vindicating the vaccines, made from years of controlled studies, reviewed by experts in their respective fields, must be wrong. Why? Because someone disputed it on the Internet claiming that the studies are wrong - motivated by vaccine-manufacturer's greed and profit, or a neighbor told her that she had a cousin that got autism from the vaccine. Rumors, anecdotal claims, and unsubstantiated personal testimonials appear to have more credibility than a published study in the New England Journal of Medicine. In the end, the mother agreed to get the MMR vaccine, but did not want to get the other three required, school-entry vaccines at this time. Okay, one vaccine (three, actually) is better than none at all.

I feel sorry for the media. Unless they have a good story, no one will watch the news or read the paper. If readership goes down and people stop watching, advertisers will not buy time or space. If advertisers stop advertising; newspapers and television stations will go under. It has already happened with the economic downturn.

There are some days, when I am getting my morning "Disease of the Day" briefing on television, that there are no good stories. They may have a "breaking news" story about a new meat-slicer at the local market that is safer than the older, finger-amputating model. A few years ago, I turned on the news to see live helicopter footage of a local swimming pool. Someone (unnamed) had pushed the wrong button to automatically chlorinate the pool, and several people had become sick from the chlorine fumes, while others had bleached-out Speedos. I could see ambulances with light flashing. Paramedics ran dragging gurneys with people on oxygen. It was chaos. Two hours later at work, I saw an endless dance of potential chlorine victims. A few hours after that, it was determined that the chlorine levels in the pool were really not that high; certainly not toxic.

About 12 years ago, when I was teaching in Michigan, another chlorine incident happened. The people doing the laundry at the Indian Casino used concentrated chlorine instead of Clorox. The fumes wafted through the casino, much to the horror of the semi-drugged gamblers. Some became nauseated. A few vomited. The rest fled in a wild panic. The rumor was that there was a terrorist, nerve gas attack. The local fire department quickly set up a make-shift decontamination area for the many victims before transporting them to the local emergency room. Totally-naked gamblers stood in the freezing weather and were systematically hosed down with even colder water. Once they were blue and placed in paper gowns, they were sent to the ER. I can tell you that this was big news for Mt. Pleasant, Michigan. I was puzzled all day why anyone would think that terrorists or a disgruntled loser would consider an Indian casino in Mt. Pleasant to be a target.

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Three Summer Problems That Get Under My Skin

2009-05-21T09:00:00.002-04:00

With the exception of the H1N1 (swine) flu that surprised all of us, the spring and summer months are typically a time when we see a drastic reduction in respiratory infections, like colds and ear infections, and see an increase in "warm weather" health issues.

Soon, schools will be closed for the summer months so the kids can help plow the fields and bring in the crops (sarcasm). Other families will be traveling to their favorite vacation spots, camping, having picnics, hanging out at Little League games, or swimming.

Photo: blmurch

Poison Oak: Like the swallows returning to Capistrano or the blooming for spring flowers, I started to see my first cases of poison oak this week. In our area, poison oak flourishes along a popular bike trail, near the river. All it takes is an innocent brush-by of this toxic plant and you will be rewarded with a pretty impressive, itchy skin eruption a day or so later. Children (and adults) often use the more private, wooded areas as make-shift restrooms, increasing the chance of skin exposure to those more delicate areas. Camping areas that permit open fires often see children actively collecting twigs to add to the smoky fire pit. Being downwind to a poison oak-laden fire will likely expose those happy faces.

Contrary to popular belief, poison oak dermatitis is not contagious. You cannot catch it from another person, but you can catch it from the clothes or shoes they were wearing, or even from the bicycle tires. Any object contaminated with the oily oleoresin of the plant can potentially cause this allergic skin reaction. This oil is very stable and can remain on unwashed objects for a long, long time. The oil can also reside on the fur of your loving pets.

There is really no such thing as a mild case of poison oak if you happen to be the person who has it. It can be absolutely miserable for weeks unless it is definitively treated. I am a big fan of a course of oral steroids (No, not the body-building, Barry Bonds-type steroids). Topical hydrocortisone can only do so much. Treating the itching with colloidal oatmeal baths and antihistamines are usually necessary.

Photo: nicolaitan

Mosquito bites: If it were possible to lose weight by being bitten repeatedly by mosquitoes, I would be thin as a rail. I am literally a mosquito magnet. It can be over 100 degrees, and I will be wearing a long shirt, long pants and hat, smelling of DEET.

Our local mosquitoes still seem to find a hidden place that is unprotected and have lunch...on me. The DEET products do help somewhat, but once I am bitten, I will immediately have an allergic response - big welts that itch like crazy.

I have to plan my garden work during the heat of the day when mosquitoes are not active. I built a bat house, and I never kill a lizard or frog; all creatures that eat them. I would love to eat dinner outdoors on the deck, but I do not lose, yet another battle, with hungry mosquitoes. I have tried Citronella, bug-zappers, and toxic fog to no avail. Even when I am huddled inside, I see them repeatedly pounding on my window glass like those zombies in the Night of the Living Dead.

We are seeing more and more cases of West Nile Fever in our area, so my unique ability to attract mosquitoes has me a bit worried. I have always wanted to travel to Central America and the tropics, but unless I walked around in a huge mosquito net, I would most likely come home with malaria or yellow fever.

Photo: mugley

Sunburn: Humans always seem to underestimate the burning power of the sun - solar radiation. A heard a talk at a medical meeting a few years ago, where the female dermatologist said there should be "no pain treatment" for a teenager with sunburn. She stated that teenagers must experience the pain in its full intensity in order to remember to use sunscreen and protective clothing next time. In Australia, where melanomas are rampant, children are required to wear hats to school as a part of their school uniform. On the beaches, children wear full body swim suits for sunburn protection. It seems that most people in the U.S. are complacent when it comes to sun exposure. Sure, they apply a sunscreen once or twice while at the beach, but many varieties simply wash off after a few minutes in the water. Most have to be re-applied every two hours.

If you do get sunburned (and it is usually your own fault), treat it like any other thermal injury. Cool it down with cold compresses. Take some ibuprofen for the inflammation and use of soothing skin lotions. The best defense is always to avoid the sun, but if you cannot - avoid the sun between 10 AM and 4 PM when the ultraviolet rays are most intense. Use a good sunscreen product that protects against UVA and UVB rays with an SPF (sun protection factor) of at least 30. However, sunscreen is not permission or an excuse for increasing sun exposure.

My brother was diagnosed with melanoma several years ago (it was completely excised) and several of my friends have had melanomas. Nearly every person who is diagnosed with melanoma has a history of at least one, blistering sunburn. Try not to let it happen to you.

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Nuclear and Other Fears

2009-05-13T10:54:00.004-04:00

Photo: quinn.anya

The siren made a different sound; it was constant, striking fear in all of us. The teachers knew it was a drill; we did not. As a 6th grader and a big fan of my hero, John F. Kennedy, I knew what to do. I quickly crawled under my wooden desk near the window, a piece of old chewing gum (Black Jack, I think) stuck to my flat top. Our desks, we were told, would act as our individual bomb shelters.

Anxiously, I glanced in the direction of Pittsburgh, a more likely nuclear target than Fairchance, population 1,200. As the siren wailed, I half expected to see the flash, followed by that mushroom cloud. It would give me a few seconds to overt my eyes before being blinded, or cut by the inevitable breaking of the windows. The old building would rock and sway; the heat would be unbearable. If I was lucky enough to survive a few seconds longer than my classmates, I might see them melt or burst into flames. Mrs. Gretchen with her heavily-lacquered hair would surely be one of the first to ignite. Then, it would be over. Perhaps, Cleet the Janitor, hunkering down in his furnace room, would survive, only to die later of a painful death from radiation poisoning.

As far as we knew, no one in Fairchance, Pennsylvania had a bomb shelter. Many had root cellars and cinder block coal bins, but there were no places to ride out the nuclear war. The coal miners, deep in the mines, would survive if there were not cave-ins. They would emerge at the end of their shifts to see a bleak, scorched landscape, not unlike the normal appearance of our heavily, strip-mined community. They may not even notice, except that their pickup trucks had vaporized.

My stepfather, Joe, always talked about building a bomb shelter. He even started stockpiling things that we would need. Thus far, he had a dozen cakes of Ivory soap, some cans of Spam, and a case of beer. The soap was important since the temporary location of our bomb shelter was the coal bin. If the nuclear war started in the winter, there would be little room for us, hiding in the shifting coal. In the summers, we would at least have space to lie down. He had not stockpiled water, so I wasn't sure how useful the soap would be, unless we rinsed with a precious bottle of Iron City. We didn't have any guns, so I was not sure how we would fend off hungry neighbors, now mutants, trying to get in our coal bin.

Photo Credit: Thomas Williams

Nuclear bombs concerned us the most. We were not particularly worried about the flu, although three decades before I was born, an influenza pandemic killed millions in the U.S. The parents were worried about polio. My cousin Danny got it from playing in the creek (aka, "crick") and was now crippled. We had measles, mumps, scarlet fever, whooping cough, chicken pox, rheumatic fever....you name it. We received smallpox vaccinations along with a stern warning never to touch or pick off the scab; otherwise we would have to get another one. I am sure that people died or had other serious complications from those diseases, but we didn't know of any.

In kindergarten, the school doctor (we had one of those) and the two school nurses (twins) lined us up and gave us some of the newer vaccines, even if we already had the disease it prevented. There were no excuses. Everyone had to get them. It was the law. No one developed autism, even though the vaccines (and our creek) were loaded with thimerisol (mercury). If any child was mentally-challenged, it happened before those vaccines and we knew who they were already. In the late 1950's and the early years of the 1960's, it seemed that everything was out to get us, from that cigar-smoking Fidel Castro and his pal, that shoe-pounding Commie, Nikita Kruschev to this endless list of diseases that required us to get shots.

For some reason, we rarely got sick. It was rare to miss school due to an illness. In my family, if you had a heartbeat, you went to school. Rain or snow, we walked. To shave off a few minutes, I would often walk through the woods along the sewer and mine run-off polluted, orange creek. That is, until I seemed to scare up an unusual number of snakes. I am not a big fan of sudden snake appearances, nor was I convinced that snakes do not chase you. I had what I believed to be snake magnetism.

Later, I selected a safer route to school; walking the railroad tracks. Several times a day, heavily-laden coal trains would come through town. They were not particularly fast and did blow their whistles, so you would have ample time to get out of the way. Perhaps one of the most dangerous acts that we frequently committed was crawling under a train that had temporarily stopped. Not knowing how long our route would be blocked, we would wait, listen for any sounds of movement, and then dash under the train to the other side. Of all of the children, only one was injured by a train, He ran into it on his bike, breaking his leg.

The nuclear war never came and we didn't have to live in the coal bin eating Spam and washing up afterwards. President Kennedy was killed in Dallas. No one we knew died of vaccine-preventable diseases. I was never bitten by a snake or hit by a train. I was hit by a car crossing an icy road, but that is another story...another blog.

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Life's Weavings - Everyone Should Blog

2009-05-12T05:50:00.001-04:00

Our lives are really a tapestry of our experiences; our stories, all woven together. Lives are often referred to as an open book. This book, of course, has many chapters and many pages, but not all people put those stories down on paper, so to speak. As we age, some people get dementia or Alzheimer's disease. I like to think of this time as pages being randomly torn from their life book as they struggle desperately to make sense of what is left. My mother is in this place now.

Native Americans were great storytellers. Like their magnificent blankets, they would weave fascinating stories about hunting or folklore, much to the delight and entertainment of those who chose to listen. The elders were the televisions and Internet of their times. Those stories, repeated over and over around warming fires, were handed down through the generations and generations. These were the oral traditions that made us who we are. They were blogs.

People used to write beautiful letters; so beautiful, in fact, that people saved them. Today, grandchildren can read letters written by serviceman getting ready to be deployed; or rare letters from a WW II POW in Burma to his wife who thought he was dead. People wrote diaries with their most intimate thoughts, not realizing that someone would eventually read them - if not a nosy brother, it would be a tearful grandchild fifty years later. Those letters and diaries were their blogs.

I had my grandparents, and my aunts and uncles to tell those stories. Some were truthful; some were clearly embellished, and others, merely lies. Nonetheless, those stories helped frame my personality and direct my imagination. Without televisions and computers to talk for you, people conversed freely. Good conversation was literally an art form. As kids, we would hang out at the barbershop just to hear the stories. I discovered that if you kept a low-enough profile, the stories became even more interesting. Long before there was formal sex education, there were barbers and their clients. I shall be ever so grateful to Nolan the barber and his "art collection"

In college, I loved the bullt sessions (as we called them). My former life was as a child in a small town with few secrets, but these were peers from all over the world with new stories and different experiences. Those stories defined the hidden souls of my friends. My friend Jim told about his year of living in Amsterdam. Several years ago, Jim suddenly developed metastatic colon cancer. I traveled across the country to spend an afternoon with him. It didn't take long before those college stories started to emerge. We laughed our asses off for several hours. He had two young daughters, one being a teenager. During our rowdy uprising, I suddenly realized that we were being secretly tape recorded. His daughters, knowing that they may never hear these stories again, were recording them for posterity. We both pretended not to notice. A few months later, my friend passed away.

As young medical students, we had our patient stories. Long before confidentiality rules, we just told it all. "You are not going to believe what came in to the ER tonight." A crowd would gather. To this day, medical clinicians still talk about you. We do not use your name, but you can be certain that your case will be openly discussed in some manner, either for educational purposes or tasteless amusement. This year at the state medical conference, I will be talking about how to deal with these bizarre patient encounters - the medical equivalent of Dave Letterman's Stupid Human Tricks.

As of today, I have written over 300 posts on the All Ears blog. If I never get around to writing a book about my life, a legacy for my children and grandchildren, I will just refer them to my blog. My brother is an avid reader of my Blog, mostly to make sure I am not telling secrets about him. He basically confirms what my friends often confirm: If you want to know what is going on in Rod Moser's life, don't call him, just read his blog.

Personally, I don't think my life is all that interesting, so this is why I often weave stories about others. I blog about my family, my kids, my grandkids, my wife, my friends, my co-workers, and yes, even some of my patients. I seriously upset my medical assistant a few weeks ago when I blogged about incompetence, using one of her (very rare) errors as an example. She read it on a day I was not working, stewed about it all weekend, and jumped my case on Monday, crying and yelling about it. I apologized, of course, learning once again, that you do not diss a woman and get away it. I never intended to hurt her feelings, but she did make me aware that not all people share my views and opinions. I dearly love my medical assistant and can't imagine my clinical life without her. I hope she reads this.

One of my best friends is facing the challenges of a terminal illness. He has a brain cancer and will soon be starting an aggressive treatment regime of surgery, chemotherapy, radiation treatments, and experimental drug trials. As a cultural anthropologist, his entire life has been about the study of people and their traditions. He has traveled the world and experienced things that I will likely never see or experience myself. I need to spend time with him to hear his stories. I don't know if he will have time now to write them for his children and grandchildren, so I need to listen to them, just in case I have to tell them someday. Just like Mitch Albom's Tuesdays with Morrie, I need to plan Wednesdays with George. I can be his blog if he needs me.

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H1N1 Flu: But, They're PIGS!

2009-05-01T16:36:00.014-04:00

Photo Credit: Laurel Fan

I knew this would happen. The Swine Flu is not a nice name. It sounds kind of dirty and unappealing. Jews and Muslims do not like pigs; animal rights activists do. The pork lobby and the commodities market for pork bellies do not favor the name. You have to change it, so let's call it H1N1. I guess everyone will know that the "N" stands for neuraminidase. Everyone else can just call it the H1N1 (high-knee) flu.

When there is a pandemic on the horizon, governments must have scapegoats, or in this case, a scape-pig. During the last major pandemic, we called it the Spanish Flu just to tick off Spain who refused to provide information about flu deaths in their country during World War I. We could have called it the German Flu, but everyone already hated Germany and we already named a type of measles after them. It should have been named the Kansas Flu since this is where it started, but Kansas is such a nice place. There is no place like home, Toto.

Later on, we had the Asian Flu or Hong Kong Flu. This may have been more appropriately named, since this strain of influenza did originate in China. God forbid that we call this one the Mexican Flu. Mexicans are having enough problems as it is with those drug wars and a crash in the tourism business. Just yesterday, a patient informed me that their Mexican cruise has been canceled by the cruise company due to the flu pandemic.

I wish they would have had a contest and let the American people name this flu. There could be call-ins and text messages, like the American Idol. How about the al-Qaida Flu? I thought this was a good one until I heard there was a guy in Cleveland named Al Kida. That would not have been fair to him. He already lives in Cleveland. Oops, I did it again. What I meant to say was, "I love Cleveland." WKRP! Wait, that was Cincinnati. Now I have Kansas and Ohio upset. How about the Kim Jong-il Flu? This is another good one; it already has "ill" in the name.

This morning as I was getting my morning flu briefing from Matt Lauer, I discovered that the name was changed yesterday to the it's scientific name - the H1N1 influenza, after many pigs were needlessly slaughtered in Egypt and people stopped buying pork in the grocery stores. Regardless of the reassurance that you cannot catch swine flu from processed pork products or uninfected pigs, people are not convinced. I am sure glad that pigs do not cause autism, or do they? Now, I did it. Oops.

A slip of the tongue or joking can really backfire nowadays. Poor Joe Biden. Much of the morning news was filled with White House spokesmen that were trying to explain what Joe "really meant" so the American people can relax and say, "Whew! Now I feel better." VP Joe is staying home and will not be traveling on commercial airlines, subways, and buses, like he normally does (sarcasm). The air transportation czars were up in arms with the approaching summer travel season defending the cleanliness of their planes. Personally, that would be like defending the cleanliness of those Mexican pigs.

Granted, most commercial airlines do have HEPA filters to scrub the air of pathogens. While this may help a little bit, it is not going to protect you against the sneezer in the seat behind you that just blew up the back of your hair, or the snotty-nose kid that wipes his hands all the way down the aisle to the bathroom, where God knows what happens inside. Between flights, airline personal empty the seat back pouches of all of the trash we stuff in there, including napkins, Kleenex, and I am sure, but have no conclusive proof - dirty diapers. They probably vacuum up the pretzel crumbs at some point at the end of the flight days. Peanuts are no more. They may try and sanitize those stinky toilet closets and load up the TP containers, but they DO NOT SANITIZE those planes. How can they? Viral pathogens can remain on surfaces for hours, and we only have a short time when people disembark and others board. Pathogens will remain on those tray tables, even in the upright positions (germs do not fall off). They will remain on those cloth seats. They are on the call button and that little air deflector that you point at the sneezer behind you. Pathogens are everywhere, so if you are going to get sick, this is the place. I included airplanes high on my list of the Dirty Dozen - the Twelve Dirtiest Places. My feelings have not changed any more than the airline's traditional hygiene practices.

Pigs do have hygiene issues, but we do not hesitate to harvest heart valves from them, or use them to test our pharmaceuticals. It's not bad enough that we make fun of their appearance and eat them, now we have to blame a pandemic on them. Researchers feels that AIDS originally came from monkeys, or from someone monkeying around with monkeys. If that is really true, then why haven't we taken it out on those monkeys? Monkeys are cute, that's why. Pigs? Not so much, although those Vietnamese potbellied pigs are sort of cute in piggy sort of way.

Arnold on Green Acres was not only cute; he was one of the more intelligent mammals in Hooterville. Porky Pig, in spite of the fact that he does not wear pants, is an American icon. Of course, not having genitalia sort of excuses him. People love to "pig-out" or go hog-wild. Actors ham it up. Pigs wear lipstick. Politicians talk about pork-barrel spending. Little girls wear pig-tails. Hell's Angels ride hogs. People hog seats on the bus, assuming they are still riding a bus now that Joe gave 'em up. Sue-EEEEE!

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Bird Flu? Swine Flu? Mexican Flu?

2009-04-28T17:09:00.005-04:00

Last year, it was the bird flu panic. People stopped eating chicken (you can't get it that way), feeding pigeons, and worried about living along migratory bird routes. Many stockpiled is oseltamivir or zanamivir - antiviral flu medications - and waited anxiously for cases to appear in their neighborhood. The bird flu is still out there (somewhere) and a few cases are still popping up from time to time, but it was not the worldwide pandemic that it promised to be.

Now, we have the swine flu panic and public health departments are gearing up for what could be another potential disaster. Since a particularly-virulent flu bug was the cause of the last worldwide pandemic in 1918 and resulted in several million (yes, million) deaths, we tend to take notice.

This pandemic occurred during the height of the First World War and was erroneously dubbed the Spanish Flu, apparently to take the heat off of the good people in Kansas where it actually started. Other flu pandemics and epidemics have been called the Hong Kong flu since many of these strains were identified first in China, where people, birds, and pigs live in much closer proximity. Since the swine flu appears to have originated in Mexico, I suspect someone will start calling it the Mexican Flu. Influenza by any name is just as concerning.

The swine flu virus tends to live quite contently in pigs, hence its namesake. However, flu viruses have an annoying tendency to mutate and adapt, sometimes making the jump from pigs to humans (or birds to humans). When it jumps species, the next step is the worst of all - human to human transmission. The Type A strain of swine flu (H1N1) is transmitted from human to human. So far, nearly 1300 cases have been reported including over a 100 deaths in Mexico. There are at least seven cases in the U.S. now. Incidentally, you cannot get swine flu from eating pork or pork products. Don't throw away your stockpile of Spam or Honey-baked Ham.

Today, one case was reported in our local neighborhood at a Catholic school. The school is now closed until further notice and several frightened parents have brought children in to be tested. We have one parent coming in today (in a mask) because her child owns a pig. Although their pig has not traveled to Mexico to visit relatives, they want the child tested. Our local health department has gone into high gear and heightened surveillance to prepare for the worst, should it happen; although when we tried to send in a specimen today, the Health Department was closed! Within the first hours of work today, we have received numerous instructions on the proper way to collect specimens from any person that has vague "flu-like" symptoms such as fever, cough, or sore throat (just about ALL of my ill patients have those).

Several years ago, there were three cases of meningitis at one local high school. For months, people would not even shop in that town, or allow their children to play in the McDonald's playground. I am surprised there weren't guard towers and razor wire surrounding the town.

Right now in Mexico City, large gatherings of people such as sporting events or church services have been canceled and millions of surgical masks have been handed out. I haven't seen this many surgical masks since I went to Japan. In Japan, people often voluntarily wear surgical masks on subways when they are ill to protect their fellow travelers. You don't really see that level of courtesy in the U.S., where someone is likely to sneeze or cough directly in your face. During the 1918 flu pandemic, movie houses and taverns in the U.S. were closed in large cities and yes, people were wearing cloth masks or handkerchiefs over their mouths and washing their hands.

People tend to panic when these things public health issues happen. Misinformation and fear often trumps common sense. We had a person today, who was exposed to a neighbor, and this neighbor was exposed to a parent who had a child in kindergarten who goes to the school where there was one case of confirmed swine flu. Whew!

A year ago today, my wife and I were driving through Mexico to deliver children's clothing to an impoverished area in Baja. At that time, we were not worried about influenza, just the drug wars along the border that so far, has taken the lives of over eight thousand people. Medical care in Mexico can be sparse and many of those deaths may have been because people did not have access to medical services soon enough. As of today, there were no confirmed swine flu deaths in the U.S. and I pray that the Mexican health officials can contain this virus before there are any more deaths in this country.

Until the breadth and extent of this potential pandemic is confirmed, people should just relax, get the facts, follow the news, wash their hands, avoid getting downwind of a sneeze, and wait until the public health department offers specific instructions for your particular area.

It is still okay to still eat a BLT.

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HPV and Doraldo - An Update

2009-04-24T15:38:00.003-04:00

It was an unusual phone message. The accent was heavy, but somehow, familiar. It took us several times listening to the message before my wife figured it out. It was Doraldo's mother calling from Florida.

We met Doraldo in November, 1997 at the Almond Leaf Health Fair in Runaway Bay, Jamaica, where my wife and I were medical volunteers at a tiny community clinic. When we arrived in the early morning hours, still dark, there were hundreds of people in their Sunday finest, waiting to be seen at the clinic. Our mission was to detect hypertension, provide free eye glasses, and see just about everything that came through the door.

Our team quickly set up shop, divided up the medical supplies that we had carried from Michigan. It seems like an endless stream of desperate people, many with easily-treatable illnesses and other with more serious health problems. There were uncontrolled diabetics, skin infections, kids with ear infections, older folks with cataracts (more common in bright sun areas), and a few surprises. The cardiac team brought an echocardiogram and found dozens of people with heart murmurs of various types. And, then I met Doraldo.

He was fifteen years old, but looked about twelve. He had a small frame, very shy, and a large smile covered most of his face. His voice was gravelly; nearly inaudible, and he was having problems taking a deep breath. Doraldo had a condition that is quite rare in the U.S. and other industrialized nations. He had laryngeal papillomatosis - an HPV infection of the voice box. These warts are typically venereal, but can be transmitted to the baby at birth, as was the case for Doraldo. The warts had grown to such proportion that they not only compromised his ability to talk, but to breathe. His mother asked if we could help him. I said that I would try.

A week later, we were back in the Michigan snow, but Doraldo was constantly on my mind. An ENT specialist from Saginaw was speaking at a lunch conference, so I decided to go. After the talk, I waited around to speak with him. I told him about Doraldo and asked if there was anything that could be done to help him.

It was a strange coincidence - Dr. James Letson was a former volunteer on the old hospital boat "Hope" when it was stationed in Jamaica. Not only was he familiar with Doraldo's affliction, he had a particular affection for the Jamaican people. He said if I could get Doraldo to the states, he would treat him for free. Doraldo needed laser surgery.

It took nearly a year to get the U.S. State Department to approve a medical visa. Covenant Healthcare in Saginaw donated the operating room and care. A local travel agency paid for the air transportation for Doraldo and his mother. All the pieces were in order now. Doraldo came, had his (first) surgery, and returned home. Shortly after his surgery in November 1998, we left Michigan to return home to California. Volunteers in Michigan, including a Jamaican woman that read Doraldo's story in the newspaper took care of him when he returned for his second laser treatment. That was over ten years ago.

Being in California, we lost touch with Doraldo. The PA that ran the annual Almond Leaf Health Fair died of a heart attack, so there were no more medical missions to Runaway Bay. Then, yesterday, we heard from Doraldo's mother.

For the last several years, now, Doraldo (now 27) has been residing in Florida with his mother. Unfortunately, his laryngeal papillomas had returned. This morning, I spoke to his mother from the hospital where Doraldo had surgery again. He was doing fine, but obviously, could not come to the phone.

Soon I hope to hear this "voice" from the past.

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The Cats of Mirikitani: A Survivor's Tale

2009-04-20T22:15:00.008-04:00

Japanese Internment

Jimmy Tsutomu Mirikitani

I love to watch documentaries, but I am rarely moved to tears. The Academy Award winning documentary of 2000, "Into the Arms of Strangers" did it, and this latest one, "The Cats of Mirikitani" is another one.

I was a baby boomer, born several years after WWII. The 1950's were a time of recovery, so I was really spared the stresses of a world wide war. My brother was born in 1943. As a baby in Baltimore, when my father worked in the shipyards, he experienced the rationing of food and other essentials that we take for granted. Your parents, and certainly your grandparents, can tell you those stories, if you take the time to listen. WWII veterans are dying, and those stories may die with them.

It wasn't just the brave young men and women who went off to fight in Europe or the Pacific, the families that sacrificed at home, or the women who replaced men in traditional male jobs, like welding - there were countless other victims (and heroes), too.

Franklin Roosevelt signed Executive Order 9066 on February 19, 1942, resulting in the forced "relocation" of over 11,000 people of Japanese ancestry to concentration camps. Nearly 3/4 of those people were American citizens, some for many generations. It didn't really matter. If you looked Japanese, had a Japanese surname, or admitted to being Japanese, you were off to those prison-like camps. This was a prime example of racial fear and of course, profiling. A very large portion of our population is German. If the government had decided that people of German heritage should be interned, too, my family would have gone.

Japanese submarines were frequently seen off of the California coast. Pearl Harbor had been bombed just a few months before. What if these Japanese-Americans were spies preparing for a mainland invasion, or saboteurs? Our government's paranoia sent thousands of innocent men, women, and children to horrible camps in the middle of nowhere. Hopes, dreams, and lives were forever disrupted.

This happened to my good friend's grandmother. She was forced to leave her family farm near Bakersfield, taking only a suitcase. Like many Japanese people, my friend's grandmother was forced to sell valuable property to unscrupulous land speculators for a few dollars. There is a large shopping mall on this land now. My friend remembers that his grandmother made dried persimmons called hoshigaki, in their attic space. A few years ago, I sat in a persimmon orchard with my Japanese-American friend as we made our own hoshigaki (we took a class!).

Jimmy Tsutomu Mirikitani

In the heartening documentary, "The Cats of Mirikitani", filmmaker Linda Hattendorf tells how she discovered and helped save internment camp survivor and talented artist, Jimmy Mirikitani, from the streets of New York City. She tells how she found his long-lost relatives, including a sister living in Seattle and a cousin who is the poet laureate of San Francisco. She shows how a caring individual can make a difference in the remaining years of one man's life - a man damaged by the effects of war, injustice, and incarceration. The Mirikitani family was originally from Hiroshima. Jimmy Mirikitani was born in Sacramento. He was sent to Tule Lake Internment camp in Northern California. He was not a terrorist or a saboteur. He was an artist and a man with a heart of gold. He still lives and works in New York and will be 89 years old this June.

Last year, my wife and I toured Manzanar, one of the largest internment camps in California. We picked up a stone, probably not something you should do in this historic area, but we placed this stone under a Japanese maple tree planted by our Japanese exchange student's family. I can look out my window now and see it.

Jimmy Tsutomu Mirikitani

We were fortunate to visit the Peace Park in Hiroshima many years ago, escorted by our Japanese exchange student's family. One of our dear friends is a Hiroshima survivor. We helped her through many illnesses and she never forgets her annual gift to us of the best oranges we have ever tasted, except when we visited Hiroshima. She refused to tell us where she locally buys them, but did say they were from trees brought from Hiroshima before the war. They are growing (somewhere) in the Sierra Foothills, tended by the caring hands of a Japanese family. In return, we gave her some of our homemade hoshigaki.

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Giving Bad or Unexpected News

2009-04-12T17:14:00.007-04:00

I have been fortunate in my medical career and type of practice settings that I have worked, that giving "bad news" is a rare event. During the course of a typical week, I inform patients of abnormal laboratory tests, or x-ray/imaging findings. Most of these abnormalities are expected and correctable by various treatments, or even "Tincture of Time."

When I order a pregnancy test on a teenager, it is for a reason. They may have been having unprotected sex and are having symptoms of pregnancy, such as a missed period. When I inform them of the results, they have already sort-of prepared themselves. Sometimes, I will simply ask, "How will you react if I tell you that you are pregnant today?" Knowing how they might react, will prepare ME on how to deliver the final news.

Many teenagers play Russian roulette with sex. They secretly wonder if they can actually get pregnant. They are practicing suboptimal forms of birth control, or none at all. Many will be pleased when I tell them they are pregnant; some will "freak out". Both will need some extensive counseling, of course.

Several years ago, I was doing an annual exam on a dear patient of mine. She was in her early 40's and had not had regular periods for years. Thinking she was menopausal, she did not really see the need for birth control.

"Any chance you could be pregnant?" I asked.

"Absolutely not," she responded, as I was palpating a suspiciously-enlarged uterus.

Of course, she was pregnant, and that "surprise baby" was Katie - a beautiful little girl, the love of their lives, and now, a beautiful young woman. This was unexpected news, but not "bad news".

I love giving good news. Who wouldn't? Telling someone that has been trying to get pregnant for years that they were successful; or telling someone who fears their skin lesion is a melanoma that it is benign is all great news. The patient is ecstatic. I feel good. It is a win-win situation. However, life and medicine is not always an endless stream of good news.

No medical provider wants to give a patient bad news, but that is part of our job. If you read my recent blog post about my friend who was diagnosed with a brain tumor last week, you will realize that these types of events are unbelievably frightening to the patient and their families/friends. You pace about and pray for "good news". You stare at the clock waiting for the doctor to come out and reassure you that everything is fine. The tension is thick enough to be cut by a knife.

My friend was five hours into his surgery. Finally, the surgeon came out into the crowded waiting room where the family had gathered. His face was not unlike a jury returning a guilty verdict. Pulses raced. Tears flowed.

In a subdued voice, almost too quiet to be heard, he gave his brief report. "He had a glioma - brain cancer. I was able to remove all of it. I sent the specimen off to pathology for a final report. Your husband is in the recovery room. Do you have any questions?" The only response came from my wife: "When can his wife see him?"

Everyone sat stunned. This was not the news we wanted to hear. Yes, everyone was pleased that the surgery was over and he was in the recovery room, but.....cancer! It is really difficult to hear anything, not even words of encouragement if they were offered, after hearing this dreaded word.

The family decided that it would be best that my friend hear this news from the doctor himself. He went back toward the recovery room.

Later that evening, it was evident that the doctor did NOT tell my friend he had cancer. Perhaps he wanted to wait until morning, after the effects of the anesthesia wore off, to tell him. That made sense.

The next morning, he made his rounds. My friend's wife was at this side. He inquired about how he was feeling, looked at the surgical site, and left after a few minutes. He did not sit down, nor did he discuss the cancer. He did not mention anything about meeting with the oncologist. Nothing.

The following morning, two days after brain surgery, my friend was to be discharged. I was a bit shocked, remembering the days when we would routinely admit men overnight for a vasectomy. The doctor came in and told him to make an appointment in his office for two weeks for a follow-up. Again, there was absolutely no discussion; no mention of his diagnosis.

"I guess I will have to wait two weeks to know if I have cancer."

My friend's wife called in a panic. "The doctor didn't tell him! What should we do? Can you tell him for me? I can't do it."

We were flabbergasted. How could the doctor NOT have told him? Did he forget? Did he think when he told the entire family, that he told the patient, too? Did he tell my friend, who just had brain surgery and was still under the after-effects of anesthesia, and he just forgot? Was he waiting for the final pathology report? Regardless of the reason, my friend needed to know what we already knew. We agreed to tell him.

So, one hour after he came home; sitting at the dining room table where we have shared so many meals and laughs, we told our friend that his brain tumor was, indeed, a cancer.

At first, he sat there in stunned disbelief. Then, he cried. Then, we cried. After a few minutes, our friend was "back". He thanked us for being there for him. He needed time to reflect on the news that was just delivered. He looked understandably tired and frightened.

I had written him a letter while he was having surgery. I read it to him. I will not disclose the content of that letter; it is much too personal. I can tell you that fighting cancer is not an individual battle, but a war - a war that intimately involves all of us. His cancer is a war that we plan on winning.

Now...with the help of God and the miracles of modern medicine, we can plan start those battle plans.

At about 9 PM last night, my friend called to thank us again. He sounded a bit better; more optimistic. Now that he knows his enemy - the cancer - he is ready to join the fight, too.

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A Bad Week for Health, My Friends

2009-04-08T06:00:00.003-04:00

The older you become, the more likely you will have to deal with health problems, not only your own, but those of your close friends and relatives.

Last year, it was a friend's wife with lymphoma and my sister-in-law with breast cancer. This week, one of my best friends was diagnosed with a particularly aggressive form of prostate cancer. And, yesterday, one of our closest friends was rushed to the hospital when he could no longer speak. Later in the ER, a CT revealed the cause. He had a brain tumor.

Prostate Cancer
Bob has been my friend since college. We met in line since our school felt it necessary that everyone stand in alphabetical order for various functions. Both of our last names began with "M". We were even assigned dorm rooms in alphabetical order, so he lived two doors down the hall. His major was music, and he could really blow the saxophone, plus play the piano and sing. It didn't take us long to join forces with his roommate Danny (now a Baptist minister in the Midwest) before we had a singing trio - the "A-Courtians". The name originated from the fact that we lived in a dorm called A-Court. For the next several years, the A-Courtians would sing for assemblies and a few gigs for the Office of Admissions.

We were both from Pennsylvania and now, over thirty years later, we both live in California. Of course, I pursued a medical career; Bob used his music background to prepare him for a very successful career owning a pump company. After years of losing touch living our separate lives, we found each other's friendship again. We only get together one or two times per year. That is about all my splitting sides can take, since it is a non-stop laugh fest.

Bob's doctor has been monitoring his PSA levels - an indicator of troublesome prostate activity - for a few years. Sometimes the level was elevated; other times, it would go back in the normal range. It was never at the point where his doctor felt further investigation was needed; until recently, that is. His doctor decided it would be a good idea to do a prostate biopsy, in the office, without any anesthesia. This, of course, would never be something that I would agree to. I am personally at the point where I want anesthesia for a hair cut. Bob agreed to this transrectal procedure, telling me it was the most painful thing he has ever experienced - even worse than the time I hit him in the head with an entire sheet of plywood. A complication quickly developed when the surgeon hit a bleeder - an artery. Bob was rushed from his urologist's office to the hospital, losing about three pints of blood in the process. Having cheated death, Bob felt that he deserved to have the biopsy be negative for cancer. Unfortunately, it was not. Although I do not know the details of my friend's case, Bob tells me that it is a particularly aggressive type.

Aggressive types of cancer require aggressive treatments in my opinion. I insisted that he contact the best oncologist in the area. He was particularly fond of the oncologist that took care of his life-partner's lung cancer several years ago. I told him to make that call. Cancer treatment has made leaps and bounds over the years, and newer, more effective therapies orchestrate actual cures, not just palliative treatments. In the experienced hands of a good oncologist, I expect to be laughing and singing with my friend for decades to come.

Brain Tumor
It started with a phone call from George's wife.

"I think George had a stroke. I gave him three baby aspirins. Should I take him to the hospital?"

"Get off of the phone NOW. Call 911."

The paramedics arrived promptly and the stroke team at the ER was waiting for him. Prompt anti-clot treatment is critical; minutes or even seconds can determine outcome. However, George was not having a stroke.

George is a retired professor of anthropology. He speaks about four languages and has traveled and lived and lectured in many parts of the world, from Iceland to Pakistan. As a connoisseur of all foods ethnic, he was preparing a chicken dish for a lunch. He came up to his wife and started to talk. Instead of the usual rhetoric of a learned scholar, what came out of his mouth was gibberish. George thought he was communicating, but the words were not words at all - they were not words in any of his four languages either. They were aphasic words from a damaged brain.

A CT scan revealed the source of George's sudden loss of speech, and subsequent seizures. Silently, a tumor had been growing in the left side of his brain. Was it a cancer? Was it a metastatic tumor from a cancer somewhere else in his body? At this point, we do not have those critical answers.

Throughout the day, George was having periods of normal communication, followed by odd periods where he was speaking in tongues unknown. The hospital's only neurosurgeon met with him this morning and he is scheduled for surgery in two days. We will keep you posted.

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Living Without Pharmaceutical Pens

2009-04-07T12:31:00.001-04:00

I am down to my last few hundred pharmaceutical pens. Some of the pens are older now, perhaps advertising drugs that are no longer available, pulled from the market due to side effects. Some are for medications that I have never used, or will never use. I don't really pay attention to what is written on those giveaway pens. I am more concerned that they write smoothly, have a retractable tip, and fit in my pocket.

We do live in a world of subliminal cues - the purpose of advertising pens anyway. I noticed that I used a Singulair pen to jot down a few ideas this morning. It did not make me want to write a prescription for it though. I think I do pretty well about ignoring pop-up Internet ads, billboards, magazine advertisements, radio/television ads (that I fast-forward through), but perhaps I am still subtly influenced.

About a year ago, our group decided to severely limit the pharmaceutical representatives. They can no longer waltz into our office, asking us to sign for samples, or having them plop down in the middle of a busy day, telling us some new information about an old drug, or about a new drug with old information.

I always try to be respectful to the reps. Many times, they do offer an educational service, providing me with information about a certain drug that I didn't know. They have been trained not to bug us, but on a busy Monday morning with every exam room full, they can't help but bug us.

My stash of pharmaceutical pens must have been discovered by the medical providers who use my office on my day off. I now have to hide my favorite pens. I lose about three pens a day, leaving them in patient rooms where my medical assistant snatches them, or on the counter in the lab where they can be inadvertently contaminated by urine or something. I consider those pens to be lost.

Gone are the days when pharmaceutical reps would bring us t-shirts, hats, paperweights (who in the world uses paperweights anymore?), back-to-school notes, blank note pads, and such clever giveaways as a scorpion embedded in a block of Lucite (who thought of that one - and why?). When the kids were still home, they happily took advertising pens to school. I distinctly remember my son going off to Junior High wearing a Flagyl Vaginal Cream t-shirt, or an Ortho-Novum Contraceptive baseball hat. They didn't care what they wore most days. We even intercepted one of the kids wearing my wife's pants that mistakenly ended up in his drawer! You would think that the side zipper would have given him a clue.

All stops are removed when you go to medical conferences. Pharmaceutical companies pay big bucks for booth space at the bigger conventions. Pharmaceutical giveaways are in high demand, especially by the students. They walk around with HUGE shopping bags filled with every worthless trinket they can get their hands on. There are Frisbees, anatomical models of genitalia, posters, decks of cards, candy, more bags to put inside your bag, and of course, the pens. I must admit that I will use a pharmaceutical pen at their booth to sign their book, evidence to their bosses that they spoke to us. If the pen is a good one, I take it. It they are real good, I take a lot of them. A few hours in the exhibit area can get me enough pens for the entire year. I will be speaking again at the state medical conference in September. I only accept the gratuity of free conference tuition, but my real mission is to get more pens.

I have bought pens in bulk at Costco. I must admit that they are better, but they are also stolen more often and harder to trace. I am always accusing people of taking my pens. Sometimes, they sheepishly produce it, and claim they did not know it was mine. Sometimes my thorough interrogation and body searches are fruitless. My pens simply disappear into thin air. Some people will deny that the pen in their pocket is mine. Frequently, I will have to show them the ink marks on my front pocket to prove that the ink is a perfect match. I have little sympathy for pen thieves. They should be prosecuted to the fullest extent of the law.

I lost the key to my desk, so I can't lock up the remaining pens. A quick inventory yesterday produced some serious doubts that I will make September without going to Costco. I have even considered stealing other people's pens under the guise that I am just retrieving the ones stolen from me.

We are supposed to be a paperless office. If this is true, then why do I even need pens? I use up most of the ink writing notes for school or work. School notes are worth about $35 each - the federal funds given per day of instruction. If a child has an excused absence, the school still gets the money. Ten kids without notes can be a teacher's salary for the day, so I write those notes...all day long. Parents, too, need work notes saying that they took off to take their kids to the clinic. What kind of society have we created that requires "doctor notes" for just about everything?

The value of legitimate-looking doctor notes cannot be underestimated. When I used to work in family practice, I would always have some guy request a note for a day or two he missed last week when he claimed he was sick, but did not want to come in and "bother me". Most people are honest about these things, but some guys just went fishing. I would quiz them a bit, and usually the fisherman would fess up under my highly-honed interrogation style. Depending on my mood, I may still give them the note for being honest. In return, I would get a lot of fish. One guy even brought me a fifty pound tuna - much better than ink pens.

Side Note: This is my 300th Blog Post!

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The Fine Art of Incompetence

2009-04-02T13:41:00.004-04:00

Everyone makes mistakes. To err is human. Making a mistake is not incompetence. Repeating mistakes, over and over, and not learning from those mistakes is incompetence. Some people have just taken incompetence to a much higher and more refined level than others.

Today is my day off so I was in line at a large box home improvement store. I brought in a painted, broken piece of baseboard, complete with bent nails sticking out of it, so that I could buy the same type. While I was checking out, the cashier was very troubled by the fact that this piece of wood that I brought from home did not have a price tag.

"Did you bring this from home?" She asked.

"Well, yeah. It old, broken, and has nails sticking in it. Do you sell them like this?"

On Sunday, I had to call the satellite TV tech support because my DVR was not recording the shows that I pre-programmed. My wife went ballistic because Dancing with the Stars did not record. She insinuated the problem was my incompetence - that I had not set it correctly. I dislike calling the tech line, especially on Sundays. I assume (usually correctly) that the newest and least-competent people have to work the lines on Sunday. My heart raced as I navigated the phone tree. Will I be talking to a heavily-accented foreigner who claims his name is Jeff? As a fatalist, I know the person will not be competent, or perhaps I set my goals too high.

"My name is Jeff. How can I help you?" (Damn, I knew it!)

"My DVR is not recording shows that are programmed."

"Is it plugged in?"

"You are really good, Jeff. Thank you." (I called back on Monday)

We have a very large medical office; many providers, many medical assistants, and many support staff. Some days, it looks (and sounds) like Grand Central Station. We are just ending a very long "cold and flu" season, just in time to start our spring allergy season. Instead of feverish, coughing kids and kids with ear infections, we now have the wheezers and sneezers. Spring break is upon us and nervous parents are bringing in the ill and suspected-ill children to make sure they will be well before going to Disneyland. The busier the office, the more likely mistakes will be made.

Let's start with the front desk and receptionist. Within ten minutes of my arrival, a contrite receptionist will be standing in my doorway requesting a "big favor". Some unknown person apparently made a mistake. Instead of booking the appointment for tomorrow, they booked it for next year (just one number off).

"The patient is here now; you are completely booked. Can you see them?"

"Yes, of course." They always ask me because I rarely, if ever, will turn them away. No matter how busy I am, I can see just "one more patient". This wasn't the patient's fault; it was a bit of incompetence on our part.

An hour later, another receptionist is hanging out by my office, waiting for me to come out of an examination room.

"It is 9:30 and your 8:45 patient just arrived and wants to be seen. They claim that the automatic, appointment-reminder call system told them the wrong time (that really doesn't happen since calls are directly linked to the appointment time)."

If people would just tell the truth, or at least come up with a more creative and entertaining lie, I would be more willing to forgive them. I actually enjoy hearing bogus excuses, though. Over the years, I have heard lots of them. In most cases, failing to make appointments on-time is really incompetence - poor planning.

Now, the medical assistants: Many names sound the same. Yesterday, I saw Caden (age 5) for a physical exam. Caden had gained 30 pounds since his last visit a month ago; grew eleven inches taller. My medical assistant did not seem to notice. Caden was also not Caden; but really Aiden (age 9). Blame it on being rushed, or the noise, or a simple mistake. Or, call it like it is: incompetence. In the scope of things, this is a little mistake in a medical office. There can be big ones, too. We ALL have to check and double-check: comparing names with birth dates and confirming that we do, indeed, have the right person and the right chart.

Before my wife went in for abdominal surgery, I physically wrote her name and the type of surgery she was going to receive ON HER STOMACH. Her surgeon was amused, but at least she didn't get the wrong surgery.

The pharmacist: We use electronic or e-prescriptions (and e-faxes) in our office to limit mistakes. It is now more difficult to give a medication to a person who was allergic to it. People no longer lose their prescriptions on the way to the pharmacy, and of course, druggies can no longer change the amount, say from 10 to 100 pills. We can however fax the prescription to the wrong pharmacy in the wrong state. Every state in America seems to have a town named Roseville and a Walgreens. A slip of the finger could send your amoxicillin to Minnesota.

The patient was sitting there when I sent her prescription electronically. There was confirmation that it was successfully sent. She showed up in the pharmacy about an hour later and was told that no prescription was sent. She called me. I confirmed (again) that I had sent it. Cyber-crap does happen, so I just sent it again. She went back to the pharmacy and was told they never received it. Now, I am mad, so I called the pharmacist personally. It took about 15 minutes for him to get to the phone. I nearly had a nervous breakdown listening to bad music on hold. I told him of the two prior failed prescriptions, and he told me what was happening.

When the pharmacy technicians get busy, they simply remove the paper from the fax machine and allow the fax to be stored in the buffer. That way, when the patient arrives at the pharmacy, they can honestly tell them "they did not get it". As soon as they catch up, or when the next shift is getting ready to come on, they simply put the paper back in the fax and magically, a few dozen prescriptions (including both of mine) come out. I orally gave the prescription to the pharmacist this time.

Twenty minutes later, the patient is on the phone again. This time she is standing in the pharmacy where she is being told A THIRD TIME that they do not have her prescription! No one bothered to even ask the pharmacist in the back if he had it. This is incompetence.

As a medical consumer, it is imperative that you take an active, participatory role in your care. Make sure the prescription at the pharmacy is the same as what your medical provider told you that you were getting. Of course, there is the "generic versus brand name" issue.

"I am going to fax over a prescription for Omnicef."

Of course, when you arrive at the pharmacy, the bottle will say "cefdinir". Unless specified, the pharmacist is obligated to give the generic because it is less-expensive. A quick consultation with the pharmacist will confirm that you did, indeed, get the right prescription. Just like Caden and Aiden, there are many drug names that sound the same, too.

I was re-editing this blog post today before publication and the phone rang. It was my tax-preparer. She said that I apparently gave her a wrong social security number for my wife and the electronically-filed taxes were rejected and that I would need to file by mail.

"You have my wife's social security number. The same one you used last year, and the same one that is on the W2 form. You were the one that transposed one number differently on the 1040 form, not me." Silence followed.

"Yes. I see that is what happened. Thanks." Click. No apology for the mistake. No apology for her lame attempt to shift the blame. I am sure glad that I complained about their increased fee this year to do the exact same job. I guess the more you pay, the less we get.

If one out of four people are incompetent, then think of three other people. If they seem okay, then maybe it is you. Just kidding. Again, everyone makes mistakes. It is quite easy to blame others. It takes an honest person to admit your errors.

Don't just assume because your medical provider has a lot of letters after his/her name, that it automatically means they are always competent. I have been in the medical biz for over three decades and I have seen a lot of mistake; even made a few (little ones) myself. I thank God every day that I have never harmed anyone with a medical mistake -- a record I intend to keep.

It has been said that medical providers hide their incompetencies and bury their mistakes. My personal philosophy was inspired by a book years ago called Kill as Few Patients as Possible by Oscar London, MD, WBD. (Incidentally, the WBD means "World's Best Doctor" - a tongue-in-cheek degree.) There are no such animal as the "best doctor", only the best person.

I will end with Dr. London's (a pseudonym) final words in the book: "Keep out of jails...and hospitals."

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Dancing with the Scars (Emotional Ones)

2009-03-24T18:30:00.007-04:00

Photo Credit: Seth Anderson

We all have emotional scars of some sort and my nemesis has always been dancing. I enjoy watching all types of dancing, but when it comes to taking the dance floor, I can't do it. I have been pressured into an occasional slow dance at a wedding, my senior prom, or some other special event, but when it comes to getting' down, I'm not getting up. I actually find dancing, even slow dancing, physically, as well as emotionally, painful. After two minutes of uncomfortable dancing, my hips, knees, and feet hurt.

The last time I danced was at my son's wedding - the Hora. One of my sons, Benjamin, actually broke his arm at the wedding trying to impress the ladies with his slick dance moves. There is nothing like leap-frogging over another dancer and breaking your arm to impress women.

Someone by the name of Vicki posted a comment on one of my blog posts to suggest that I dance with my wife as a way of getting exercise. At first thought, I would rather be chased by a pack of rabid pit bulls then dance. She did suggest that we do it privately (at home) which would eliminate that performance anxiety. I do realize that dancing would be a good exercise outlet, but in order for any exercise to be effective, it needs to be sustainable. I would have to LIKE dancing, and I do not. Of course, bad dancing may have more aerobic benefit than good dancing.

I do not have a problem singing in front of crowds. In college, I was in a Kingston Trio-like group, and I have sung in barbershop quartets. My barbershop group even sang the National Anthem at an Oakland Raiders game back in the ‘70s. But any type of dancing in front of other people terrifies me.

I have been on numerous (live) television shows. I have given medical talks in front of thousands of people. I once gave a lecture on "Fever in Children" dressed as Satan, complete with horns and pitchfork. Again, I had no problems. When I entered the lecture hall to the music of Fever by Peggy Lee, I did try to dance a bit. I quickly stopped when I realized how badly I was doing. One of my colleagues did mention to my wife that, "that boy has no rhythm", further validating what I have always known.

Like many men, I have to tolerate Dancing with the Stars, a virtual showcase of good dancers teamed with klutzes, like myself. They have fat people, old people, and the rhythm-impaired. Unfortunately, I am all of those. My wife loves that show and keeps pointing out the big guys that have learned to move like Fred Astaire. She insists that a singer has natural rhythm. I insist that I do not. Even when the barbershop quartet would do a synchronized move, I would be doing something totally different.

My mother loved to dance, mostly the polka, which I found to be odd. My first wife's family were Slovak and they, too, loved to polka. In my experience, the vast majority of polka dancers are heavily influenced by alcohol. Since I never drank alcohol, I blamed my lack of polka enthusiasm by simply being sober.

My high school years were in the late 1960's - a period of some very odd dancing styles. In rural Pennsylvania, we did not have free-loving, dance-crazed hippies - just hillbillies. Hillbillies liked to clog to banjo or fiddle music, or even church music. Again, I did not fit in. After college, I moved to San Francisco, working in a clinic a few blocks from the Haight-Ashbury district. Pot-smoking hippies loved to dance, and since I did not smoke pot, I mostly sat and watched. Then came the disco years, yet another reason not to dance. Besides, I didn't own a white disco suit.

As I am writing this post, Dirty Dancing is playing on the television in another room. I really enjoyed that movie, but I did not envy those dancers one bit. I only identified with the rhythm-impaired sister singing the Hawaiian song. One of my favorite movies of all time is Billy Elliott, but in this one, I identify with the caring father - not the ballet dancer. I have gone to dozens of dance recitals, starting thirty years ago with my daughter, and ending about six years ago with my granddaughter. I find recitals interesting, but if I had to miss one, I would not be heartbroken.

I have tried to analyze myself to determine the origin of my emotional scars about dancing. I do believe that some of us are rhythm-impaired. I am not very good at sports either. Both dancing and sports require a certain level of rhythm and coordination. I can sew up a lacerated eyelid or lip on a struggling two-year old. Let's see a dancer do that!

Maybe it started in kindergarten. Kindergarten teachers (Miss Hickle) loved to make us dance; sort of an evil spell. I distinctly remember doing the hokey-pokey. I felt the name of the dance was appropriate: it was hokey, and I was pokey. The hokey-pokey was NOT what it was all about.

I didn't fare in better by junior high. A group of guys would be sitting on the bleachers watching girls dance with each other. Girls had to dance with each other, since we were on the bleachers. Occasionally, one of the guys would go up and ask someone to dance - usually a slow dance. We would laugh at him, but secretly envy him for his nerve, and of course, the fact that he was holding a nice-looking girl very close. The Twist was the rage about that time, perhaps the easiest dance in the world to learn. I couldn't do it. I had problems with the hula-hoop, too.

My high school girlfriend was a cheerleader. She had lots of rhythm and liked to dance. I would feel obligated to dance with her from time to time, mostly so no one else would dance with her. Guys are like that. We won't dance, but we don't want anyone else dancing with our women.

In college, I didn't dance either. I went to a Baptist college in West Virginia for my undergrad. We had a joke: "Why don't Baptists have sex standing upright? They are afraid someone will think they are dancing." I told that joke to one of my patients - a Baptist minister. He loved it. For reasons unclear, some Baptists feel that dancing is ungodly. In Appalachia, only the fringe Pentecostals danced - with snakes!

My wife loves to dance, unfortunately. I gave my blessing when she wanted to do line dancing with a neighbor. She tried her best to get me jealous about other guys in the class, but it didn't work. I dislike doing all types of dancing, but some I dislike more than others (polka, line-dancing, fast dances). I once weakened a bit and agreed to take dancing lessons at Arthur Murray, but I never followed through. I chickened-out. Oh, yeah, that's another dance I don't like - the Chicken Dance.

I do envy those who can dance, and those that love to dance. It looks like fun. I am not sure where those dancing scars originated, but for now, I am destined to be a clumsy wallflower, to sit on the bleachers of life watching others cutting the rug, tripping the light-fantastic. I will just do my medical stuff - perhaps putting a cast on my son who broke his arm dancing, treating someone with the Tijuana Two-Step, or someone who may be "Dancing with SARS". The way I look at it, not everyone can dance. Perhaps, not everyone should dance.

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Balloons in Medicine

2009-03-17T14:24:00.001-04:00

Over the last few years, I have blogged about ballooning health care costs, or discussed health-related scares that popped my proverbial balloon. Some of my nearly 300 blogs posts have been popular; some went down like a lead balloon. In these trying economic times, we hear about balloon payments. There are pop-up balloons on many Web sites, and we read about released Mylar balloons causing major power outages. A few years ago, many people were injured at the Macy's Thanksgiving Day Parade by one of those huge renegade helium balloons. The Mars Lander used balloons for a safe, albeit bouncy, landing.

Photo Credit: a4gpa

Balloons are a part of every birthday celebration. In my office, the staff usually decorates my office with dozens of balloons; a nice gesture, but a bit annoying on a busy day. As kids (and college students), we threw water balloons, often making catapults out of surgical tubing and a plastic dog bowl.

When I turned fifty, my older brother surprised me with a hot air balloon ride over Sedona, Arizona. I chickened out, remembering those shocking videos of hot air balloons landing on power lines, and of course, the Hindenburg. My brother was disappointed. I am not a big fan of heights, so I don't regret not giving it a try. I threatened to give him scuba time in a shark cage on his birthday, so he understood (I think).

Photo Credit: Denise Chan

The medical profession has been using balloons of some sort for decades, heralding new and safer, non-surgical approaches to common human afflictions. Many people are familiar with balloon angioplasties for opening clogged blood vessels, intragastric balloons for weight management, balloon urethroplasties for those enlarged prostates (Ouch), balloons to repair a broken back (balloon kyphoplasty), balloon ablations for menstrual disorders, balloon endoscopies for treating small bowel cancers or ulcers, and even balloon dilatation for naso-lacrimal duct obstructions (clogged tear ducts). Balloons are surgically-inserted under the skin to expand tissue before certain surgical procedures where "extra skin" is needed. In many surgical procedures, a Foley catheter is inserted into the urinary bladder; a small balloon is inflated to keep it from coming out. Basically, if there is a natural (or surgically-created) hole in the body, some medical professional will think about inserting a balloon in it.

In the ENT world, there is a new procedure called balloon sinuplasty to open up those blocked sinus passages, and, for years; medical providers have used a rhino-balloon to control epistaxis (severe nose bleeds). One simple home remedy for ETD - Eustachian tube dysfunction is to try and equalize middle ear pressure. By blowing up a balloon (a difficult-to-blow up one), you can force a little air up the Eustachian tubes into the middle ear. Of course, you can do this without a balloon, too.

A condom is a balloon of sorts, too. "Get outta my room unless you brought a balloon!"

Photo Credit: Ed Luschei

Balloons can save lives, but they can also be health hazards, even cause death. Kids insert balloons (deflated, of course) in their noses and ears. I have taken out many of them, but not any of the ones that I gave them. It is also very common for children to swallow deflated balloons - something nature will dispose of naturally in most cases. Sadly, some children have died by aspirating a deflated balloon into their airway. In the United States, at least 121 children have died in a similar manner in the 15 years between 1973 and 1988 according to a report by the US Consumer Product Safety Commission. The highest mortality occurred among infants, 30 (25%) of the 121 deaths occurred in children 6 years of age or older. Balloons account for 43% of the approximately 15 childhood deaths related to children's products that are documented each year by the Consumer Product Safety Commission. Children frequently choke on tiny toys, peanuts, a Tic-Tac, pieces of apple or meat, and other foods - just about anything that fits in their curious mouths.

One of the first, practical things you learn in pediatrics is how to use a latex glove to make a balloon animal of sorts, usually a lame-looking rabbit, and for the less-creative, a big hand, a cow udder, or five-armed octopus (pentapus?). Assuming no one is allergic to latex, this can be a useful skill. Balloons can carry your germs if you blow them up yourself, so unless you have an inexpensive inflation pump, you may be passing on your pathogens to others. I have never left a latex glove inside a person after surgery, but you sure read about them.

Photo Credit: Katy Warner

Many years ago, my wife gave me an interesting birthday gift - a class to learn how to make real balloon animals. For many years, I have thrilled some of my little patients with a balloon dog, giraffe, swan, sword, or hat. I make pirate swords and scabbards, occasionally challenging them to a duel. While on a medical mission in Jamaica, I made balloon animals for the kids who came to the clinic. They were so popular that some of the women in the village asked me to make them some elaborate balloon hats for a political rally. In some of the news footage, my hats could be prominently viewed.

Last year at a medical conference, selected participants were asked to present a pearl. We were all given two minutes and could only use two slides. I won (a book store gift certificate) for showing the audience of 800 how to make a wiener dog - an "anatomically correct, male wiener dog" to be more accurate. This was one of my own, naughty creations. I have adult patients, too.

Bosco the Clown, my balloon animal mentor, claims he has handed out over a million balloons in his career and hasn't killed or harmed one child to his knowledge. He is sure that if he did, an attorney would be contacting him. Nevertheless, balloons should not be given to children under the age of three (some warning labels state age eight), developmentally-disabled children, or any child who may have irresponsible parents. Common sense is often not age-related.

Not all children are thrilled by a balloon. A heavily-inflated balloon that bursts can scare the crap out of anyone. I wonder how many parents have swerved off of the road when one of the kid's balloons exploded in the back seat, or dove for cover in the inner-city. Frightened parents may be able to experience another life-saving balloon - the automobile airbag.

Balloons do save lives, and tragically, take some away. We should always be careful with young children and balloons. I still give out occasional balloon animals to selected kids with responsible parents. Do I worry? Not really. I do worry about that prostate balloon, though.

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A Ton of Prevention - The Big FIVE

2009-03-10T13:38:00.005-04:00

It used to be an "ounce of prevention is worth a pound of cure", but everything has gone up. The cost of medical care is astronomical, but preventive efforts can be relatively cheap. Not only will you save money, you will live longer (so you can earn the money you lost in this economic crisis). I know you have heard these things over and over in your life, but hearing them...and doing something about it is an entirely different issue. I am no different that millions of other people. I have health issues and I struggle with them, too.

I have health problems that I cannot change, like my tinnitus. I can't even remember what it was like to experience quiet - not hearing that constant, high-pitched whine. I have basically learned to ignore it (sometimes). I have arthritis, both degenerative (due to age) and acquired (from injuries). I have high blood pressure - a family legacy. And, my weight has been silently creeping up on me over the last two decades, to the point where it has been affecting my overall health. I could have over a thousand dollars a year if I didn't have to take blood pressure medications.

1. STOP SMOKING. Not only are cigarettes expensive, cigarette smoking results in billions of dollars of health related costs, from respiratory diseases (bronchitis, pneumonia) to even more life-threatening problems such as emphysema and cancer. All smokers know people who have smoked all of their lives without problems, but all smokers also know people that have died as a result of this habit.

I met a fellow in my clinic the other day from Ireland - one of my favorite countries. I read that Ireland has now banned smoking in the pubs and I wanted to know his perspective. He told me that every person in Ireland knows someone who has died of lung cancer, or has emphysema, so this ban on smoking was to honor their shortened lives and to keep from attending more funerals/wakes.

I never smoked, but I do know how difficult it is to break bad habits, or in this case, nicotine addiction. At an average of $5.00 a pack, a one-pack a day person would be spending well over $1,500 per year. Since you buy things with after-tax money, you are going to need to earn more than $2,000 to support this habit. If you have missed days of work due to respiratory illnesses, then the costs are even higher. My father was a smoker. He died of lung cancer at age 39.

2. EAT BETTER AND WISER. This is my biggest nemesis, since I love to eat and I hate dieting. I track my families spending on Quicken so it is easy to see how much we spend on food per month. It saddens me to see how much we waste by throwing it away - we either made too much and no one wants to eat leftovers, or we bought too much (like fresh vegetables) and they went bad before we got around to eating them. We used to cook for five kids, so our food bill was unbelievable. I know we prepare larger meals than we need, still thinking we are cooking for a small army.

I think we eat relatively well, but perhaps too much. Both my wife and I work long hours (12-13 hour shifts, not including commute times), and we just do not plan well enough. We only have an hour of awake-time after we get home. We tend to eat lunch at our desks completing patient charts, and we do not have time to have dinner at work before our evening shift.

As I was writing this Blog, my wife came in trying to make a three-day meal plan. We are trying to do better; one step at a time. She is on a mission right now after getting weighed at her doctor's office last week, so I expect to be suffering along with her for a while. I need to lose weight, too. Not only would my blood pressure and arthritis improve, but I would not have to spend money on bigger pants.

I suspect we could trim our expenses hundreds of dollar per month by preparing less food, pre-planning meals, and shopping wiser. We do try not to eat out, especially a fast-food lunch, but sometimes we wake up too late to make lunches. I am a big sushi fan, a healthy but expensive alternative to a packed lunch. Grocery store sushi is cheaper, but not very good, so I tend to buy it anyway. I eat less when it doesn't taste very good.

I have a stressful profession and good food was always a reward. I don't drink alcohol - never did - and I don't take sedatives. There are times when I would risk prison time to get a good chocolate chip cookie. For people who do drink (excessively), you know you have a problem.
And, for you vitamin-takers - vitamins do not really correct poor nutrition or prevent the kind of illnesses that are likely to kill you. Don't fool yourself that taking vitamins, herbs, or other concoctions will assure you longevity.

3. EXERCISE. I absolutely hate to exercise. I permanently injured my ankle several years ago trying to stand on my kid's skateboard (Don't laugh. It looked easy.) My neck and back were injured in a car accident and if I overdo it, I will feel it for days. I work very hard all day, probably putting on several miles between exam rooms, and my days-off are active with gardening, stacking firewood, and mowing the lawns. I do not sit on my butt, but you wouldn't know that by looking at my butt. I just can't get beyond the fact that I find walking boring and a waste of time. I hate to go to a gym and deal with that eclectic crowd. My wife joins a woman's gym at least every year and doesn't go, so that is a waste of money, too. She insisted on buying a treadmill, and as you know, it quickly becomes a dust-collector and a place to hang up your clothes. I can effectively justify a hundred reasons for not exercising except one. If I don't overcome my own personal block and devote a reasonable amount of time doing purposeful, organized exercise, I will be paying a big price. Because of my long working days, I do have four days off per week, so I will have to start by walking the dogs. Maybe I can get them to pull me on a skateboard? No, tried that once. Bad outcome. All of us need to find a physical outlet that is both enjoyable and safe.

4. PHYSICAL EXAMS. If you have lost your insurance, you may be avoiding the doctor's office at any cost. Men, in particular, avoid medical offices like the IRS. Men tend to wait until things are really bad and their spouse drags them in. Even though I am in the profession, it has been a while since I saw my own medical provider. I guess I am avoiding the lectures about all the things that I am not doing - the same lectures that I give to other people every day. I can dish it out, but I hate hearing it from the patient-end of things. I am a believer in self-care; the concept that people can and should take responsibility for their own health. However, believing in it and doing it are two different things. I know my health risks, but like many people, I have a reluctance to do something about it.

Ignoring preventative care is a dangerous practice. No one want to have a gloved finger up their butt or worse yet, a colonoscopy, but ignoring efforts to detect colon cancer won't prevent it from happening.

Something as simple as an annual flu vaccine can save your life. Although it doesn't make the evening news, thousands of people die every year as a result of influenza. Adults need tetanus vaccine (the disease is 100% fatal), too, with diphtheria and now, whooping cough vaccine again (its back!). Pneumonia vaccines are helpful for older people and those with asthma and other respiratory illnesses.

Women need periodic pap smears and mammograms, and most of them are pretty diligent about getting them. Men need to take a lesson from this dedication.

Work closely with your medical provider and make sure that you openly disclose any financial problems you may be having. Less-expensive, generic medications, less-expensive diagnostic tests, etc. are usually available IF your provider is aware of your situation.

5. SAFETY AND ACCIDENT PREVENTION. You can save a lot of health care dollars by not being stupid and getting hurt. If you do not wear seat belts, talk on the cell phone, eat (fast food) in the car, and drive too fast or aggressively, or God-forbid, drive while impaired, then you going to be seriously hurt or killed...eventually. If you climb up a rickety ladder to hang Christmas lights, or try to do your own electrical work, you may be asking for an injury. Loose throw rugs at the top of stairs, slippery bathtubs, poor lighting, etc., all take their annual toll. People are killed or seriously disabled from some of the more obvious home hazards - hazards that are preventable.

These are just FIVE of the many preventative health measures that we all can do. The longer we live, the more we have the opportunity to enjoy life. Like the immortal words of Spock to "Live Long and Prosper", we need to prosper by remaining healthy.

We all need to tighten our belts - financially and physically. I am going to do it and I strongly suggest you do it as well.

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When the COBRA Strikes

2009-03-05T13:00:00.006-05:00

More and more patients have been presenting to my office for complete physical examination, asking for extensive lab work and refills of medications. Why? They are losing their insurance, often due to losing their jobs. And, even if they do quickly find a job in this troubled economy, there is often a delay of months until a new insurance will be in effect. To make matters worse, the new insurance may be an HMO may not have our office as a preferred provider. This visit may be their last visit to our office. Obviously, continuity of care and provider preferences are not high priorities for insurance companies. Their unwritten goal is to provide an acceptable quality of care for the least amount of money.

It is required by law that employers offer COBRA insurance when an employee leaves or is terminated. The law does not require that the insurance is affordable. Since many companies pay all or at least a significant part of the premiums, the terminated employee, without an income, is required to pay the full amount. In many cases, it can cost a family $1000 a month. I like to call this the bite of the COBRA. As long as people do not eat or pay their housing costs, their unemployment checks may cover COBRA costs.

Companies have group insurance, usually at a discounted rate, and usually from the low-bidder. The insurance company is required to insure all employees (and their family members), even if they have a pre-existing medical condition, such as diabetes or cancer. When the employee loses their jobs, any pre-existing condition would preclude them from getting private insurance from another vendor. So, often, the only option for recently terminated employees is to pay the astronomically-high COBRA premiums.

Obama's Economic Incentives Plan has a provision for the government to pay about 65% of the cost of COBRA for people who have lost their jobs, for up to nine months. This will help, but what will really help is complete health care reform, and some government oversight on what insurance companies can charge. The housing market has taken a huge dive, so it is really time for a substantial adjustment in health care costs, including insurance premiums and drug costs. Health care giants, like oil companies, have taken huge profits in the last few decades. Universal health coverage is in all industrialized countries, except the U.S. About 28 percent of the country is receiving health benefits through the federal government, however, through Medicare, Medicaid, and Veterans services. All in all, 15% of our country's GNP is health-related services, more than any other country. In addition, illegal aliens living in the U.S rack up billions of dollars in charges just using the emergency room for mostly non-emergencies.

Compared to other countries, the cost of medical care in the U.S. is among the most expensive. An American friend of mine, living in Mexico, pays only a few hundred dollars a year for basic health insurance. While the level of technological care in Mexico may not be up to U.S. standards, neither are their standard fees. Granted, I would rather receive medical care in the U.S. if I were ill, but it would really be nice if those fees reflected the cost of doing business. A private doctor that I know once bragged about charging $30 for a lab test that cost him about three CENTS in his office. He laughed all the way to the bank.

While traveling in New Zealand years ago, I saw a posting of charges on a health clinic wall. I was shocked that the same services provided in the U.S. are many times greater. One common antibiotic in the US was nearly sixty dollars; it was on eight dollars in New Zealand. The pharmacist explained to me that the entire country of New Zealand is the collective bargaining unit, so the government negotiated for a lower fee. In the U.S., we pay what the market allows. Walmart is advertising hundred of prescriptions now for just $4.00 and why not? Naprosyn 500mg, for instance, costs a pharmacy about $17 per thousand. They are able to fill over 17 prescriptions of sixty tablets - a one month supply - at $4.00 each, they would still make a 388% profit (not counting the cost for the pharmacist to put it in a smaller bottle, of course).

Basically, insurance premiums are high largely in part because medical charges are high. Medical charges are high for many reasons - high malpractice premiums, high salaries, expensive laboratory tests, expensive imaging (x-ray, CT, MRI) studies, administrative costs, and of course, expensive medications. In the end, the wage-earning consumer (or the federal government) eventually picks up the heavily inflated tab.

A former patient of mine, a Hiroshima survivor and now a U.S. citizen, was between a rock and hard place. She is entitled to free medical care in Japan, but in the U.S., she has to pay out of pocket. She cannot afford health insurance. Since the atomic bomb dropped on her city, she has been worried about cancer (rightfully so). Every time she had a sore throat, she would think it was throat cancer. When she coughed, it was lung cancer. I spent a great deal of time reassuring her and trying to keep down her costs by charging less (sometimes free). I was on vacation when she ended up at the local emergency room with a cough. Since they were not familiar with her medical history, they ran some very extensive tests. Her total ER bill for a one hour ER visit was about $5000. In tears, she showed me the bill. I spent the better part of one month trying to negotiate a lesser fee for those excessive charges, to no avail. She ended up paying it all from her savings. She told me that it would have been less expensive for her to fly back to Japan for care. More and more Americans are doing just that - they are flying to other countries to get medical care, like hip replacements.

The cobra is one of the most poisonous snakes on this planet. Like its insurance namesake, its bite can kill and certainly disable a victim - medically and financially.

I am in my 36th year of medical practice and I pray for health care reform. I pray for less-expensive insurance and medical services. I pray that Mr. Obama can pull it off. If not, praying may be our ONLY insurance.

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When Ellis Met Grandpa

2009-03-04T08:26:00.000-05:00

Photo Credit: Rod Moser

I waited three weeks to see him, mostly to avoid the chaos that a new baby creates in the family. The grandmothers were there, an uncle, the uncle's girlfriend, the other grandfather, and an assortment of friends and neighbors - too many people. I knew he was healthy and I saw his picture (actually, a hundred or so pictures) that were posted on the Internet by the proud parents. When I finally did meet my grandson, I felt I already knew him.

Ellis lives with his new parents about 9-10 hours away by car. My wife and I like to drive when we can so that we can create our own schedule. So, we both canceled some previously-scheduled patients (we hate to do this, but all of my patients know this is important) and took off at 5 AM. I love driving early in the mornings before traffic starts. It is quiet; the stars are out, and besides, I am awake anyway. For some reason, as I have aged, I tend to require less sleep, which is contrary to what others might experience. I would love to sleep for eight hours, but my body simply refuses.

We live in Northern California in the Sierra foothills, so the quickest route south is through the Central Valley. This time of year, the valley is just awakening with all of the fruit and nut trees blooming. In contrast to the boring scenery most of the year, springtime in the Central Valley is beautiful. There was even some snow on the Grapevine - a high pass out of the valley into the Los Angeles area.

Perhaps it was my anxiety about meeting my grandson, but I made "good time" on the route south, hitting the highly-congested LA traffic just right. An hour later and I would be sitting in a slowly-moving parking lot.

We arrived at our hotel promptly at 2 PM, their check-in time. Of course, the room was not ready. Exhausted from the long drive, we waited...and waited. They offered us a smaller room (for the same price, of course), but I chose to wait. After about an hour, they offered me a room normally reserved for handicapped guests. I refused; just like I refuse to use the handicapped stall in the restroom. What if someone came in and needed it? I agreed to the smaller room.

Of course, the hotel was being remodeled - just my luck. The smaller room reeked of fresh paint to the point of utter nausea. The window was open to air it out, but of course, that looked out on the freeway. They offered to bring an ozone machine, but told me that we could not be in the room while it was running! Should we camp out in the hall? They offered the handicapped room again. This time, I accepted. At 8 AM the following morning, I regretted that decision, too. The workman in the room next door where apparently setting up a saw mill and had a hammering contest. Nice place. This will be the last time I will stay there, of course. The front desk offered to reduce our room rate. I saved ten dollars!

Ellis had no idea what we went through to see him. We drove to my son's house. He had mistakenly given me the name of the wrong hotel, so it was about another half hour away. We passed the hotel that he really intended to tell us about a mile or so from their home. Don't feel bad for me. A lot of our trips are like this. I sort of expect it now.

We knocked lightly on the door so that we would not wake up the baby. A cacophony of barking dogs followed. If Ellis was sleeping, he is awake now. My son and his wife have two young Boston Bull Terriers that are not noted for their quiet demeanor. They were jumping and barking, in spite of their bark collars. Like many new couples, they often get dogs to see if they will be capable of being good parents. Those dogs are pampered (not literally). Later, I wish they were in Pampers. They were the Farting Dogs (see my previous blog post). I had experienced my first (of many) raunchy dog farts, initially thinking it was a poopy diaper. A poopy diaper is like a flower compared to what emanates from those two dogs.

Ellis was upstairs nursing. I could hear him fussing around, but I had to patiently wait until he was finished. New mothers tend to be a bit shy when breast-feeding, as they should. Breast-feeding is natural and beautiful, but it does not have to be a public performance.

We brought Ellis a blanket that was handmade and embroidered by my mother - his 87 year old great-grandmother who is now in a nursing home with Alzheimer's. She made it in 1980; when my son was only two years old. Sadly, she does not know she has another great-grandchild, so we gave Ellis a picture of my late father and my mother - two of his great-grandparents.

Photo Credit: Rod Moser

My heart raced as my daughter-in-law proudly carried Ellis down the stairs. There he was; satiated and bundled in a blanket. He looked just like my son, only smaller. She handed him to me; my grandson. I looked into his little eyes. He looked at me (or the ceiling fan). I smiled. I did not cry (on the outside). For the next two days, I tried to hold him as much as I could. I sang to him. We talked. Well, I talked and he listened. I really wanted to call him Elmo, my chosen nickname, but I know my daughter-in-law does not like it, so I restrained my normally-unrestrained self. Ellis will be loved.

I was proud of these new, albeit sleep-deprived, parents; this is not an easy job. Babies nurse, poop, and sleep, interspersed by crying and fussing. Sometimes, they just lie their quietly staring at nothing, perhaps wondering where in the hell they are. Their little senses are being constantly challenged with new faces, new sounds, new experiences, new things to touch, and new smells (like those dog farts).

I have three other grandchildren from my wife's lineage and prior marriage. I love them just as much, but seeing your first, biological grandchild is an unbelievable experience. When your youngest child has a child, you do feel a bit older, but that is expected. I wish we lived closer.

Today, I got my first phone call for advice and I was thrilled. They found "crystals" in his diaper and were worried. Immediately, I knew they were from the diaper, not the diaper-user.

I gave my son an otoscope and my book, Ears: An Owner's Manual. He will need it in about six months when the maternal immunity wears off and the ear infection years begin. My son is an RN; my daughter-in-law is a teacher. They will both need those complimentary skills in raising my grandson.

Photo Credit: Rod Moser

Ellis will make me take better care of myself. I want to be around a long, long time to watch him grow and hear him call me Grandpa. Grandparents are very important and I plan on being important to him and my other grandchildren. That is what grandparents are supposed to do.

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Farting Dogs

2009-02-25T17:08:00.013-05:00

Bella and Gordy Photo: Rod Moser

I may have reached a new low on Blog topics, so I apologize in advance. As a lifelong dog-lover, I think this is a topic that should be discussed. I am not the only one that feels this way, either. When I put "dog farts" in my Google search engine, there were 340,000 citations. Much to my personal horror, some of those citations were videos! Anyone that has ever owned dogs know that dogs will occasionally clear a room with an eye-watering, gassy ripper. Sometimes the dogs are just blamed by a shifty-eyed man sitting next to him, but sometimes it IS the dog, or in my most recent experience...two dogs.

Dogs have similar gastrointestinal tracts as humans. They eat and intestinal bacteria try to digest and break the food down into fuel. Depending on what is eaten, some foods are just more-gassy. Foods high in sugars, carbohydrates, and slowly-digestible fibers can produce quite a bit of flatulence. Notorious in the gas department has always been beans, cabbage, cauliflower, broccoli, onions, garlic, potatoes, brussel sprouts, milk/lactose, and even pasta. Most people have identified foods that react in this way. This is why we don't feed bean burritos to dogs (or Grandpa) or why it is not a good idea to eat a big bowl of chili before a job interview. Much of dry or even wet dog food has a lot of grains, and most grains fit this gassy category.

Other things that fill our intestinal tracks with gas would be carbonated beverages, eating too quickly, and aerophagia - the medical term for swallowing air. Stomach gas will come out as a belch (eructation), but some of this unwanted air will migrate into the intestinal track where it blends and mellows with the gassy products of digestion.

Gas expands at higher altitudes, so this explains why air travel often causes flatulence. Most questions that I get on the Ear, Nose, and Throat message board involved ear pressure with air travel; not farting. Even with my tinnitus and decreasing hearing, I still hear (and smell) an occasional fart on my travels. The culprits are usually sleeping (or pretending to be sleeping).

I had a farting dog when I was about twelve. He ate mostly what we ate, and his name was Casper - an albino boxer. Not only would he sleep on my bed and lie across my legs to the point I was dreaming I was paralyzed, he was a big farter. Because of that, he spent most of his time sleeping in our basement. My mother was not a big fan of dog farts.

I recently read a National Geographic article on whales and they discussed foul-smelling, whale-farts. On a trip to Baja two years ago, I personally experienced a few of those, although the Mexican tour guide looked a bit guilty in my opinion. There were no dogs around to blame.

So, everyone and every mammal will fart from time to time, although a significant percentage of the human population will deny it. When I was in medical training, I was horrified one day when the lecturing radiologist suddenly stops talking and let out one of the loudest intestinal explosions that I had every heard. Naturally, a fart causes a reaction, and in this case, the reaction was laughter.

"Why are you laughing? Flatus is a normal, human response", he said.

We knew that, of course, but we were not expecting a distinguished member of the medical community to fart in front of the entire class. I hope this is not going to be on the final. Throughout the semester, he would fart at least two to three times per class - loud ones - and pretty much getting the same class response. After a few weeks, we sort of got used to them. I did try to come to class early so I could get one of the cherished seats toward the back. It is one thing to hear a fart. I did not intend to have a multi-sensory experience.

I went to visit my new grandson for the first time this week. I will blog about that "First Encounter" on a separate post. It seems sacrilegious to talk about your grandson and farting dogs in the same story. My new grandson lives with his parents (of course), a cat, and two Boston Bull Terriers: Bella and Gordy, the Farting Dogs.

Babies fart all of the time, much to the amusement of older siblings. Working in medicine, especially pediatrics, I have become accustomed to these random acts of innocence. I have encountered some of the more noxious and odoriferous smells known to man, but these two dogs can quickly clear a room. I am not exaggerating. Not only are they very sociable; jumping all over you, they will randomly fart a dozen or more times every hour. It was unbelievable. I once read that dogs have a sense of smell a thousand times greater than man. If this is true, then why did they not seem to mind the stench?

Photo: Rod Moser

They have even taken the dogs to see veterinarian specialists to no avail. The dogs are on a special diet (including duck!) and take special anti-fart food additives. Nothing works. One of my son's proud possessions is an air purifier (one of those expensive ones that are not supposed to really work). I now know why he needs it. There are cans of room deodorizers all over the place, including special ones that are sold for dog farts. If these were my dogs, they would be eating activated charcoal, attached to a catalytic converter, or spending a considerable amount of time outdoors. This was a real learning experience for me.

Inhaling dog farts cannot be healthy, but surprisingly, they have not been proven to cause tumors or respiratory problems. Or, do they? My son was diagnosed a few days ago with left lower lobe pneumonia. Is there a connection? If people can try to blame autism on vaccinations, then I can claim that dog farts cause pneumonia. I worry about my little grandson. He does seem to cry a lot. Can we really catch something from dog farts (other than nausea, of course)?

Farts are composed mostly of nitrogen with a little carbon dioxide. The rotten egg smell is hydrogen sulfide. The flammable gases of methane and hydrogen are also produced in varying amounts. For those of you that have not witnessed the fine art of lighting a fart - a memorable experience from my undergraduate years - it does work. You can get a little blue flame, not unlike a gas stove. My son and his wife had a lot of perfumed candles burning. Hopefully, there will not be an explosion.

I only had one patient over the years that specifically made an appointment because of farting. She had one of the original intestinal bypass surgeries for weight loss and no one really warned her about foul-smelling flatulence as a side-effect. We were able to help her using bismuth subgallate. I suggested this as a remedy for the farting dogs, but I don't really know if this is safe or will even work.

Probiotics used to restore intestinal balance are the new buzz word at the natural food stores. Perhaps, probiotics or some combination of digestive enzymes will help these dogs. Again, I don't know. We use simethicone in babies (and adults) to control gas but I don't think this will help with the odor. Simethicone does make larger gas bubbles smaller, so maybe a smaller dog fart will be more tolerable. If these were my dogs (unlikely), I would be actively experimenting on finding a cure.

My son and his wife love their dogs (obviously). For the health of my new grandson, I will continue my research. Maybe I will call my congressman to see if the new economic stimulus package has funding for research in this area.

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