long lost friend

I found an old friend today. We went to med school together. He graduated a year ahead of me and went into the Marines. We sort of lost touch for a while. Last week, I sent an email into the void, just to see how things were. His reply came this morning to my inbox, "unclassified" status. Turns out, he just left for Iraq. Before he left, though, he started a blog, Another Doc in the Sandbox. Check it out and wish him safe journeys.

U2

On the way to work this morning, I heard three songs on the radio. I tend to flip stations frequently, so they were all on different stations. But all three songs were by U2. What are the odds?

don't get sick in july

There's a piece in the NY Times Week In Review that details the worst days to do certain things. To sum up:

• Don't have a heart attack on a weekend, as you are more likely to die from lack of aggressive treatment.
• Don't go to the theater on a Saturday night, as you are likely to be surrounded by snoring, drunken couples who wanted to have a night away from the kids.
• Don't go to a nice restaurant on Monday, as you are likely to be served left-over fish by second-string staff.
• Don't have a baby on a weekend unless you can help it, as the hospital is more likely to be under-staffed and your baby is more likely to die (the author's contention, not one that I agree with).
• Don't send email on Sundays or late at night; apparently spam goes out between 2-5 am and your email will be mixed in with offers for cheap Viagra or notices that somehow they lost your personal identifying information on that order you never placed (under the rock they think you were born under) and would you please re-send your SSN and bank routing number?
• Don't buy a car on a weekend day in the fall (try weekday in July or August).
• Don't fly in the late afternoon (or anytime in December if you can help it). Duh.
• Don't get arrested on a weekend, as you will likely find yourself in a holding cell until the judge gets back from his golf game or hunting trip.

I would add the following:

• Don't get really sick in July unless you want an intern taking care of you who has no idea what they are doing.
• Don't make appointments in clinic for late in the afternoon (early morning or first appointment after lunch are better bets for not having to wait).
• Don't go to the emergency room for anything that isn't an actual emergency (bleeding, broken, not conscious, can't breathe...well, you get the point).

Any other tips from readers out there?

if you want to end the war and stuff, you gotta sing loud!

My housemate decided to play Alice's Restaurant tonight. I haven't listened to it in ages but all the words came flooding back, filling me with nostalgia for that summer afternoon when I first heard it.

I was 12 and my life was never quite the same afterwards.

My brother was outside, washing his VW GTI. He was 17, my idol. I wanted to be just like him when I grew up. He had his JVC boombox outside with him. Playing at the loudest possible volume was Alice's Restaurant.

I had never heard of such a song, a song that was essentially a story. It was a completely revolutionary concept to me. I wandered outside to ask him who this was, this avant garde story teller.

He rewound the tape and started it over again. "Arlo Guthrie," was all he said. We both sat on the concrete of the driveway for twenty minutes while the song played, laughing at the funny parts.

"Yes, sir, Officer Obie. I cannot tell a lie. I put that envelope under that garbage."

"Obie, I don't think I can pick up the garbage with these handcuffs on."

"Kid, we don't want any hangings." And I said, "Obie, did you think I was gonna hang myself for littering?"

And the meanest, ugliest, nastiest one, the meanest father-raper of 'em all, was coming over to me and he was mean n' ugly n' nasty n' horrible and all kinds a things and he sat down next to me and said, "Kid, whaddya get?" And I said, "I didn't get nothin'. I had to pay fifty dollars and pick up the garbage." He said, "What was you arrested for, kid?" And I said, "Littering."

"I mean, I mean, I mean, I'm sittin' here on the bench, I'm sittin' here on the group W bench 'cause you wanna know if I'm moral enough to join the army, burn women/kids/houses n' villages after bein' a litterbug." He looked at me and said, "Kid, we don't like your kind."

The intangible thing about this song, the genius of this song, is the subtle, radical nature of the story. It's a simple enough story about a guy who was, fortuitously as it turns out, arrested for littering. That turns out to be the reason he was rejected from the draft. The messages are clearly relevant to the 60's anti-war movement, but if you listen carefully, they are still applicable today.

"If you wanna end the war and stuff, you gotta sing loud."

I think the seeds of my liberal activism were already planted, maybe they had always been there, but they certainly blossomed a little that afternoon in the driveway.

I didn't grow up to be exactly like my brother, but we are very close. He's been pretty sad lately, which makes me sad for him. We were IMing tonight and I randomly typed some of the above lyrics. He immediately got the reference. It made him smile.

cura te ipsum or primum non nocere?

I didn't enter the medical profession to make money. I entered medicine, pediatrics specifically, because I had that semi-altruistic desire to help people. I say semi-altruistic because some would argue that true altruism does not exist, that there is always something in it for you, even if it's just feeling good about helping someone.

But that's a philosophical debate for another day.

I read an article this morning in the NY Times that troubled me on many levels. Doctors in Shymkent, Kazakhstan being sued for giving unnecessary blood transfusions because they profited from it. They claim that their salaries are so low that it forces them to make money where they can, $10 per transfusion as it turns out.

Ok. While the ethical quandaries abound, some might argue that if they're not hurting anyone, then what's the problem, right?

Wrong.

Some of the children who received these unnecessary blood transfusions now have HIV.

Primum non nocere, in this case, trumps cura te ipsum. $10? Seriously?

updates

It's been an interesting week in health care. Just a few highlights, in no particular order, in case you were paying more attention to the Alberto Gonzales shenanigans.

• Low-acid coffee, like low-acid OJ, is now being marketed for people who have bad reflux. Not that there's really any evidence to support this. An excerpt from the NY Times article by Andrew Martin :
  

  A recent study by Stanford University researchers found that there was little scientific evidence to support the idea that eliminating coffee — and several other foods and drinks — helps cure persistent heartburn.

  “It’s as much mythology as anything,” said Dr. Joel E. Richter, chief of medicine at Temple University’s School of Medicine in Philadelphia and past president of the American College of Gastroenterology. “The evidence that coffee is injurious to the stomach isn’t there.”

  The Stanford study, that appeared in May in The Archives of Internal Medicine, evaluated published medical reports from 1975 to 2004 on heartburn.

  The study found that there was no evidence that giving up tobacco, alcohol, coffee, spicy foods, citrus or chocolate helped decrease heartburn, known to professionals as gastroesophageal reflux disease, or GERD.

  Research on coffee’s impact on the digestive system was contradictory, the Stanford study found. “Given the conflicting reported data, the relationship between caffeine and coffee and GERD remains unclear,” the study concluded. “There is insufficient evidence to support the routine recommendation that patients with GERD avoid such behavior.”

  Dr. Lauren B. Gerson, one of the study’s authors and the director of the Esophageal and Small Bowel Disorder Center at Stanford University, acknowledges that when patients complain that coffee irritates their stomachs, she tells them to stay away from it.

  But she questions the wisdom of routinely telling patients with acid reflux to stop eating certain foods, even though such advice is still offered by the National Institutes of Health and the American Gastroenterological Association.

  All I know is that when I eat garlic or tomato, I regret it. Luckily, coffee is not an issue for me. I don't know what I would do if it was. Isn't it funny how anecdote trumps evidence in an individual, if not a population?

• Antidepressants don't help kleptomaniacs. Well, if you read the lay media coverage, that's the impression they give. However, if you read the fine print, the study published in the Journal of Clinical Psychiatry was a very small trial of Lexapro (escitalopram) vs placebo in 15 people diagnosed with kleptomania. No significant difference was found between the drug and placebo. Interestingly, this study was funded by the manufacturer of Lexapro. In case you wonder why any of this matters, there are an estimated 1.2 million kleptomaniacs in the U.S. alone.
  

• The FDA is putting new warnings on sleeping pills (Ambien, Lunesta), confirming what many people chalked up to urban myth. From the NY Times article by Stephanie Saul:

  The review was prompted, in part, by queries to the agency from The New York Times last year, after some users of the most widely prescribed drug, Ambien, started complaining online and to their doctors about unusual reactions ranging from fairly benign sleepwalking episodes to hallucinations, violent outbursts, nocturnal binge eating and — most troubling of all — driving while asleep.
  
  Night eaters said they woke up to find Tostitos and Snickers wrappers in their beds, missing food, kitchen counters overflowing with flour from baking sprees, and even lighted stoves.
  
  Sleep-drivers reported frightening episodes in which they recalled going to bed, but woke up to find they had been arrested roadside in their underwear or nightclothes. The agency said that it was not aware of any deaths caused by sleep-driving.
  
  The reports gained credence from scientific studies. A forensic toxicologist in Wisconsin, Laura J. Liddicoat, gave a presentation at a national meeting on six instances of Ambien-impaired driving.
  
  And Dr. Carlos H. Schenck and Dr. Mark W. Mahowald of the University of Minnesota said that they had been studying cases of nearly 30 Ambien users who developed unusual nighttime eating disorders.
  
  Last May in Washington, Rep. Patrick Kennedy, Democrat of Rhode Island, blamed Ambien when he crashed his car near the Capitol building.
  
  The agency also received reports of people making phone calls, purchasing items over the Internet, or having sex under the influence of sleep medication.
  
  In each case the consumers had no recollection of the events, which they said had occurred after they took their pills and headed for bed.

• Hillary Clinton and John Dingell (Dem, Michigan) introduced a bill that would expand CHIP (Children's Health Insurance Program). No matter what you think of Hillary, expanding health insurance coverage for kids is a fantastic idea.
  

  Under the bill, virtually all uninsured children would have access to coverage of some type, with or without federal subsidies. Mr. Dingell and Mrs. Clinton would give states financial incentives to cover children with family incomes up to four times the poverty level. A family of three is considered poor if its annual income is less than $17,170. Thus, the bill would allow the federal government to pay subsidies for coverage of children in a three-person family with annual income up to $68,680.

  That is higher than the limit in any state. In January, 24 states had limits at 200 percent of the poverty level, 10 had lower limits and 16 had higher ceilings. New Jersey covered children up to 350 percent of the poverty level. Gov. Eliot Spitzer of New York has proposed increasing the limit to 400 percent, from 250 percent.

  The latest budget request from President Bush would move in the opposite direction. He proposed reducing federal payments for children with family incomes above 200 percent of the poverty level, saying that would return the program to its “original objective.”

  Under the Dingell-Clinton bill, states could allow employers and parents to buy coverage through the Children’s Health Insurance Program. States could subsidize the premiums, and the federal government would help pay the cost in states that expanded their programs to cover children with family incomes up to four times the poverty level.

Not a complete round-up but at least food for thought. I didn't even mention the birth control pill ruling, as that will be a separate post when I am less irate.

more caffeine with that donut?

Caffeinated Donut Invented

Molecular biologist Robert Bohannon has created pastries with the caffeine equivalent of two cups of coffee. What do you think?

Since this is from the Onion, one immediately scoffs and says, it can't be true. However, why not? They put caffeine in so many other things, why not donuts? It would just defeat the purpose of drinking coffee with your donut. But who does that anyway?

night float

I don't think I've ever been so exhausted.

I am a person who craves sunlight.

Not only are the days shorter but I've been working nights for the last month. Sort of.

Our program, in it's infinite wisdom, designed our night float system to flirt with the boundaries of sanity and safety.

It all starts on Sunday, when you work a 24h shift through Monday morning at 7am. On Monday afternoon, you come back by 5pm and work overnight until 9am on Tuesday. Tuesday night you have off. Wednesday from noon to 5pm is continuity clinic, because God knows the earth would stop spinning if I missed a clinic. Another overnight shift from 5pm on Wednesday through Thursday morning at 7am. Back for another overnight from 5pm until 9am on Friday. Blessedly, Saturday you have free. To sleep. Then it starts all over again on Sunday.

To add to the torture, you have to do rounds with the attending on Tuesday and Friday mornings after you sign out the ward. This consists of going over patients you saw in the ED, parent calls that you had and any management decisions on the inpatient ward. The reason for this charade of a session is quite simple...it's required by the RRC (Residency Review Committee) in order to justify a night float rotation and somehow make it seem like there's actual learning taking place. Who's kidding who? You can barely think by the end of a shift, let alone rehash what happened overnight.

My circadian rhythms are severely out of whack. I have been the most cranky I've ever been. The guy I had been dating decided that now was the time to call it quits. Like I have the energy to care.

Here's to adolescent medicine. Bring on the healthy college students who want to get out of class or exams or practice because they have the sniffles. I'll take that any month over night float.

Here's to Daylight Savings, which starts Sunday. More sunlight is good.