HPH (Harry Potter Hiatus)

I haven't posted in a couple of days because I was unable to resist the lure of that big, thick book with the orange-black cover and embossed red letters. Although it arrived on Saturday the 21st (no, this time I didn't stay up until midnight at the bookstore; no kids at home to go with me) I was holding off; waiting -- I told myself -- until after re-reading number six, only to discover that I couldn't find my copy of it anywhere in the house (horrors!)

So I bit the bullet and dived in. Luckily there was plenty of re-orienting to get me back into the story quickly (and boy does the story start quickly!) Unfortunately, my request to the Ministry of Magic to extend the day from 24 to 28 hours must have gotten lost in the mail, so as I read, something else had to go. Sleeping? Half an hour here and there. Working? Tell it to the sick people. Eating? Are you MAD! Personal hygiene? Don't think I didn't consider it. In the end, however, it was blogging that took a back seat.

But now, it is done.

How was it? Well...

I was right about the main thing, but not really. I totally expected that, but thought it would happen differently. I was pretty sure about that, but it wasn't who I thought it was going to be. I knew that would happen, but I thought it would be because of that and not that. I figured out that's where it was, but I was completely surprised at how he got it. I was pretty sure that guy wasn't going to turn out as bad as he'd been portrayed earlier, but I thought it was pretty cool how it finally fit together. And how about that ending!

Sorry for the spoilers.

PS And I thought the Epilogue was silly.

Really Bad Pun Alert

Place: Nursing home hospice unit

Scenario: Elderly patient has just expired half an hour after her family's arrival at 2:00 am


Nurse: Are you ok?

Patient's daughter: (dabbing at eyes with tissue) Yes. I'm just so grateful we could be here to say our final goodbyes in time. Thank you for calling us. One thing puzzles me, though. How did you know just when to call? That she was about to die?

Nurse: (smiling modestly) We could tell from the cat scan.

My Contribution to the Burgeoning Blogging about Oscar, the Psychic Cat

Oscar the cat lives in a nursing home/hospice unit, and curls up next to people within hours of their death.*

From I Can Has Cheezburger, a hilarious site replete with funny cat pictures.


*Poor Oscar has been ALL over the media lately. Still, I included this so that six months from now, I can remember WTF was so funny about this post.

Cheney to have Minor Surgery

Vice President Dick Cheney is due to have minor surgery tomorrow to replace the pacemaker currently implanted in his chest.

Oh no! Does that mean that Bush will be temporarily in charge?

Be very afraid.

Oh wait: I already am.

Treatment Plans

"Treatment Plans" seem to be a nursing thing. I generally talk about "the plan" or just "here's what we're going to do." But other professionals have other ways of formulating and recording their thoughts.

That's cool.

Then again, there are times when patients come up with the best treatment plans all on their own.

I have a patient who had a baby about three weeks ago and the baby wasn't gaining weight fast enough. The nurses in the pediatrician's office [yes, she's taking the baby elsewhere; perhaps not for long, though...read on] waggled their fingers at her and suggested she consult with a Lactation Consultant. The Lactation Consultant came and consulted, and generated a "Care Plan," of which the mother got the yellow carbonless copy. The Lactation Consultant also ordered some labs...sorry; the Lactation Consultant felt it would be wise to check the mom's hormone levels, so she suggested she come see me to have them drawn. (Never heard of that before but what the hell. I drew the suggested labs; her TSH was fine; her testosterone was <20; her prolactin was 78; all perfectly appropriate levels for a lactating mom.)

By the time I saw her, the baby was doing great with some supplemental bottles, though she had decided to stop pumping. Between nursing and pumping, she told me, there wasn't any time to do anything else all day. So she was just going to offer the baby the breast before the bottle and chill out about the whole thing.

Her words:

My treatment plan is to not make myself crazy.

I approve. (I also may be impressing her sufficiently with my laid-back approach to peds that she may decide to bring the baby to me after all, even though she'd have to drive farther.)

Drug Seeking in Primary Care

Most of the (blog) "literature" on drug seeking comes from the ER and pre-hospital bloggers. To them, seekers are all stupid, lazy, unwilling to confront their demons/addictions, often belligerent and overall pains in the ass.

While I don't dispute the picture painted by those bloggers, I must point out that there are some significant differences between drug seekers in primary care and those encountered in the ER setting. For starters, the smart ones (no, "smart drug seeker" is not an oxymoron) don't usually go to ERs, preferring to form an ongoing relationship with someone they can get drugs from more than just once or twice.

Many patients presenting either with explicit requests or with diagnoses implying the need for controlled substances are not "drug seekers" in the usual sense of the term. There are legitimate patients out there with chronic pain, ADHD and anxiety, among other conditions, who use controlled substances successfully and appropriately, and it is a mistake to assume otherwise. However there is a greater onus on the practitioner to distinguish the legitimate patient from the savvy seeker, a task that usually requires something unique to primary care: the forming of a relationship over multiple encounters.

Another difference between the ER and the office is that patients rarely present to us in acute pain. Sure, I've been burned by the girl with "renal colic" -- complete with blood in her urine -- who got a percocet script off me. But when she wouldn't go for the IVP, and then called after a car crash in which "my meds were towed away in the car", I eventually caught on. There was also the guy carrying the x-ray showing a vertebral body in two pieces who got medicated for his acute fracture pain -- until I saw the report describing the x-ray finding as chronic; a congenital anomaly. By and large, I'd rather err on the side of being fooled than not treating legitimate pain. But I'm generally not fooled for long.

Most drug seekers we see come in with a history of an ongoing chronic or episodic painful condition -- migraines or back pain, for example -- requesting prescriptions for maintenance pain meds. A full history and physical is part of the initial evaluation. Failure to sit still for that ("I don't have time for a full exam today. Just give me the prescription and I'll re-schedule") is a red flag. No script. As always, the history provides clues. "What else have you tried?" usually elicits either "nothing" or "everything," the latter usually with suboptimal relief or intolerable side effects (including "allergies", of course.) The response to my suggestion of alternate therapies is telling: the seeker finds a way to refuse. The patient with, say, legitimate menstrual migraines ought to be open to the idea of continuous contraception.

What are the hallmarks of the patient legitimately seeking to form a new doctor-patient relationship for management of a chronic condition requiring controlled substances?

• Honesty, including a willingness to verify statements (ie, signing a records release)
• Consistency (neither the history nor the requests change over time; not seeing multiple physicians or using multiple pharmacies)
• Recognition that trust takes time; I need time to get to know the patient. Trust goes both ways, too: patients should be willing to try other strategies (anticonvulsants for neuropathic pain, for example)

Two such legitimate pain patients over the years stick in my mind:

Once in the early 1990s a patient walked into my office and said, "I'm addicted to narcotics for my chronic back pain from an accident ten years ago. My doctor is retiring, and I need a new one to work with me." I was a bit taken aback; I had only been in practice for a couple of years, but I asked him to ask his previous physician to write me a letter documenting that fact. He did, and she did, sending it along with his records documenting that he never abused them, never called early and used only one pharmacy. In fourteen years with me the pattern has continued. He has better times when he doesn't call as often, and worse times when he calls more regularly. He never waits until the last minute to call for refills, allowing enough time to receive written scripts in the mail. And he always comes in when I ask him to; a model patient.

Another time I took over a patient on massive doses of chronic narcotics because, among other things, he broke ribs just by coughing. The chart was full of fruitless workups for metabolic disorders to explain his fragile ribs, but x-rays always confirmed them. No alcohol either; he had Hep C and didn't drink, generally confirmed by all lab work. He was a big old biker dude covered with tattoos, and when I first met him I confess I was concerned that I was being taken. But I asked him to give me the opportunity to get to know him -- x-ray his ribs a few times rather than just taking his word that he'd broken one again; maybe repeat a few other metabolic tests -- and he wasn't the least bit offended. He did everything I asked: came back regularly for follow-up; tried NSAIDs; never abused pain meds nor asked for early refills. When he started going longer spells without fractures, the refills slowed down. And only once in seven years did he call for a new prescription, having "torn the house apart; I just can't find them. I think the dog knocked the bottle over." That was just this past April, but by now, after all these years, I trust him.

Make no mistake: we certainly see drug seekers in the office. Many of them are charming and have extremely legitimate-sounding stories. Over the years, though, I've discovered something in my own thought processes that flags them unerringly: in the course of the history and exam, in which the long-suffering patient is telling a tale of such woe, such suffering, such angst, the thought occurs to me, Could this patient just be out for drugs? and I say to myself, How could you even THINK that about this nice person! That second thought is the key. More often than not, yes: that nice person is looking for drugs.

Poaching Patients

I was covering for another doctor a month or two ago. Dr. W is very nice, but he does have a noticeable Italian accent. Perfectly understandable, but definitely speaks with an accent.

I got a call from one of his patients and could barely understand her message on the phone due to her heavy Russian accent. I called back and spoke to the husband, who explained that his wife had been seen the week before. Tests had been done and some antibiotics had been called in by the office (after the doctor was away) this week. The problem was that the antibiotics were finished and the patient now had a fever.

WTF?

I called the other office and had them fax over the office notes and labs, then called the patient back and asked her to come in to help sort out what was wrong with her.

In person, her English was fine, despite the Russian accent. I took a history and did an exam, and tried to figure out what was wrong. I wasn't at all certain it was a UTI (treated for by the other doc) so I repeated some of the tests and sent some others, then tried a different antibiotic and told the patient to follow up with Dr. W next week. Poaching patients while covering for another physician is not a Good Idea. But the patient requested otherwise:

"Please, can I stay with you," she asked. "I haven't been seeing him very long, and he's nice enough, but I can't really understand him that well, because of his accent."

Google Health Advisory Panel

There's been quite a bit of hullabaloo over the composition of the new Google Health Advisory Panel. Assorted people have pointed out, with varying degrees of indignation, the absence of nurses, medical librarians and radiologists on the panel.

Who cares!

The whole thing is complete and utter bullshit.

When searching for an all-night pharmacy for a patient brings up a sidebar full of ads to buy Vicodin, Viagra and all sorts of other substances WITHOUT A PRESCRIPTION [emphasis theirs, of course] who the hell does Google think they're fooling? You can also locate an acupuncturist, a chiropractor and a Reiki practitioner near you 24/7. You could probably find a hit man without too much difficulty as well.

Although it may not be illegal to advertise something illegal (but it should be) Google is still a joke -- and not a very funny one -- when it comes to health promotion.

Great Alternative to a Busy Signal

Just when you thought you've seen it all:

We got a fax from a patient who had gone to a breast cancer risk assessment screening. Although she had tested negative for BRCA 1 & 2, her horrific family history qualified her -- according to the guidelines of this particular screening -- for annual breast MRI in addition to annual mammography.

Unfortunately, her insurance required pre-certification for the MRI.

My wonderful, woefully underpaid, long-suffering office manager spent 45 minutes on the phone answering dozens of questions over and over and over. Standard pre-cert shit. Their determination was that the patient didn't meet *their* guidelines for screening breast MRI. But I had options:

• I could fax the letter saying that she met someone else's criteria for screening, or
• I could call for "peer-review."

What the hell. I had a few minutes in the afternoon, so while finishing up charts I went ahead and used the speaker phone, dialed the peer reviewer number and hit option 4 as advised. I was then instructed to press 1 if I was a PA or NP, and 2 if I was a physician. Please don't be shocked to hear I was told that "All physicians are busy with other callers. Please hold."

At least the music wasn't too bad.

A minute or two later -- not long at all -- a woman got on the phone. She introduced herself as "Ms. So-and-so" (not "Doctor") and said this:

I apologize but all physicians are busy speaking with other physicians. Would you like to take the notification number or do you want to put your staff back on?

No questions; no nothing. Rather than keep me waiting or making me call back, because they didn't have a doctor available to speak with me right then, they APPROVED THE TEST.

WTF?

Words to Inspire Great Fear

From a new patient:

I'm going to make this very easy for you.

Hearing that as an opening, you just know-know-know that deciphering the history from the torrent of words to follow -- down to figuring out the actual chief complaint -- is going to be anything but "easy."

Reminded me of a time many years ago when my very first staffer answered the phone, listened for a while, eventually hung up and began to laugh. What's so funny, I asked. Answer:

This lady says, "I'm a no-nonsense kind of person," and then she proceeds to talk ten minutes of nonsense!

More Linguistic Fun

I once met an extremely talented parrot who could imitate the voice of every family member, all their cell phones, beepers; everything.

I totally stumped him with this:

"Idiopathic hypertrophic subaortic stenosis"

Language Development: Check!

Four-year-old niece at the pediatrician for her checkup:

Gross and fine motor development: reviewed, doing well.

Social development: plays well with others; doing fine.

Question: "How's her language development?"

Keep in mind this is an only child with parents in their 40's and 50's, so she is talking up a storm. She's also had some minor-ish health problems in her short life. Nothing serious in the long run, but enough that she's already got an orthopedist and a hematologist in her stable of health care providers.

Mom turns to kid: "What do we call the boo-boo in your blood?"

Kid [unprompted]: "Spherocytosis."

Mom turns back to doc; no words but with one eyebrow elevated.

Doc: "OK then."

Things I Won't Do; and Some That I Will

While reading Dr. Rob's post on what makes patients angry, I was struck by how similar our practice styles are. As a solo doc, ie, no partners to whom I can compare, I found this reassuring. Yes, I'm fairly confident that I'm practicing good medicine; still, validation is nice, however it comes.

So here is a brief list -- not exclusive by any means -- of things I won't do, even at the risk of angering a patient:

• I won't call in antibiotics without a visit, with two exceptions: endocarditis prophylaxis, and the family member with documented strep scenario.
• I won't prescribe narcotics without a visit.
• I won't call in a prescription under someone else's name (if someone doesn't have insurance but a family member does.)
• I won't treat "yeast infections" over the phone. Surprise: BV doesn't respond to antifungals. (Exception: if someone is already on antibiotics, though I usually ask and prescribe Diflucan concurrently.)
• I won't treat UTIs over the phone (except MAYBE on weekends, and even then I don't like it.) The only time I really need the urine culture is when I didn't get it.

Here are some things I will do; I know some would disagree on some of them, but I've included my rationale:

• I will write one controlled substance prescription for a new patient. No refills until I've seen your records, but you will get the benefit of the doubt once. Only once, though.
• I will prescribe birth control pills without a pap. Contraception and cervical cancer screening have nothing to do with each other. Besides, even though gynecologists are not allowed to trust women (because every single one of them has been burned by someone who swears she's a virgin but turns up pregnant) if I've known you since you were five and you're asking for BCPs on your way to college, I believe you when you tell me you haven't had sex.
• I will write for full pills even if you're splitting them. I didn't used to, thinking of it as insurance fraud, but given the obscenities that co-pays, pharmacy benefit managers, formularies and their profits have become, who's defrauding whom?
• I will treat upper respiratory infections over the phone 'til the bovines are re-domiciled. Sore throat, stuffy nose, little cough for two days: go to bed and drink fluids for chrissakes. Don't call me unless something changes or you're not getting better after a week.

As I said, these lists are anything but exclusive. They're just the hot button issues that seem to come up most frequently.

Note to Clark re: Mr. Furious, "Close, but no cigar": Good thing I don't smoke.

Marble Dinosaur Egg: Extending Your Scale

How to weigh someone over 350 pounds (or the upper limit of your scale; in my extensive research -- looking for this picture -- I found scales that go up to 500 lbs.) on a standard, upright, balance scale:

The trick is to add a counterweight, hanging it from the little piece of metal sticking out at the top of the beam on the top. I find the large rubber bands used by the post office (available from them for free) work well; I use three of them looped end to end.

I use a screwdriver for my counterweight, but anything you can hang freely from the beam will work. Here's how to do the calibration:

Step on the scale yourself and record the reading [assuming you weigh less than your scale's limit, for cryin' out loud!] Then add the counterweight and re-weigh yourself. The difference in the two readings is what your counterweight adds. For example, my approximately 3 oz. screwdriver adds 94 lbs. to my scale's 350 lbs.

When you weigh a patient over 350, begin with the counterweight in place and then add your known differential to the measurement you get.

From the comments on the previous post, the double-scale method (two scales, one foot on each, add the readings) should work mathematically, but it strikes me as cumbersome. Technically, there's no limit using this technique, except that after a certain point, larger people won't physically fit on the scale.

Bellies

I saw a family for a physical.

The father went first. He weighed over 350 pounds (email me if you want to know my trick for weighing him on my scale anyway) and so we discussed exercise and diet and so forth.

The 9-month-old was next. We did the weigh and measure thing, then went back into the exam room for the physical. As I often do, most of the exam was performed with the baby sitting on the dad's lap.

As I went to palpate the baby's abdomen, the dad cooed, "Where's that big belly?"

I looked at him and said, "No, it's the baby's turn now."

Yet Another New (to me) Blog

With thanks to BabsRN (it's a tossup between her Living Single in the Buckle of the Bible Belt and Rickety Contrivances of Doing Good for the best blog name ever) another paramedic blog:

DTs EMT

Among other things, s/he talks like my daughter.

Another Side Effect of Vaccines

I was seeing a charming little one-year-old girl who had two older sisters and a mother who is so cool she didn't even realize just how cool she is.

I enjoy chatting with this lady because her humor is just as dry as mine. She can also keep a straight face almost as long as I can, which is good, because one thing I tell people when they have children is this:

The hardest part of being a parent is keeping a straight face.

We did the checkup, and then the baby needed two shots.

Although the mom is a smart health professional, she still asked for some last minute reassurance that the shots didn't cause autism. I gave it. She was fine.

(This is how most of my "anti-vax" encounters go, by the way. Very few people are as hard-core crazee as the commenters on assorted posts about vaccines, and are easily reassured with information that the incidence of autism hasn't decreased since the removal of mercury from childhood vaccines for the last five year.)

She had one more question:

Mom: Will she cry?
Me: No.

Held the straight face too. And the baby did great; just a little whimper with the first, and only as I was done with the second did the wailing began. I pointed out that it was the mom's fault for holding her too tightly. That's why she was crying; not my fault.

Within a minute she was back in the waiting room playing with her sisters, while Mom and I kept chatting. We were enjoying our conversation so much that it took us a moment to realize the baby had wandered into the bathroom and was starting to play with the toilet water. As Mom scooped her up to wash her hands, she mock-scolded me:

See? She never did this before getting those shots. This is all your fault.

What could I say? Her point was valid. Gd help me at the fifteen month visit: I wonder what I'll get blamed for then?

9,999 and Still Counting

As so many continue to report with glee, the Philadelphia Phillies are the losing-est team in Major League Baseball, now hovering at 9,999 lifetime losses for the franchise. With their next loss, they will be the first team to lose 10,000 games, a non-event being prepared for with 10,000 black balloons and 10,000 birds ready for release, among other humorous twists on the number 10,000.

Everyone seemed sure that playing a game on Friday the 13th would be the kicker. It wasn't. The only thing that got kicked yesterday was some St. Louis Cardinal butt, in a 13-3 rout that featured 23 Phillies hits and 3 Cardinal errors, including a catcher who dropped a throw to the plate for a score instead of an out. (Note to Mr. Molina: requirement for the position of "catcher" is actually catching the ball.)

The newspaper still sports that big red numeral "1" on the sports page; the countdown to 10,000, and it will be there again tomorrow.

Today they only beat the Cards 10-4, with a measly 14 hits.

So maybe tomorrow will be the day. Or maybe not.

How 'bout them Phils!

A Picture is Worth a Thousand Words

Many thanks to Maria of Intueri for letting me participate after the fact, so to speak.

Here are the rules: Write a medically related story of fewer than 1000 words inspired by the following image:

George and Joan sat together in the front seat of their car, gathering their courage. In the back seat sat their infant daughter, sleeping peacefully in her car seat, too young to understand the deformity her parents were desperately seeking to correct.

"Shall we?" asked George.

Joan nodded silently, but didn't unbuckle her seatbelt. George put his arm around her.

"What's wrong?"

Joan buried her head in his shoulder.

"What if this doctor can't do anything for her either?"

George's arm tightened about his young wife.

"Then we'll find someone else. And we won't stop until we can find someone who can."

Joan shook her head.

"She's so beautiful! Just -- different. All I want is for her to grow up normally, to live a normal life. Not have everyone staring at her." Joan sighed again, then undid her seatbelt and opened the car door. "I'm ready. Let's go."

George reached into the back seat and unbuckled little Mollie, gently lifting her onto his shoulder without waking her. They rode the elevator to the sixth floor of the medical building in silence. As the door opened, Mollie began to stir. George rearranged her in his arms while Joan perused the directory on the wall. She pointed to the right.

"Down here."

They proceeded down the hallway to suite 614 where the words "Plastic Surgery" stood out in stark plastic letters on the walnut door. George pushed it open and let Joan enter before him. She walked straight over to the desk, returning with the usual clipboard of forms. She sat down and handed them to George, taking the baby from him to nurse. Mollie suckled away as her father made short work of the sheaf of forms. He'd filled out similar ones at least a dozen times since her birth a month ago.

Finally they were escorted back into the inner sanctum of the consultation room. Like the other plastic surgery offices they'd seen so many of, it was ornately decorated in sophisticated mahogany and leather. The doctor kept them waiting just long enough for them to be impressed but not long enough to become annoyed.

This doctor was older than the others they had consulted. George and Joan had chosen him for precisely this reason. Perhaps his greater experience would make the difference between a normal life and the one their daughter currently faced.

This was one medical scenario where the history was secondary. One look at the infant's face told the doctor all he needed to know. He walked around his desk and knelt in front of Joan, gently pulling the blanket away from the baby's face as he asked, "May I?"

Joan nodded her assent and sat silently as the doctor turned the baby's head first this way, then that. To her surprise, Mollie tolerated his touch. Perhaps she knew he only wanted to help. He palpated both sides of her face carefully, considering the texture of the tissues. Finally he stood up, walked back around the desk and seated himself, folding his hands in front of him.

"I'm very sorry, but there really isn't anything we can do."

Joan struggled with tears while George struggled with his temper.

"What do you mean, there's nothing you can do? There must be something. We've seen every plastic surgeon in town. Someone must be able to do something!"

"I'm really very sorry, but it wouldn't matter if you spoke to every plastic surgeon in the universe. I'm afraid there's nothing that can be done. As you know, our masks are more than just pigmentation. They consist of complex tissues containing collections of dilated blood vessels that give each one of us our uniquely textured and colored mask around the eyes and cheeks." He nodded to Joan. "For example, Mrs. Smith, your mask is fine and flat between your eyes, becoming fuller and more variegated on your cheeks, whereas your husband's is much wider over the nose, and comes all the way down to the corners of his mouth."

Ignoring his flattering assessment of her looks, Joan refused to accept the finality of the doctor's pronouncement.

"What about tattooing? Anything to make it more symmetrical. More…" Her voice cracked. "More normal."

"I'm sorry, Mrs. Smith, but a tattoo wouldn't look genuine. A lot of the character of the mask is its texture."

George had heard enough.

"Thank you for your time, Doctor." He stood and leaned over to take little Mollie in his arms. She smiled at him, her lopsided face brightening.

"You're welcome, Mr. Smith. As I say, I really wish there was something I could offer."

"Never mind, Doctor. You've been very kind. Come on, honey."

Joan stood and turned to go, but twisted around to look pleadingly at the doctor one last time. He saw her glance and shook his head sadly, but firmly and with finality.

Silently the young family retraced their steps down the hall, to the elevator, through the lobby and out into the bright sunshine. George turned to Joan and saw that she was crying.

"Don't worry, honey," he murmured reassuringly as he put his arm around her. "Everything will be alright."

Joan nodded, but found herself despairing. The pale, smooth, unmarked left side of her poor little daughter's face would forever be a source of staring and pointing. Somehow she and George would have to teach their child to hold her head high, ignoring the whispers and worse, trying to help her to live a full and happy life despite having only half a face to present to the world.

As if echoing her father's optimism, Mollie smiled at her mother, her asymmetric features beaming with love and innocence. Joan couldn't help but smile back.

Spelunking

Getting away is wonderful, especially when exploring such exotic (to us Easterners) landscapes as those found on a day trip to Colorado Springs.

Cave of the Winds was just one of our destinations that day. As pretty experienced cave tourists, we chimed right in when the guide asked, "What is the most important rule of caves?"

Answer: Don't touch anything. The formations are suprisingly fragile, even though they're made of rock, and they take centuries to grow. Do. Not. Touch. Anything.

We saw stalactites, so named because they hold "tight" to the ceiling:


We saw stalagmites, so named because (according to our guide, in the early days of cave exploration with poor lighting) you "might" trip over them, or you "might" not:


But we also learned about two new formations I wasn't familiar with.

Apparently, Cave of the Winds was one of the very first caves to receive electric lighting. Thomas Edison himself supposedly toured the cave and was impressed with the illumination. Hence, this new formation on the ceiling:

"Stalac-light"

And finally, the exception to the rule about no touching: we were not only allowed but encouraged to touch this formation (and hold on tightly), that was found in many place along the tour:

"Stalac-pipe"

Who said bad jokes were limited to the East coast?

I Cured Her

Elderly Vietnamese lady with diabetes, hypertension, new dementia and what her family was certain was depression. She wouldn't eat, was losing weight and was plagued with diarrhea. She'd been hospitalized within the last year for emergency surgery for a small bowel obstruction, so her GI workup was recent and negative.

She spoke no English, so her wonderfully attentive children did all the translating. (No, I don't have access to any other source of translation. Yes, I considered elder abuse-type scenarios and ruled them all out to my satisfaction.) I was very hesitant to treat her for mental issues without being able to communicate with her directly, and even found a relatively nearby Vietnamese FP. The family refused the referral and pleaded with me to treat her.

I went over her med list and recent labs. Noticing that her A1C was 5.7 on metformin only, I figured her diabetes was under pretty good control. Certainly good enough that stopping the metformin for a bit wouldn't be immediately fatal, so that's what I did. At the family's insistence, I also gave her a tiny dose of antidepressant, warning that I thought she'd find the side effects troublesome.

Saw her back the other day: All better.

Appetite back; no more diarrhea; she was even brighter and chattier as she walked into the office unassisted vs. clinging to the son or the daughter's arm, as she had the last few visits. No more "dementia"; no more depression, and yes, they had discontinued the antidepressant after only a few days because of side effects.

I love curing people by stopping meds.

For you diabetes purists, yes, her blood sugars rose from 120's-130's to 200-220, but I gave her a smidgen of glimiprizide (Amaryl 2 mg.) and asked them to keep an eye on her sugars, as well as hypoglycemic precautions. And yes, I know it can cause weight gain. As it is, she's a whopping 109 lbs, and could stand to gain back some of what she's lost over the last few months.

I still get a kick out of paring med lists.

Positive Proof of Global Warming

Res ipsa loquitur.

Say no more.

How 'Bout Them Phillies

As it happened, our vacation to Denver coincided with the Phillies road trip there.

Darling Spouse messed up our plans a little by inadvertently purchasing tickets to the Saturday game instead of the Friday one. (Getting up at 5:30 on Sunday to fly back was hard enough without getting in at 11:30 the night before.)

When they dropped the Friday game 7-6 in 11 innings -- after Alfonseca let the Rockies tie it up on a 2-out, 2-strike homer (d'oh!) I figured oh well, maybe we'd see them win on lucky 7/7/07. No such luck. But we did get an hour of rain delay, which included the (at the time) hugely entertaining sight of watching the ground crew struggle with the tarp as the wind flung it up into huge billowing silver waves that pulled one guy about ten feet along the ground at one point.

But it wasn't until after we got back and watched the end of the game on TV Sunday afternoon that we found out just how classy our Fightin' Phils (though I've been frequently known to call them the F***in' Phils) really are.

Sure as shooting, Denver got rain again. But this time the winds threw the tarp around even more violently, at one point hurling a member of the ground crew ten feet into the air and then smothering him under it.

That's when the Phillies -- my Phillies -- showed their class: the entire team emerged from the dugout to help:

Check out the whole article here.

What about the Rockies?

Only LaTroy Hawkins came out to help for the Rockies.

"You never know what can happen," Rockies infielder Jamey Carroll said. "I've been on tarp duty in college and it can whip around, yank you around your shoulders and stuff. After the fact you think what could have happened to one of the guys, they would have got thrown around or something like some of the guys did, you're risking a lot.

Damn right you're taking a risk. But that's what the Phillies did, because it was necessary:

"The guy might have died," Greg Dobbs said. "He was trapped under there. We were watching and once it got to a point, we were all like, 'We gotta do something.'"...

...Aaron Rowand and Chase Utley clung to a section in left field. Michael Bourn, Jimmy Rollins and Cole Hamels grabbed a large piece along the third-base line. Shane Victorino waged his own personal war near third base -- tightly gripping his section and not letting go. He won.

"You see something like that, you get worried that somebody is going to get hurt," Victorino said. "It was funny to see us out there trying to pull the tarp and act like we know what we're doing."

They knew enough. The extra player and coach power provided serious help to the roughly 20 grounds crew members in a 10-minute fight with the elements.

"It was incredible," said Mark Razum, Colorado's head groundskeeper. "They literally grabbed it and took over. It changes your outlook on a baseball player. It was overwhelming to see the guys who were actually playing in the game help out. Maybe a bench guy, but it was the starting pitcher, the starting lineup."

Razum doesn't want to think about what would've happened had the Phillies, umpires John Hirshbeck and Bill Welke and the Rockies' LaTroy Hawkins and Ryan Spilborghs not rushed in. The situation would've gotten much uglier because the material was getting bunched up and incredibly heavy.

"It saved us, really," Razum said. "It was huge for them to do that."

How 'bout them Phillies.

They even came back and won the game.

Random Thought/Old Joke

If the earth is 93,000,000 miles from the sun, does that mean that as I sit here in Denver, those 90+ degree waves of heat only had to travel 92,999,999 miles?

Also, if those same rays only had to travel a little more than 92,999,997 miles to reach me at the summit of Pike's Peak yesterday (elevation 14,110 feet), why was a bone chilling 41 windy, bitter degrees up there?

What Part of "Cheap" is So Hard to Understand?

• Prescription drugs are expensive.
• Doctors don't know how much drugs cost.

No argument there. Doctors are systematically and intentionally prevented from getting too precise a handle on drug prices because then we might be tempted to try and talk someone OUT of a prescriptions for Levaquin for that cold.

Seriously, from a sales standpoint, prescription medicine is unique. Think about it: despite the fact that all sales figures are dependent on my actions, I neither use nor pay for the product. Same goes for medical devices. Crazy.

So when some of us go out of our way to discover that certain old but extremely effective medications are not just inexpensive but downright cheap -- and then actually make an effort not only to prescribe them but explain to the patient why such old, cheap drugs are really an excellent choice for their mild hypertension -- exchanges like this become frustrating as all hell:

Patient on phone: "I need a refill of my HCTZ 12.5 mg."

Me: "I gave you a prescription for 90 of them in March. You should still have refills."

Patient: "But my pharmacy said my insurance would only cover 30, so that's what they gave me. And now I'm out of refills."

Ok: let me interject here that *perhaps* it costs a little more to fill 90 teeny tiny capsules with 12.5 mg of a drug that costs about $5.00 for one hundred 25 mg tablets than it would to purchase 45 said tablets and break them in half. I'll even grant you that not everyone wants to be bothered splitting pills. Still. What the hell happened to the other 60 capsules from each prescription?

No way around it: I have to write another Rx as I explain (yet again) to the patient that the medication should be very inexpensive and perhaps she should consider switching pharmacies. Or offer her the opportunity to split her pills. As it turns out, the real problem is that her insurance company now insists that she get them by mail order.

People have become so conditioned to the idea of "insurance" that they don't even realize the don't have to use it. All it is, after all, is a way to help pay for expensive medicines. But when the meds really are dirt cheap, no one even thinks of telling the pharmacist, "Never mind; I'll just pay for it." Then again, I'm pretty sure there are pharmacies ripping people off right and left for their HCTZ, atenolol, lisinopril, and all my other first-line generics.

Put that in your pipe and smoke it, all you folks still blaming me for your drug costs.