What's Wrong with This Country?

Our glorious leader is ok with asking $200 billion for a war that does nothing but harming more people but vetoed a bill for giving $35 billion that can protect 4 million American kids' lives?

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WASHINGTON (AP) -- President Bush vetoed legislation Wednesday that would have expanded government-provided health insurance for children, his second slap-down of a bipartisan effort in Congress to dramatically increase funding for the popular program...

The bill Bush vetoed would have increased federal funding for SCHIP by $35 billion over five years, to add an estimated 4 million people to the program that provides insurance coverage for children from families who earn too much to qualify for Medicaid but cannot afford private insurance.

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WASHINGTON (CNN) -- Democratic lawmakers and staffers privately say they're closing in on a broad budget deal that would give President Bush as much as $70 billion in new war funding...

A senior Republican aide also said both sides are nearing a deal that would give Bush a large chunk of the $200 billion in war funding he requested earlier this year. "We're not there yet, but we're close," the Republican aide said.

Be Afraid...

Came across this special weather alert today... by the sound of it this could be big!

A STRONG STORM FOR SEPTEMBER MAY MOVE THROUGH SOUTHERN CALIFORNIA LATE THURSDAY THROUGH EARLY SATURDAY. THIS STORM HAS THE POTENTIAL TO PRODUCE WEATHER VERY RARELY SEEN IN SOUTHERN CALIFORNIA IN SEPTEMBER. THIS COULD BE THE STRONGEST MID LATITUDE SEPTEMBER STORM FOR SOUTHERN CALIFORNIA IN AROUND 20 YEARS. SEPTEMBER STORMS WITH SOME SIMILARITY TO THIS STORM OCCURRED IN 1986 AND IN 1963.

What One Sees Can Be Deceiving

In ER today, I saw a 30 year old male with a 1-week history of decreased hearing from his right ear. He didn't have any pain complaints or fever. The symptom started after he came back from the beach last week. He tried some OTC ear drops and q-tips with no relief. He jokingly said that he feels like there's "a piece of grass or fish stuck in his ear." Otoscopic exam showed a complete blockage of the ear canal with some yellowish substance that is either cerumen or purulent discharge from an otitis media. I went ahead and lavage the ear and interestingly, a 5-cm piece of yellowish looking stripe came out - it's a piece of seaweed that got stuck in the ear. The patient has immediate relief.

Sometimes what one sees in an otoscope is deceiving - the piece of seaweed looks nothing like cerumen or pus once it's out of the ear. The childhood tale of "3 blind men examining an elephant" comes to mind.

Music Blog

I have created a separate blog to share some of the tunes I like. The link can be found below and also in the sidebar:

Relishing rhythms
http://babydocjackie-rr.blogspot.com

Crazy ER

Got a page from the ER to admit a multiple sclerosis patient who's been having "2 month history of worsening unilateral arm and leg pain and paresthesia", and diagnosed her with "MS exacerbations". I knew something is not right - after finding out more about the story, it turns out that she has been having the same symptoms for 2 months and were just a little worse this morning. She couldn't get an appointment from her clinic soon enough and decided to go to the ER instead.When we saw her, the pain has resolved. She doesn't have any neurological deficits and no visual changes or orbital tenderness. How this qualifies as an "exacerbation" requiring keeping the patient in the hospital is beyond me. A call to neurology confirms our plan, and the patient is sent home on oral steroid with outpatient follow-up.

Sometimes I am just amazed by how low some ER attendings' admission thresholds are.

It's Nice Being an R2

This month is my first month working on the ward as an 2nd year resident (R2), carrying my own team with an intern and medical students, and today is the first admission day. The fact that I am actually making decisions for my patients (and others actually following them) is kinda fun. At the same time, I am feeling that I am more directly responsible for the patients too.

Birthday, Part II

My first continuity obstetric patient from the family health clinic gave birth to a baby boy today! Too bad I didn't deliver the baby because it is a C-section and I wasn't informed that that patient is already in the hospital.

Which means this little guy, who is of course also my first newborn continuity patient by default, shares my birthday. This is great ;-)

Perhaps he'll be a doctor too some day...

Birthday

I found out today that I have the same birthday as Mélissa Theuriau:



Ms. Theuriau(29) is the unbelievably hot news anchorwoman in France who has gained unexpected international fame through fans on the internet. Video clips of her on YouTube have received over 1 million views. Happy birthday to us :)

YouTube - "Beautiful News Reporter"

Some of the famous people also sharing my birthday today include Nelson Mandela(89), John Glenn(86), Steve Forbes(60), Vin Diesel(40), and Kristen Bell(27).

Hungry Doctors, Rich Salesmen

I went to another pharmaceutical-sponsored "educational dinner meetings" last night. Obviously, it's not the "education" part that draws the event to my attention (this is not to say that the meeting doesn't have its educational value). It was at a really upscale steakhouse in Rancho Cucamonga that I just have to try. The place was PACKED.

So the next morning someone asked me about the meeting:
"Great steak!" I said.
"Actually, I was trying to ask you about the talk."

The "Medicine" in Family Medicine

I was talking to a fellow FP resident who's complaining that some of the faculty members in our program are playing down on the scientific aspects of family medicine and placing too much emphasis on "non-scientific" things like emotional/spiritual support and "integrative medicine". I agree with him to a certain degree.

A catchphrase for the FPs is to "treat a patient as a whole", which sets apart from specialists who treat "only parts of a body." I think it is important to understand, however, that the building blocks of FP is still the core knowledge of medicine. Our goal to become a good FP doctor is to be a physician who know "at least" as much as any other doctor, with the value-added bonus of being sensitive to a patient's emotional need. We are not psychologists or priests, and we are not referral robots. We should be physicians with a heart.

Traffic Law Hoax

Last week I read an article from the local weekly paper that there will be new changes to the traffic violation fines - what catches my eyes is the purported hike in carpool violation fine: $1,068.50 for 1st timer, *doubles* for 2nd offense, and *triples* for 3rd offense.

I just found out today that this whole thing is a hoax. It is one of those viral emails that got so widespread that it becomes the truth to some people. Even the local paper got fooled. My sister always says, "a lie told a hundred times becomes the truth." Here's an actually example. Ha!

Lactation Nurse

This whole specialized nurse business is getting out of hand. I was in disbelief when I learned that we have a "lactation nurse" during my peds rotation. You would think that for something as easy and as natural as breastfeeding, you wouldn't need some special nurse's help. What's worse is that she work at a supervisor level and has lower ranking nurse working under her. And what's even worse is that the county actually pays for this nonsense, which at the same time doesn't give us even 1 cent of salary raise or give us funds to update our computers in our clinics.

I would say to the county, if you want to promote breastfeeding, start charging moms for formulas. It'd be at least 90% effective in our population. Just a thought.

PS: I can understand wound care nurses, but "ostomy nurses"? Come on. What's next, "vital signs nurses"?

First Post in 3 Months

I just realized that it has been 3 months since I last updated this blog. I had rather hectic rotations in April and May (a month of surgery and a month of surgical ICU), and I think I was a little burned out from them afterwards. Today is my first real day off in 20 days; in fact, all interns get
a week off from today.

That brings the news - I AM OFFICIALLY DONE WITH INTERNSHIP!

One Year Ago

It was exactly one year ago today that determined my life at least for the next 3 years. That calls for a celebration!

Faded

Seeing her again after 9 months, I felt the power of time - affection does fade with time when it's not deep and when you don't keep up with it. I can't imagine myself falling for her again, nor can I now reason to myself why I had fallen for her in the first place. I feel good about her avoidance that day - it reassured me that I am not the one who's in the wrongs.

Home Sweet Home

This week is my last vacation break of my internship year and I've decided to return to and spend some quality time with my folks and my sister. I must say - it's good to be home. Not much has changed since I was last here 9 months ago, and even though there are certain aspects of Socal that appeal to me, I'd still pick SF over LA in a heartbeat.

Busy Day in the RH Clinic

This week I have been working in a county reproductive health clinic in the area (perhaps an euphemism for STD clinic). For me who, like most of the male doctors nowadays, is somewhat deficient in getting trained for gyn exams, it is a pretty wonderful experience. If I haven't learned anything else, I have learned to do pelvic and breast exams efficiently and picked up some techniques to help ease patients' stress.

An interesting observation is that some of the patients have no questions with a male doing their exams, whereas the rest have different degrees of reluntance. A couple of them even freaked out when they saw a guy walking into the room. And while I always keep everything professional, I think it is absolutely against nature when you walk into a room, see this gorgeous 19-year-old blonde, and not have other thoughts. It's kind of a guilty pleasure. It's times like this when I really start to wonder - how much do these patients trust you for them to let you touch their most sacred parts of their body?

A Little Girl Has Made My Day

Today is the last day of my inpatient service rotation. I had a fun time indeed - I've been blessed with a cool, fun team with a GREAT attending that has now become my role model.

As I was taking the escalator down after a long day to get my car, an Asian mother pointed me to her little girl.

Mother: "Ask him if he is a doctor..."
Toddler: "Are you a doctor?"
Me: "Yes, I am." (with a great smile of course)
Me: "Do you want to be a doctor?"
Toddler: "Yes~"
Me: "Good girl!"

It totally made my day.

Pronouncing Death

Every now and then, I'd get a page from the ICU or the floor to pronounce a patient's death. I know people who absolutely hate it; but hey, if you think of it as the rare time when you are 100% certain of your diagnosis, it doesn't really sound like a bad task!

The strange thing about pronouncing death is that it is usually not taught in medical school. It's one of those things that you somehow just know eventually, and everyone comes up with his or her own style after a few runs. As easy as it sounds, to legally pronounce a patient dead requires a systematic approach to avoid the 1 in a million chance that the "dead" patient is still alive and kicking!

When there is no one accompanying the patient, I usually start by greeting the patient by his name. Then I usually examine the patient in this order:
- Watch for spontaneous breathing
- Auscultate for heart beats and lung sounds
- Palpate for carotid and/or radial pulses
- Check pupils and negative "doll's eye sign"
- Apply pressure to sternum for response (I usually skip this if family members are present)

The above should be suffice to pronounce a patient, unless for brain death cases. It may not be comfortable alone with a dead patient, but knowing that the patient's suffering with sickness has ended may come as a relief.

A Tale of Two Young CHFers

Last night on call, we admitted 2 patients with CHF (Congestive Heart Failure) exacerbation. CHFers are nothing new, but what's interesting is that they are both young. They are both obese, and present with shortness of breath as their chief complaint. The similarities end here, however.

CHFer#1 is an obese African male who presented to the ER with SOB for 1 week. He has a long history of atrial fibrillation/flutter that is refractory to chemical cardioversion. He did undergo a successful electrical cardioversion a few years ago. He has a history of medication non-compliance, but apparently has finally been taking his diuretics and rate-control meds regularly. Last echocardiogram shows marked decrease in cardiac function and an enlarged heart. He is a mild-mannered gentleman who has never smoked, only drinks occasionally and denied any drug use.

CHFer #2 is an obese Caucasian diabetic female who presented to the ER with SOB and difficulty sleeping for 1 week. Symptoms started after she ran out of medications last week. She has a history of methamphetamine abuse in which she snorts about $20 worth of the drug every day. She stated her last use was 4 days ago. Her last echocardiogram also shows marked decrease in cardiac function. In the ER, she threatened to leave because no one is taking care of her difficult sleeping, and was uncooperative to the ER staff. At one point, she refuses diuretics, saying that she wouldn't able to sleep if she has to pee every 30 minutes. A Foley catheter would have solved this problem, but she refuses as well.

It is easy to feel pitiful to CHFer #1 because of his pleasant manner and overall tragic history, and as the same time feel angry towards CHFer #2 because of her "obnoxiousness" and her apparent "she has done all this to herself" history. A family physician is all about caring and solving his patients' medical and social issues, but what do you do when your emotions affect your desire to help your patients? What do you do when your patients don't meet your expectation?

You Woke Me Up For THIS?

4:30 in the morning:

Me: This is Dr. L, I was paged.
Nurse: I have your patient here in Room ####; his Accu-chek is 46 so I gave him 1 amp of D50. So I need an order for that.
Me: But you gave the D50 already right?
Nurse: Yeah. I just need an order.
Me: So you ask for an order AFTER you carried it out?
Nurse: I gave him D50 because his sugar is low.
Me: So do you know when you are going to check his sugar again?
Nurse: In about 30-60 minutes.
Me: Okay. Just so you know, you can call me at 6:30am instead of 4:30, and it wouldn't change a thing. Please tell me you are not calling me in the middle of the night just for this...
Nurse: So can I get an order for the D50?
Me: (Arrrrh!) Yes, you may have the order.
Nurse: Thank you. [Hung up]

Just wondering: Can I have an order to not call me for a retrospective D50 order?

Leuprolide for Alzheimer's

One of the clinical trials I was involved in, the ALADDIN study, was terminated abruptly last year because of financial issues from the sponsoring pharmaceutical company. The study had a promising start - Memryte, which is basically an implantable form of leuprolide, has shown to be effective for Alzheimer's treatment in Phase II trials. Some of the patients that I had been following showed improved cognition as well. The theory behind leuprolide, which involves LH production and cell division, is very interesting but is beyond the scope of this entry.

I am glad to see that they are still working on reviving the study. Alzheimer's is a hot research field right now because of its lucrativeness but to the end, the general public will benefit so let's keep them running!